HYPERTENSION

IN GERIATRIC POPULATION
Hanna Kujawska-Danecka
Department of Internal Medicine, Geriatrics and Clinical
Toxicology, Medical University of Gdask

Hypertension
one of the in aging diseases
an estimated 6070% of population of persons > 60 years suffers
from hypertension
NHANES III Study
in the U.S. the hypertension prevalence in population > 60 years
is 65,4%

Gdask Research 1999 (team work conducted by prof. KrupaWojciechowska)

in a population > 64 years hypertension

among women 81%,

among men 66,1%

NATPOL PLUS Study 2002 (prof. T. Zdrojewski)

in a population > 64 years 59%

Forms of hypertension in the elderly

isolated systolic hypertension (IHS):
62,867,4% caused by an age-related
increase in arterial stiffness, more
common among women
systolic-diastolic hypertension:
27,630,3%
diastolic hypertension sporadically

Pathophysiology
The hypertension in elderly patients is a consequence of the aging
processes of cardiovascular system, esp. the age-related increase
in arterial stiffness.
Changes in arteries
walls stiffening
decrease in distension abilities and compliance of arteries (esp.
elastic arteries, e.g. the aorta)
wall thickening of peripheral arteries
higher vascular wall reactivity to vasoconstrictive factors

Media

increase in muscular layer thickness (higher proliferation of

vessels smooth muscles in the elderly)
change of interstitials composition: increase in the amount of
dermatan and heparan; hyaluronan decrease
(glycosaminoglycans)
decrease and degeneration of elastin fibers
increase in collagen deposition and changes in the crosslinking of collagen

Intima

structural changes of the endothelium: increased permeability,

laminar flow dysfunction, increased lipids deposition
disturbance of the secretion balance between vasoconstrictive and
vasodilative factors (cytokines produced during chronic
inflammatory processes lead to the impairment of nitric oxide and
prostacyclin synthesis in the endothelium; increased synthesis of
endothelin and other vasoconstrictive factors)

Telomere hypothesis of cell aging

telomerase deficiency

free
radicals

homocysteine

telomere shortening

vessels stiffening

Other aging processes

higher sympathetic system activity
NA muscular layer hypertrophy

vessel walls restructuring

with simultaneous decrease in density and sensitivity of betareceptors and proper functionality of alpha-receptors

vasoconstrictive effect
decrease in sensitivity of beta-receptors stimulation of
sympathetic system due to physical effort does not cause an
evident increase in heart rate and its contractility

 disturbance of balance between the sympathetic and

parasympathetic systems patients non dippers no physiologic
blood pressure decrease during night hours
impaired renal function reduced kidney weight, nephrons amount
and filtration surface area lower renal flow and glomerular
filtration
impaired sensitivity of baroreceptors (reset to a higher value of
blood pressure) due to changes in vessels structure
orthostatic hypotonia, higher variability of blood pressure
(organic complications!), oversensitivity to vasodilative drugs

Definition or when one should recognize

hypertension

140/90 mmHg
Recognition criteria of hypertension are identical in each age group,
even in the population > 65 years.
In order to recognize hypertension it is essential to take numerous
BP measurements. Due to white-coat hypertension, more frequent
in the elderly, 24-h ambulatory BP monitoring (ABPM) or multiple
home-based BP measurements may also be helpful.

BP values for defining hypertension depending on measurement

method (acc. to ESH/ESC 2013/PTNT 2011)

SBP

DBP

At doctors

140

90

ABPM

130

80

day

135

85

night

120

70

130

85

At home

White coat - hypertension

significant differences in BP values measured at home and
at doctors

suspition of hypertension resistant to pharmacological

treatment

lack of systemic changes typical for hypertension

accurate BP values in self-control
hypotension in course of pharmacotherapy

The aim of treatment

recommended BP values are 140/90 150/90 mmHg,
- in patients <80 years it can be considerd to maintain BP values < 140/90 if
the subject is in good general condition, in patients in poor general
condition the target BP values should be conseidered individually;
- in patients > 80. years provided, that they are in good general condition;
decreasing BP values under 150/90 mmHg should be very carful
achievement of the therapy goal should be stretched over a long period of
time (longer than by younger patients), up to several months in some cases
it is useful to set some staging posts of the therapy, e.g. reaching the BP
values of 160/90 mmHg
such symptoms as: ill-being, vertigo, balance disorders, vision disorders
(e.g. scotoma), confusion decreasing the dosage or changing the group
of antihypertensives
the higher initial BP values are, the more carefully they should be reduced

Treatment benefits
Patietns under and over 65 years proportionally similar benefit
from hypertension treatment (similar reduction of cardiovascular
events risk)

According to HYVETrial: the antyhypertensive treatment in

patients >80 (without serious comorbidities) should be started if
SBP is > 160 mmHg and SBP values should not exceed 150 mmHg

Due to differencies of general condition of elderly patients

the hypertension therapy should be considered indiyidually
and dynamics of BP decrease should be always graduall
and strictly monitored
Trials results suggest, that the antyhypertensive therapy
should be started with long-acting thiazide-like diuretic and
sequently ACEI.

Treatment benefits
Isolated systolic hypertension
over 50% of cases of hypertension in the elderly (main arteries
stiffness)
SBP value and pulse pressure are crucial prognostic factors of
hypertension complications in the elderly
cardiovascular mortality rate is almost three times higher as
compared to other hypertension forms
first-line treatment Calcium antagonists and diuretics

Meta-analysis (SHEP, Syst-Eur, Syst-China, HEP, MRC-2, EWPHE)

14 825 elderly persons with ISH
reduction in:
all-cause mortality rate by 14%
cardiovascular mortality rate by 20%
fatal and non-fatal cardiovascular events rate by 20%
stroke rate by 33%

Dementia
Hypertension is one of the primary factors leading to dementia in the
elderly (vasogenic dementia as well as Alzheimers disease)
patients with untreated hypertension may develop dementia in
advanced age
Alzheimers disease: cerebral microflow disturbance due to
persisting increased arterial blood pressure (collagen deposition
and thickening of basement membrane of capillaries slowing
down the pace of transporting nutritious substances into neurons
as well as of elimination of toxic waste products
dementia can be a common consequence of a stroke (hypertension
complications); patients with hypertension > 84 years tend to have
ten times higher incidence of stroke than patients aged 55-64

Dementia (cont.)

Syst-Eur Study:
4700 patients > 60 years, treated for ISH (nitrendipine)
diagnosed dementia by 50%
(Alzheimers and vasogenic types)
PROGRESS Study
6150 patients with/without hypertension, history data: ischemic stroke
or TIA (perindopril /+indapamide);
dementia rate by 34%
stroke rate by 28%

When to start treatment?

The decision of beginning of treatment should be based on BP values, risk
factors, systemic complications and co-morbidities

According to recommendations of ESH/ESC 2013, in elderly the therapy

should be started if BP is over 160 mmHg, pharmacotherapy can be also
considered (at least in patients < 80 years) also whan BP values are 140159 mmHg, provided, that antyhypertensive treatment is well tolerated

Risk factors

age: M > 55 years

male sex

smoking

lipid disorders (CH total > 190mg/dl; LDL > 115mg/dl;

F > 65 years

HDL M < 40mg/dl F < 46mg/dl; TG > 150mg/dl)

family history premature cardiovascular complications:

M < 55 years
F < 65 years

overweight (BMI 30kg/m2)

fasting glucose 100 mg/dl or impared glucose tolerance in OGTT

abdominal obesity (waist size M > 102 cm; F > 88 cm)

At least 2 risk factors are usually found in the elderly.

Organic complications

left ventricle hypertrophy (Sokolov-Lyons criterion > 35 mm

and RaVL> 1,1 mV))

left ventricle mass index: M 115

USG of carotid artery: thickening of intima-media complex

0,9 mm or presence of atheromatous plaque

ankle-brachial index (ABI) < 0,9

pulse pressure (in the elderly) > 60 mmHg

carotid-femoral pulse wave velocity > 10 m/s

chronic kidney disease (eGFR 30-60 ml/min/1,73m2)

F 95 g/m2

a slight increase of creatinine level:

M: 115133 mol/l (1,3-1,5 mg/dl)

F: 107124 mol/l (1,2-1,4)

Microalbuminuria 30300 mg/day or albumin/creatinine ratio

(M 22 mg/g; F 31 mg/g)

Coexisting diseases

Diabetes or metabolic syndrome

cerebral circulation disturbances (stroke, TIA)

heart disease (myocardial infarction, coronary artery disease,

PTCA Percutaneous Transluminal Coronary Angioplasty,
CABG Coronary Artery Bypass Graft)

heart failure

renal failure

peripheral vascular disease

advanced retinopathy (effusions, petechias, papilloedema)

Pretreatment diagnostic procedure

blood cell count
renal profile (creatinine, electrolytes)
glucose, uric acid, lipids
urine analysis (proteinuria)
ECG
orthostatic hypotonia test
alternatively TSH thyrotropin (secondary form of hypertension
related to hypothyreosis)
recommended diagnostic tests: fundus of the eye, chest X-rays,
echocardiography, USG of kidneys and carotid arteries,
microalbuminuria, Calcium level, Oral Glucose Tolerance Test,
ankle-brachial index, carotid-femoral pulse wave velocity,
Epworth Sleepiness Scale

Non-pharmacological treatment
Non-pharmacological treatment significantly results in:

BP value

reduction in cardiovascular complications

lipid profile improvement

hyperinsulinism

Non-pharmacological treatment cont.

sodium intake reduction up to 6 g/day
(min. 5-weeks diet necessary for a hypotensive effect)
other advantages: LV hypertrophy, proteinuria, calciuria
osteoporosis and the risk of calcium nephrolithiasis,
an improvement of antyhypertensive treatment
normalization of body mass the most effective nonpharmacological method of BP reduction, leading to reduction
of other risk factors (obesity, hyperinsulinism, hyperlipidemia)
These are the two best statistically proved methods of BP
reduction, esp. when practiced simultaneously

 diet
beneficial: fruits (esp. citrus), vegetables, unsaturated fatty acids,
esp. omega-3 fatty acids (saltwater fish); Dietary Approaches to
Stop Hypertension (DASH)
non-beneficial: saturated fatty acids, high intake of proteins and
carbohydrates
Potassium suplementation 60 mmol/day; additionally it is crucial
in the stroke prevention in the elderly
alcohol has a hypertensive effect, however small amounts may
be beneficial; by persons of 50-74 years this effect is stronger than
in younger population
Notice: in the elderly impaired hepatic metabolism, smaller
distribution volume, drugs interactions
tobbacco hypertensively i atherogenically

physical effort isotonic exercises: walking, gardening, cycling,

swimming; initially 1520 min. 23 times a week, then gradual
progress up to 3045 min. most day of a week
moderate physical effort < 60% of maximum effort
(easy breathing, HR = 220 age)

Pharmacological treatment
There 5 groups of antihypertensive treatment, which may be
used in monotherapy as well as in combined therapy and
their effect on prognosis is proven
thiazid and thiazid-like diuretics
B-blockers (vasodilatative preffered)
Calcium chanel blockers
ACE inhibitors
AT1 receptors anatagonists

First line treatment the therapeutic decision is based on risk

factors, co-morbidities, systemic complication,
hypertension type, other drugs taken.
In elderly patients the first line treatment are:

diuretic esp. thiazides and thiazide-like (ALLHAT,

ADVANCE, HYVET, PATS); in the age group >80 indapamid
is recomended
Dihydropyridine calcium channel antagonists esp.
effective
in ISH

DIURETICS
Potassium-sparing diuretics

thiazides
indapamide reduction of LV
hypertophy
smaller metabolic influence
smaller hipokalemia
NOTICE:
diabetes
Gout
hyperkalcemia

(spironolaktone is recommended
as 4. line treatment in resistent
hypertension)

loop diuretics
CHF, RF
NOTICE:
hipokalemia

contraindications:
decompensated RF
NOTICE:
hyperkalemia

In most clinical studies diuretics form the basis for antihypertensive

treatment. Thiazides enhance the hypotensive effect of all primary
hypotensive drugs therefore they seem a perfect component of
a combined therapy.

CALCIUM CHANNEL ANTAGONISTS

verapamil
diltiazem

dihydropyridine derivatives
(nitrendipine, amlodipine)

chronotropic negative
inotropic negative
NOTICE: CHF, bradycardia, heart blocks (atrioventricular
blocks), esp. combined with z -blockers
INDICATIONS: ISH, peripheral vascular disease, diabetes, renal failure, CAD,

COPD chronic obstructive pulmonary disease ( pulmonary hypertension)

NOTICE: headaches, flush, ankle edema, tachycardia, constipation, CHF
exacerbation
CONTRAINDICATIONS: short-acting dihydropyridine derivatives are

contraindicated in long-term therapy due to high fluctuations of BP values and

adrenergic stimulation ischemia and hypertrophy of LV

ACEI

hypotensive effect
target organ effects:
endothelium function improvement
coronary circulation and coronary reserve improvement
regression of LV hypertrophy and remodelling process
pressure in renal glomerule delayed development of
nephropathy
esp. effective when combined with drugs increasing activity of
renin-angiotensin-aldosterone system (diuretics)

ACEI cont.

INDICATIONS:
hypertension, CAD (esp. after myocardial infarction), CHF, diabetes,
nephropathy (incl. diabetic), after stroke (secondary prevention)
NOTICE:
hiperkalemia, orthostatic hypotonia, renal artery stenosis (of the only
kidney or bilateral)

Antagonici receptora AT1

(losartan, telmisartan, valsartan, kandesartan)
indication: hypertension + diabetes, LV hypertrophy, chronic kindey
disease, after a stroke, they are alternative for ACEI in cases of
intolerance due to a cough

Contradictions: renal artery stenosis (of the only kidney or bilateral)

AT1 antagonists may be used in combined antyhypertensive therapy,

also with ACEI (additive cardio- and nephro- protective action).
However, as ONTARGET study (telmisartan\ ramipril) has shown, dubled
blockage of RAA system is very effective in protection of cardiovascular
events, is also connected with high prevalence renal complications
(hyperkaliemia, renal function deterioration)

BETA-BLOCKERS
vasodilatative
karwedilol
nebiwolol
celiprolol

cardioselective
metoprolol
bisoprolol
betaxolole

Currently this drug group is not regarded as a first-line treatment

option in the elderly as a monotherapy of non-complicated
hypertension.
However, B-blockers are important element of antyhypertensive
therapy in cases combined with diabetes, other cardiovascular
diseases or cardiovascular complications of hypertension (esp.
vasodilatative B-blokers)
INDICATIONS: hypertension + CAD, CHF, heart rhythm disturbances,

diabetes, vasorenal hypertension

NOTICE: COPD, asthma, peripheral vascular disease, severe

decompensated CHF, masking hypoglycaemia symptoms,
influence on carbohydrate and fat metabolism, bradycardia
and heart blocks, sleep disorder and depression
(lipophilic drugs: metoprolol, propranolol), metabolism
disorder ( HDL, TG, glucose tolerance i insulin
sensitivity)

Alpha-blockers (doxazosin)
This drug group can accelerate the development of heart failure
(ALLHAT study) currently not used in monotherapy. Use carefully
by patients with symptomatic heart failure, after extensive myocardial
infarction, and asymptomatic LV function impairment
INDICATIONS: in combined antihypertensive therapy, esp. by
coexisting diabetes, renal failure, obliterative atheromatosis, lipid
disorders
NOTICE: orthostatic hypotonia, vertigo, astenia, headaches,
tachycardia

NOTICE: coegxisting benign prostatae hypertophy is not a

indication for indywidualization antyhypertensive therapy!

Clinical symptoms of BPH (benign prostatae hypertophy)

are present in 30% of men > 65 years, in this same group of

elderly 2/3 suffer from hypertension

doxazosine alfa1-adrenolitic non-uroselective, it is a

hypertensive drug of 3-4 line treatment in cases of resistent

hypertension requiring combined therapy

tamsulozine uroselective alfa1-adrenolitic urologist

makes the decision about the treatment, in cases of

unsuccesful antyhypertensive treatment tamsulozine may
be changed into doxazosine

Antihypertensive therapy
start with small doses; dosage increase significantly extended in time
combined therapy (lower risk of side effects, inhibition of compensatory
reactions, various mechanisms of action)
long-acting drugs are preferred (24-h BP values fluctuations can lead to
LV hypertrophy, heart rhythm disturbances and hypotonia; better
control of BP values in the early hours of the day, better cooperation
with a patient, fewer pills)
weaker hepatic metabolism and renal function
homeostatic mechanisms disturbances (decline of a baroreceptor
mechanism orthostatic hypotonia)
coexisting diseases (diabetes, CAD, CHF)
intake of many different group of drugs (drug interactions,
polypragmasy)
inform patients accurately about the diseases character and principles
of their therapy (good patients compliance)

Therapy failures (reasons)

secondary hypertension
coexisting diseases
drugs (NSAID, steroids)
improper drugs intake (e.g. therapy breaks when BP returns to
normal)
polypragmasy (incl. improper combinations of antihypertensive
drugs)
white-coat hypertension
too expensive drugs

Orthostatic hypotonia

SBP by at least 20 mmHg, often along with DBP by min. 10

mmHg after postural change (from recumbent into standing).
We measure BP after a patient has been standing quietly for at
least 1 minutes (and then after 3 minutes)

particularly common in the elderly with hypertension

15 to 20% of community-dwelling and about 50% of

institutionalized elderly persons

10% of physically fit and > 50% of infirm persons > 65 years

Pathomechanism
Postural
change

lower limbs blood hold

venous return

stroke volume

carotid sinus flow

(baroreceptors stimulation)
HR i stroke volume
(beta-adrenergic stimulation)

Orthostatic hypotonia effects

sudden cerebral circulation decline ( stroke risk)

deterioration in coronary circulation (myocardial ischaemia /

infarction)

injuries, sometimes life-threatening (as a consequence of vertigo,

balance disturbances)

psychological trauma, anxiety of physical activity, leading to

infirmness

symptoms: vertigo, balance disturbances, dizziness, faintness,

falls and trauma, vision disorders, TIA, stenocardia, nausea

Predisposing factors

venous insuficiency (obesity, lower limbs varices, sedentary life

style, aging processes in veins walls)

disturbances of BP autonomic control (impairment of a

baroreceptor mechanism, lesser variability of HR, a reduction in
density and sensitivity of beta-receptors, peripheral neuropathy)

impaired cerebral circulation and cerebral vessels autoregulation

dehydration, low-sodium diet

drugs (diuretics, alfa-blockers, nitrates, anti-Parkinsonic,

phenothiazines, tricyclic antidepressants)

Management
slow postural change
raised-waist clothes
pressure stockings for patients with venous insufficiency
careful implementation and dosage of drugs which can intensify
hypotonia
orthostatic hypotonia test after each change of dosage or
implementation of a new drug
alternatively consider pharmacological treatment (fludrocortisone,
caffeine, ephedrine)

Postprandial hypotension

SBP by at least 20 mmHg in 2 hours after meal or < 90 mmHg,

when initial BP value > 100 mmHg

2436% of institutionalized elderly persons

often asymptomatic, however can also lead to: vertigo, balance

disturbances, faintness and falls, TIA, nausea, stenocardia

pathomechanism: blood accumulation in visceral circulation,

activity of vasoactive intestinal hormones, impaired baroreceptor
mechanism and adrenergic heart response

Secondary hypertension
every sixth elderly patient with hypertension
Causes
renal diseases (renal artery stenosis, a kidney disorder e.g. polycystic
kidney disease, glomerulonephritis, chronic pyelonephritis)
endocrine disorder (eg, Cushing's syndrome, hypothyreosis, primary
aldosteronism, pheochromocytoma)
drugs (steroids, NSAID, B2-agents)
alcohol abuse
Secondary hypertension should be always considered in cases of sudden
development of hypertension, drug-resistant hypertension and fast
increasing renal failure.

Vasorenal hypertension
the most common form of secondary hypertension due to atherosclerosis
(among more rare causes: fibromuscular dysplasia of renal arteries, renal
artery aneurysm, renal artery embolism, outside pressure)
mainly smoking men
often accompanied by symptoms of advanced atherosclerosis of other
vessels (coronary, carotid, of lower limbs, significant LV hypertrophy, heart
failure
Clinical picture:
sudden appearance of hypertension after the age of 60,
severe course and treatment resistance
fast development of renal failure after applying ACEI
intensification of hypokalemia after applying diuretics
vascular murmur in epigastric and umbilical regions, as well as other
arteries
recurrent pulmonary oedema

Diagnostics
abdominal USG and Doppler USG of renal arteries
renal arteries angiography
spiral CT of renal arteries preferred method

Treatment
percoutaneous angioplasty results are rather unsatisfactory
in the elderly patients with atheromatous renal artery sclerosis,
ca. 10% cured, 40% milder course, stent implantation gives better results
surgery treatment (when changes are very advanced and bilateral) good
results: 8090% cured or improved; no studies in the elderly population
however
non-invasive treatment (by patients not qualifying for surgery due to
contraindications and poor general condition)
Recommended drugs: Calcium channel blockers, ACEI (caution in cases of
bilateral stenosis), diuretics, beta-blockers

Renal parenchymatous hypertension

History data: renal disease (impairment of renal sodium excertion
intravascular volume, cardiac output, RAA-axis stimulation and
sympathetic system)
diagnosis: history, urinanalysis (specific weight, proteinuria,
erythrocyturia, leucocyturia), renal USG
treatment: restrictions of sodium and proteins intake, ACEI (up to
creatinine level of 4 mg/dl), Calcium channel blockers, loop diuretics,
imidazoline receptors antagonists
reference values 130/85 mmHg

Hypothyreosis
in Andersons studies 35% of patients > 60 years with secondary
hypertension (4429 persons with hypertension examined for secondary
hypertension)
25% of patients with hypothyreosis suffer from hypertension
cause: stimulation of sympathetic system (in elder age the density of betareceptors decreases while the sensitivity of alpha-receptors increases
vasoconstriction and increase of peripheral resistance)
hypothyreosis in the elderly is difficult to diagnose only ca. 30% of
patients present typical symptoms
hypothyreosis a great masquerader: usually recognised as depression,
dementia, treatment-resistant heart failure
diagnostics: THS, fT4, fT3
substitutive treatment of hypothyreosis leads to normalization of BP values
in ca. 3050% of cases