Senior citizen’s (more than 60 years of age) constitute around 10 % of our population. High blood pressure (Hypertension) is a very common problem at these ages and a figure of 40.5% was reported in a scientific study from Delhi and Puducherry.
The peculiarity of high BP in elderly is that the systolic pressure (upper reading in BP apparatus) is high because of arterial stiffness, whereas diastolic pressure (lower reading in BP apparatus) is stable or even decreases spontaneously.
It is the systolic BP which is a better correlate of cardiovascular risk than the diastolic pressure. Higher the BP, higher is the risk of stroke, heart attacks and related issues, sudden death, heart failure and end-stage kidney disease.
High BP in the aged is often associated with forgetfulness and intellectual decline with features like dementia setting in. Once the cognitive disorders set in which are the result of long-standing hypertension, the control of BP does not reverse them.
Better control of high BP in earlier stages has led to reduction in the cognitive disorders over the years. Often these patients have severe frailty and their BP drops when in standing position (Orthostatic hypotension).
They are prone to falling down and become injury prone especially with fractures.
This feature has to be kept in mind when prescribing drugs in the elderly. Diastolic pressure becoming very low (sometimes even < 50 mms hg) while bringing down the systolic pressure is also an issue with no perfect answer.
Frailty is another important accompaniment elderly persons with high BP can have and needs to be evaluated. The evaluation depends on the degree of frailty.
There are several protocols for this, the protocol from Dalhousie university, Halifax, Canada is being reproduced. Patients with moderate to severe frailty (Scales 6 to 9, Dalhousie scale) need to be looked at differently.
Those with advanced disease, dementia, severe frailty or full dependence need not be aggressively treated for high BP and in some instances may even need stoppage of medicines. Most clinical trials have excluded such patients and real benefits are not clear.
Age is no bar for treating high BP:
A number of studies have shown the benefits of bringing down the high BP even in ages beyond 80 years of life. In fact, a modest reduction from 160/90 mms to 150/90 mms Hg saw a substantial reduction in strokes, heart attacks, heart failure and all cause death rates within 2 years of treatment in the very old. The target BP to be achieved according to most authorities is the same as in younger patients (less than 140/90 mms Hg). Lower the better philosophy (<130/80 mms Hg) is recommended by the American guidelines. The drug groups are the same but the choice of drugs should be individualised, one glove fits all philosophy is discouraged.
Strategies of Treatment:
The non-drug measures like, excessive salt reduction, losing weight, increasing physical activities may not be the best way to go. Weight reduction exercises in very old patients is difficult and may bring in loss of muscle mass and even result in cachexia unless protein supplementation and exercise training program is concomitantly advocated. Absolute salt reduction may lead to hyponatremia (sodium deficiency), malnutrition and postural drop in BP leading to falls.
Elderly hypertensives can have several other co-morbidities leading to poly-pharmacy. Checking the other drugs like medicines for enlarged prostate, heart failure drugs which can potentiate the BP lowering effects needs to be kept in mind. Anti- depressants and non-steroid pain killers can have BP raising effects.
Adverse effects of the drug being used for hypertension should be known and the patient or the family warned about them. Kidney issues like raised serum creatinine and raised potassium by ACE inhibitors, ARNI and spironolactone.
Slow heart rate and fatigue by beta blockers (metoprolol, bisoprolol etc), drowsiness by alpha blockers (moxonidine, prazosin etc) are the frequently seen side effects.
Compliance for the treatment also holds the key and can be a challenge. This has to be ensured by a personalised approach. Forgetting to take the drugs and also taking it again after having already consumed it can be hazardous.
Pill boxes of various types are available ensuring AM and PM doses etc. A supervision by a family member who should be given the charge is important in case of elderly with memory losses and cognitive issues. Periodic pill count to ensure appropriate consumption is also useful.
Take Home Message
With the increase in life expectancy, hypertension has become a major in geriatric medicine. Patients more than 80 years of age is a challenging subgroup. The benefits of treating these patients are enormous. Reduction in strokes, heart attacks, heart failure, chronic kidney disease and all causes of death is proven beyond doubt. Associated frailty and fragile health is common and needs personalised care. Age is just a number; healthy senior citizens have the same targets of BP control as the younger ones.
Founder Director, Gauri Kaul foundation, Recipient of Padma Shri and Dr B C Roy Award
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.