Elderly patients hypertension

Taylor CL, Yuan Z, Selman WR, Ratcheson RA, Rimm AA (1995) Cerebral arterial aneurysm formation and rupture in 20,767 elderly patients hypertension and other risk factors. J Neurosurg 83 812-819 Teunissen LL, Rinkel GJ, Algra A, van Gijn J (1996) Risk factors for subarachnoid hemorrhage a systematic review. Stroke 27 544-549... 

Nifedipine (Table 3) is a potent vasodilator that selectively dilates resistance vessels and has fewer effects on venous vessels. It does not cause reflex tachycardia during chronic therapy. Nifedipine is one of the first-line choices for black or elderly patients and patients having concomitant angina pectoris, diabetes, or peripheral vascular diseases. Nifedipine, sublingually, is also suitable for the treatment of hypertensive emergencies. Nifedipine does not impair sexual function or worsen blood Hpid profile. The side effects are flushing, headache, and dizziness. 

P-blocker therapy was ineffective in preventing coronary heart disease, cardiovascular mortality, and all-cause mortality when compared to diuretics for elderly patients (60 years of age or greater) treated for primary hypertension. Clearly, the effects of P-blockers on blood pressure are complex and difficult to ascribe to one or two mechanisms. Rather, the varied effects of negative chronotropic and inotropic properties along with reduced renin levels (Fig. 2-3) appear to result in an overall reduction in cardiac output and/or reduction in peripheral resistance. 

The treatment of elderly patients with hypertension, as well as those with isolated systolic hypertension, should follow the same approach as with other populations with the exception that lower starting doses may be warranted to avoid symptoms and with special attention paid to postural hypotension. This should include a careful assessment of orthostatic symptoms, measurement of blood pressure in the upright position, and caution to avoid volume depletion and rapid titration of antihypertensive therapy.2 In individuals with isolated systolic hypertension, the optimal level of diastolic pressure is not known, and although treated patients who achieve diastolic pressures less than 60 to 70 mm Hg had poorer outcomes in a landmark trial, their cardiovascular event rate was still lower than those receiving placebo.69... 

Although the risk of GI complications is relatively small with short-term therapy, coadministration with a proton pump inhibitor should be considered in elderly patients and others at increased GI risk. NSAIDs should be used with caution in individuals with a history of peptic ulcer disease, heart failure, uncontrolled hypertension, renal insufficiency, coronary artery disease, or if they are receiving anticoagulants concurrently. 

Elderly patients may present with either isolated systolic hypertension or an elevation in both SBP and DBP. Epidemiologic data indicate that CV morbidity and mortality are more closely related to SBP than to DBP in patients 50 years of age and older. 

Hypertension - Usual dose is 5 mg once daily. Maximum dose is 10 mg once daily. Small, fragile, or elderly patients or patients with hepatic insufficiency may be started on 2.5 mg once daily this dose may also be used when adding amlodipine to other antihypertensive therapy. In general, titrate over 7 to 14 days proceed more rapidly if clinically warranted with frequent assessment of the patient. 

Elderly Patients at least 65 years of age are more likely to develop systolic hypertension on therapy, and more likely to show serum creatinine rises greater than or equal to 50% above the baseline after 3 to 4 months of therapy. Monitor elderly patients with particular care, because decreases in renal function also occur with age. If patients are not properly monitored and dosages are not properly adjusted, cyclosporine therapy can cause structural kidney damage and persistent renal dysfunction. 

Beta-blockers can no longer be considered as first line monotherapy for uncomplicated hypertension in older patients since some studies suggest they are less effective than diuretics and no better than placebo in reducing cardiovascular outcomes. Their use in elderly with hypertension probably should be confined to those with other indications such as angina, following myocardial infarction or with heart failure. 

Black DM, Brand RI, Greenlick M, et al Compliance to treatment for hypertension in elderly patients The SHEP pilot study. Systolic Hypertension in the Elderly Program. J Gerontol 1987 42 552-557. 

The secondary mineralocorticoid activity of glucocorticoids can lead to salt and water retention, which can cause hypertension. Although the detailed mechanisms are as yet uncertain, glucocorticoid-induced hypertension often occurs in elderly patients and is more common in patients with total serum calcium concentrations below the reference range and/or in those with a family history of essential hypertension (SEDA-20, 368 19). 

Garbe E, LeLorier J, Boivin JF, Suissa S. Risk of ocular hypertension or open-angle glaucoma in elderly patients on oral glucocorticoids. Lancet 1997 350(9083) 979-82. 

Martin U, Hill C, O Mahony D. Use of moxonidine in elderly patients with resistant hypertension. J Clin Pharm Ther. 2005 30 433-437. 

Therapeutic uses Thiazide diuretics decrease blood pressure in both the supine and standing positions postural hypotension is rarely observed, except in elderly, volume-depleted patients. These agents counteract the sodium and water retention observed with other agents used in the treatment of hypertension (for example, hydralazine). Thiazides are therefore useful in combination therapy with a variety of other antihypertensive agents including (3-blockers and ACE inhibitors. Thiazide diuretics are particularly useful in the treatment of black or elderly patients, and in those with chronic renal disease. Thiazide diuretics are not effective in patients with inadequate kidney function (creatinine clearance less than 50 mls/min). Loop diuretics may be required in these patients. 

Losartan was proved to be more effective for stroke prevention in patients with hypertension and LVH than the beta adrenoceptor blocker atenolol in the LIFE Study [8]. Furthermore, losartan in a comparative trial with hydrochlorothiazide/ atenolol [38], valsartan [39] were shown to inhibit the cognitive decline associated with hypertension in the elderly patients. 

Q5 Yes. Thiazide diuretic drugs are one of the treatments of choice for hypertension in elderly patients. Bendroflumethiazide, 2.5 mg daily, is commonly prescribed for hypertension in the United Kingdom. Although the thiazides have been in use for many years, their mechanism of action is not completely understood. They reduce renal reabsorption of sodium and water and so initially decrease blood volume they also dilate blood vessels and BP falls. However, blood volume may return to normal while the vasodilation and antihypertensive action remains. 

In 27 hypertensive patients aged 65 years or more, randomized to continue atenolol treatment for 20 weeks or to discontinue atenolol and start cilazapril, there was a significant improvement in the choice reaction time in the patients randomized to cilazapril (93). This study has confirmed previous reports that chronic beta-blockade can determine adverse effects on cognition in elderly patients. Withdrawal of beta-blockers should be... 

Atheromatous medium-sized arteries at the base of the brain, particularly the vertebral and basilar arteries, may become affected by dolichoectasia. The arteries are widened, tortuous and elongated and may be visualized on MRI or, if the walls are calcified, on CT. Dolichoectasia is usually found in elderly patients with hypertension and diabetes and it may cause stroke through embolization of thrombus or by occlusion of small branch arteries. In younger patients, it should raise the possibility of Fabry s disease. 

More recently, it has been shown that hypokalemia and other dose-related adverse metabolic effects of thiazide diuretics increase the risk of sudden death and negate the cardiovascular benefit of blood pressure lowering when high doses these drugs are prescribed (21). Hence, another explanation for the apparent inability of antihypertensive therapy to lower mortality in patients with coronary heart disease is that high thiazide doses were used in many of the trials that were analyzed. As pointed out by Temple (2), this explanation is supported by the results of a trial of antihypertensive therapy in elderly patients with isolated systolic hypertension (22). In this study, only low doses of a thiazide diuretic were prescribed and a 4-mm Hg average decrease in diastolic blood pressure was associated with a 36% reduction in the... 

Abernethy DR, Schwartz JB, Plachetka JR, Todd EL, Egan JM. Comparison in young and elderly patients of pharmacodynamics and disposition of labetalol in systemic hypertension. Am J Cardiol 1987 60 697-702. 

Hansson L, Lindholm LH, Ekbom T, Dahlof B, Lanke J, Schersten B, Wester PO, Hedner T, de Faire U. Randomised trial of old and new antihypertensive drugs in elderly patients cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Lancet 1999 354(9192) 1751-6. 

Overdose, which may be absolute or relative (due to impaired renal excretion or in elderly patients who develop adverse effects at lower dosages), leads to severe hypotonia, mental confusion and somnolence, respiratory depression, and eventually apnea, bradycardia, cardiac conduction abnormalities, hypotension, and coma. Convulsions can occur and hypertension has been reported. It is possible that during recovery the picture may be complicated by an acute withdrawal syndrome, with agitation, psychosis, tremor and dystonic movements, convulsions, and hallucinations (SEDA-11, 126) (36 0). 

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