Hypertension in Octogenarians - Treatment Strategies and Challenges

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Abstract

Abstract
The demographics of westernised countries are changing and older people now represent a larger and increasing proportion of the overall population. Since age is a potent risk factor for hypertension, this has resulted in many more octogenarians and older who require antihypertensive therapy. In this article we discuss the evidence base for drug treatment of octogenarians and older. We discuss the choice of drug therapies and outline some of the features that make treatment of such patients a challenge, in particular drug intolerance. We discuss the role of prescribing multiple low-dose therapies to increase the benefits while mitigating the adverse effects. We also discuss the thorny issues of polypharmacy and resistant hypertension and finally we discuss the role of ambulatory blood pressure monitoring as a tool for avoiding blood pressure misclassification in older subjects.

Keywords
Hypertension, systolic hypertension, very elderly, drug treatment, challenges

Disclosure: Isla S Mackenzie has no conflicts of interest to declare. Thomas M MacDonald has provided consultancy for a number of pharmaceutical companies and has received honoraria for giving lectures on hypertension, and his department has received industry funding for hypertension research. He has no specific conflicts of interest with respect to this manuscript.
Acknowledgement: The article was written by Isla S Mackenzie and edited by Thomas M MacDonald. The article is based on a faculty lecture given by Thomas M MacDonald at the European Society of Cardiology in Stockholm in 2010.
Received: 6 November 2010 Accepted: 10 February 2011 Citation: European Cardiology, 2011;7(1):25├óÔé¼ÔÇ£8
Correspondence: Isla S Mackenzie, Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Mailbox 2, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK. E: i.s.mackenzie@dundee.ac.uk

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Hypertension becomes more common with increasing age. As we gradually move towards having a higher proportion of elderly people in the population, greater numbers of octogenarians are being treated for hypertension. In this article we describe the main features of hypertension in the elderly and describe some of the particular issues that affect elderly patients. We also discuss the results of hypertension treatment trials in elderly patients and discuss treatment strategies and challenges associated with the management of hypertension in octogenarians.

Hypertension in the Elderly
According to data from the Health Survey for England 2006, 65├óÔé¼ÔÇ£70% of women ├óÔÇ░─ä80 years of age have hypertension and of these only around 20├óÔé¼ÔÇ£30% have adequate blood pressure control.1 Systolic blood pressure gradually increases from early adulthood to old age while diastolic blood pressure increases until around 50 years of age, then plateaus before decreasing again (see Figure 1).2,3 This results in widening of the pulse pressure in later life. These changes are the result of stiffening of the arteries due to a combination of functional and structural changes that occur gradually over the years. Therefore, isolated systolic hypertension is very common in octogenarians. High systolic blood pressure readings are associated with worse outcomes.4 Similarly, various measures of arterial stiffness, including pulse pressure and pulse wave velocity, have been linked to adverse outcomes in different patient groups.5├óÔé¼ÔÇ£9 Hypertension in the elderly is commonly associated with other co-morbidities and target organ damage has often already occurred.

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