Hypertension in Octogenarians - Treatment Strategies and Challenges

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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.

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



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.


  1. The NHS Information Centre, 2011. Available at: www.ic.nhs.uk/ (accessed 17 February 2011).
  2. Burt VL, Whelton P, Roccella EJ, et al., Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988├óÔé¼ÔÇ£1991, Hypertension, 1995;25:305├óÔé¼ÔÇ£13.
  3. Franklin SS, Gustin W 4th, Wong ND, et al., Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study, 1997;96:308├óÔé¼ÔÇ£15.
  4. Lewington S, Clarke R, Qizilbash N, et al., Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies, Lancet, 2002;360:1903├óÔé¼ÔÇ£13.
  5. Benetos A, Safar M, Rudnichi A, et al., Pulse pressure: a predictor of long-term cardiovascular mortality in a French male population, Hypertension, 1997;30:1410├óÔé¼ÔÇ£5.
  6. Blacher J, Guerin AP, Pannier B, et al., Impact of aortic stiffness on survival in end-stage renal disease, Circulation, 1999;99:2434├óÔé¼ÔÇ£9.
  7. Laurent S, Boutouyrie P, Asmar R, et al., Aortic stiffness is an independent predictor of all-cause and cardiovascular mortality in hypertensive patients, Hypertension, 2001;37:1236├óÔé¼ÔÇ£41.
  8. Meaume S, Benetos A, Henry OF, et al., Aortic pulse wave velocity predicts cardiovascular mortality in subjects >70 years of age, Arterioscler Thromb Vasc Biol, 2001;21:2046├óÔé¼ÔÇ£50.
  9. Cruickshank K, Riste L, Anderson SG, et al., Aortic pulse-wave velocity and its relationship to mortality in diabetes and glucose tolerance: an integrated index of vascular function?, Circulation, 2002;106:2085├óÔé¼ÔÇ£90.
  10. Beckett NS, Peters R, Fletcher AE, et al., for the HYVET study group, Treatment of hypertension in patients 80 years of age or older, N Engl J Med, 2008;358:1887├óÔé¼ÔÇ£98.
  11. Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al., INVEST investigators, A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial, JAMA, 2003;290:2805├óÔé¼ÔÇ£16.
  12. Denardo SJ, Gong Y, Nichols WW, et al., Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy, Am J Med, 2010;123:719├óÔé¼ÔÇ£26.
  13. Gueyffier F, Bulpitt C, Boissel JP, et al., for the INDANA Group, Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials, Lancet, 1999;353:793├óÔé¼ÔÇ£6.
  14. Amery A, Birkenhager W, Brixko P, et al., Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly Trial, Lancet, 1985;1:1349├óÔé¼ÔÇ£54.
  15. Coope J, Warrender TS, Randomised trial of treatment of hypertension in elderly patients in primary care, BMJ, 1986;293:1145├óÔé¼ÔÇ£51.
  16. Perry HM Jr, Smith WM, McDonald RH, et al., Morbidity and mortality in the Systolic Hypertension in the Elderly Program Pilot Study, Stroke, 1989;20:4├óÔé¼ÔÇ£13.
  17. SHEP Cooperative Research Group, Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP), JAMA, 1991;265:3255├óÔé¼ÔÇ£64.
  18. Dahlof B, Hansson L, Lindholm LH, et al., Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension), Lancet, 1991;338:1281├óÔé¼ÔÇ£5.
  19. Casiglia E, Spolaore P, Mazza A, et al., Effect of two different therapeutic approaches on total and cardiovascular mortality in a cardiovascular study in the elderly (CASTEL), Jpn Heart J, 1994;35:589├óÔé¼ÔÇ£600.
  20. Staessen JA, Fagard R, Thijs L, et al., for the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators, Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension, Lancet, 1997;350:757├óÔé¼ÔÇ£64.
  21. . NICE Guideline CG034, Management of hypertension in adults in primary care, 2006. Available at: www.nice.org.uk/CG034 (accessed 17 February 2011).
  22. Williams B, Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV, J Hum Hypertens, 2004;18:139├óÔé¼ÔÇ£85.
  23. Blood Pressure Lowering Treatment Trialists™ Collaboration, Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials, BMJ, 2008;336:1121├óÔé¼ÔÇ£3.
  24. Gribbin B, Pickering TG, Sleight P, Decrease in baroreflex sensitivity with increasing arterial pressure and with increasing age, Br Heart J, 1969;31:791├óÔé¼ÔÇ£8.
  25. Gerritsen J, Ten Voorde BJ, Dekker JM, et al., Baroreflex sensitivity in the elderly: influence of age, breathing and spectral methods, Clin Sci, 2000;99:371├óÔé¼ÔÇ£81.
  26. James MA, Robinson TG, Panerai RB, Potter JF, Arterial baroreceptor-cardiac reflex sensitivity in the elderly, Hypertension, 1996;28:953├óÔé¼ÔÇ£60.
  27. Law MR, Wald NJ, Morris JK, Jordan RE, Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials, BMJ, 2003;326:1427├óÔé¼ÔÇ£34.
  28. Wald DS, Law M, Morris JK, et al., Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials, Am J Med, 2009;122:290├óÔé¼ÔÇ£300.
  29. LeSage J, Polypharmacy in geriatric patients, Nurs Clin North Am, 1991;26:273├óÔé¼ÔÇ£90.
  30. Avorn J, Polypharmacy. A new paradigm for quality drug therapy in the elderly?, Arch Intern Med, 2004;164:1957├óÔé¼ÔÇ£9.
  31. Pimenta E, Gaddam KK, Oparil S, et al., Effects of dietary sodium restriction on blood pressure in subjects with resistant hypertension: results from a randomized trial, Hypertension, 2009;54:475├óÔé¼ÔÇ£81.
  32. Wei L, Struthers AD, Fahey T, et al., Spironolactone use and renal toxicity: population based longitudinal analysis, BMJ, 2010;340:c1768.
  33. Calhoun DA, Pimenta E, Treatment of resistant hypertension, J Hypertens, 2010;28:2194├óÔé¼ÔÇ£5.
  34. Manios ED, Koroboki EA, Tsivgoulis GK, et al., Factors influencing white-coat effect, Am J Hypertens, 2008;21:153├óÔé¼ÔÇ£8.
  35. Burr ML, Dolan E, O™Brien ET, McCormack P, The value of ambulatory blood pressure in older adults: the Dublin outcome study, Age Ageing, 2008;37:201├óÔé¼ÔÇ£6.
  36. Niiranen TJ, Hanninen MR, Johansson J, et al., Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study, Hypertension, 2010;55:1346├óÔé¼ÔÇ£51.