Hypertension in the elderly
Author: Dr Eamon Dolan, Consultant Geriatrician, Connolly Hospital, Dublin
Published: Irish Medical News on 3rd March 2010
The vast majority of cases of hypertension are easy to manage but there are individual cases that prove challenging at every level, from primary care to specialist care. These include patients that are pregnant, those with advanced renal disease, and patients who have had stroke. There is currently a gross underfunding of primary care in relation to the challenge of dealing with hypertension.
The prevalence of hypertension, particularly in the elderly, is considerable. A diagnosis of hypertension is almost always correct. The challenge is not so much the diagnosis but elucidating the right course of treatment. If you’ve got a very busy service, be it within the hospital or in the community, how do you take on the extra workload that dealing with the real prevalence of hypertension would call upon? Three out of every four patients in a certain age group that visit are hypertensive, as well as their other concurrent illnesses. The answer is you can’t take it on.
It is the long-term complications of hypertension that necessitate effective short-term treatment. Hypertension relates directly to the incidence of stroke, more so than coronary disease. The cost economics of somebody having a stroke are considerable. It makes sense that the health service should look at this.
A project in the UK has aimed to tackle the problem of hypertension in the community by measuring the percentage of patients in each practice who have achieved their hypertension goals. The higher the proportion of patients that have achieved target, which is a target of 150/90, the more the GPs involved are recompensed, so this is incentivised.
One problem with this scheme is that office blood pressure is the measurement used – ambulatory blood pressure monitoring (ABPM) would make this more accurate. One-in-five patients will experience white coat hypertension. The argument might be that the prevalence of hypertension in the elderly is so high; lowering it somewhat wouldn’t do them any harm. But if you lower people’s blood pressure, particularly the elderly who have a higher percentage of white coat, then their blood pressure might drop too much and you are putting them at risk of falls, etc.
Those with white coat hypertension must still be followed up periodically. There is some evidence that they have a slightly increased risk compared to normotensives. More of them will develop hypertension and go on to have cardiac events.
ABPM is useful at some point in everybody’s blood pressure management. Night time readings taken with ABPM are a particularly powerful measure of outcome. In people with high clinic readings this did not relate to future risk of heart attack or stroke, as much as having a high night time reading of blood pressure did. That’s another advantage of ABPM.
As elderly patients present with a complex medical history, with many factors to be taken into account when assessing their cardiovascular risk, decisions about therapy are somewhat more difficult compared to a younger patient. This doesn’t mean that we don’t treat to the same targets – it just means we have a slightly more holistic approach. The vast majority of people are going to need a number of medications, and we would welcome the number of combination products that have entered the market. It cuts down on the overall number of pills a patient is taking.
The evidence for the link between hypertension and stroke is so emphatic. If we reduce blood pressure by 10mm of mercury, we reduce the risk of stroke by 40%.
For a lot of our patients presenting with strokes and transient ischaemic attacks (TIAs), the most important thing we can do for them after the initial investigations are completed, is aggressively manage their blood pressure.
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