Management of hypertension in elderly person.

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HYPERTENSION IN OCTAGENERIAN AND BEYOND.

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  • Elderly > 65 yrs
  • Management of hypertension in elderly person.

    1. 1. PRESENTATION 81-YEAR-OLD FEMALE NON-SMOKER-DIAGNOSED WITH STAGE 2 HYPERTENSION, BY ANOTHER PRACTIONER 1 MONTH AGO AND ABPM DONE HER CLINIC BLOOD PRESSURE WAS 174/102 mmHG AND HER ABPM AVERAGE WAS 170/100 mmHG CUT OFF FOR ABPM?MEDICAL HISTORY NO SIGNIFICANT MEDICAL HISTORY. NON-DIABETIC
    2. 2. POINTS TO PONDER OVER… WHAT TESTS TO ORDER NOW? WHAT IS INITIAL TREATMENT? WHAT IS THE CV RISK? WHAT IS THE DIFFERENCE IN YOUNG AND ELDERLY IN HTN TREATMENT?
    3. 3. QUESTIONWHAT TESTS YOU ORDER NOW? WHAT IS INITIALTREATMENT? APPROPRIATE TESTS FOR TARGET ORGAN DAMAGE AND CARDIOVASCULAR RISK ASSESSMENT GIVEN HER AGE, SHE WILL SCORE VERY HIGHLY IN ALL CARDIOVASCULAR RISK ASSESSMENTS INITIAL APPROPRIATE TREATMENT IS WITH A CALCIUM-CHANNEL BLOCKER
    4. 4. • Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55—80 years, taking into account any comorbidities. [New 2011]
    5. 5. RECOMMENDATIONS1. OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO PEOPLE AGED UNDER 80 YEARS WITH STAGE 1 HYPERTENSION WHO HAVE ONE OR MORE OF THE FOLLOWING: TARGET ORGAN DAMAGE ESTABLISHED CARDIOVASCULAR DISEASE RENAL DISEASE DIABETES A 10-YEAR CARDIOVASCULAR RISK EQUIVALENT TO 20% OR GREATER. [NEW 2011]2.OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO PEOPLE OF ANY AGE WITH STAGE 2 HYPERTENSION. [NEW 2011]
    6. 6. RECOMMENDATIONS Use clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modifications or drugs. [New 2011]
    7. 7. WHAT DRUG/S IF HEART FAILURE + If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [New 2011]
    8. 8.  If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5—25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [New 2011]
    9. 9.  ONE MONTH LATER Patient’s total cholesterol is 148 mg/dland her HDL is 50 mg/dl.Glucose is normal. There is no left ventricular hypertrophy or atrial fibrillation on ECG. Her 10-year cardiovascular risk is 27%.(Using QRISK2) You measure her clinic blood pressure and it is 165/100 mmhg. What would you do next?
    10. 10.  BLOOD PRESSURE IS NOT CONTROLLED. CHECK ADHERENCE WITH STEP 1 TREATMENT. IDENTIFY IF YOU CAN HELP ENHANCE ADHERENCE - MODIFY DOSING REGIMEN, - PROVIDE A RECORD FOR HER TO MONITOR HER MEDICINE TAKING).
    11. 11.  Aim for a target clinic blood pressure below 150/90 mmhg in people aged 80 years and over, with treated hypertension. [New 2011]
    12. 12.  IF BLOOD PRESSURE IS NOT CONTROLLED BY STEP 1 TREATMENT, OFFER STEP 2 TREATMENT WITH A CCB IN COMBINATION WITH EITHER AN ACE INHIBITOR OR AN ARB. [NEW 2011]
    13. 13.  SHE RETURNS TO THE CLINIC AFTER A MONTH. HER CLINIC BLOOD PRESSURE IS 154/90 mmHG. WHAT NEXT?
    14. 14.  Review her antihypertensive medications and ensure optimal or best tolerated dose. Ensure adherence to the drug regimen and review any factors that may reduce her compliance A blood test to check her electrolytes around 2 weeks after starting the ace inhibitor and to return to the clinician after 1 month Follow the results of the electrolyte test and a further review of her blood pressure.
    15. 15. USEFUL INTERVENTIONS RECORDING THE MEDICINE-TAKING BY PATIENT ENCOURAGING PATIENTS TO MONITOR THEIR CONDITION SIMPLIFYING THE DOSING REGIMEN USING ALTERNATIVE PACKAGING USING A MULTI-COMPARTMENT MEDICINES SYSTEM.
    16. 16. 3 MONTHS LATER CLINIC APPOINTMENT BLOOD PRESSURE IS 145/85 MMHG. AN ACCEPTABLE BLOOD PRESSURE FOR A PERSON OVER 80. SHE CAN STAY ON CURRENT TREATMENT.
    17. 17. RECOMMENDATIONS AIM FOR A TARGET CLINIC BLOOD PRESSURE BELOW 150/90 MMHG IN PEOPLE AGED 80 YEARS AND OVER, WITH TREATED HYPERTENSION. [NEW 2011] BEFORE CONSIDERING STEP 3 TREATMENT, REVIEW MEDICATION TO ENSURE STEP 2 TREATMENT IS AT OPTIMAL OR BEST TOLERATED DOSES. [NEW 2011] USE INTERVENTIONS TO OVERCOME PRACTICAL PROBLEMS ASSOCIATED WITH NON-ADHERENCE IF A SPECIFIC NEED IS IDENTIFIED.
    18. 18. < 79 yrs, achieved SBP values <140 mm Hg are appropriate goals>80 yrs, 140 to 145 mm Hg, if tolerated, can be acceptable.SBP <130 and DBP <65 mm Hg should be avoidedLow-dose thiazides, CAs, and RAAS blockers are preferred,.

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