Older patients may have difficulty complying with dietary salt restriction for two reasons: ●They may ingest more salt to compensate for a decrease in taste sensitivity ●They may depend more upon processed, prepackaged foods that are high in sodium rather than fresh foods that are low in sodium
بيجيلهم كسر حوض لسقوطهم ونقيس الضغط في الوضع قائما لو نزل اقل 20 سيستوليك او 10 دياستوليك او حصل دوخة
HTN guidelines For Elderly and whom with Renal impairement
HTN Guidelines For
Elderly and whom
Dr. Mohamed Kharabish
ICU Senior Registrar
Definition of HTN
•Hypertension is defined as a systolic
blood pressure (SBP) of 140 mm Hg or
more, or a diastolic blood pressure (DBP)
of 90 mm Hg or more, or taking
antihypertensive medication (Roger et al.,2012).
Classification of Blood
Based on recommendations of the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7), the classification of BP for adults aged 18 years or older has
been as follows:
→ Normal: Systolic lower than 120 mmHg, diastolic lower than 80
→ Prehypertension: Systolic 120-139 mmHg, diastolic 80-89 mmHg
→ Stage 1: Systolic 140-159 mmHg, diastolic 90-99 mmHg
→ Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm (Chobanian et
al.,2003). Hg or greater
Hints About Mechanism
Aging with decreased compliance in intima and media of
Also increased collagen rigidity↑sclerosis and fibrosis of
* The renin- aldosterone -angiotensin system becomes ↓↓↓ less
responsive with aging, partially as a result of reduced activity of the
sympathetic nervous system; plasma renin activity, angiotensin II
and aldosterone levels↓↓↓ decrease.
Hints About Mechanism
*Geriatric hypertension is generally of a salt-sensitive nature
with ↓↓reduced ability to appropriately excrete a salt load.
*Decline in renal function and to a reduced generation of
natriuretic substances, such as prostaglandin E2 and
*Age-associated declines ↓↓ in the activity of membrane
sodium/potassium-adenosine triphosphatase (Na+-K+-
ATPase) may also contribute to geriatric hypertension
because this results in increased intracellular ↑↑ sodium
that may cause reduced sodium-calcium exchange and
thereby ↑↑↑↑ increase intracellular calcium and↑↑
related to HTN
• Is generally of a salt-sensitive nature.
• Aging is often associated with impaired baroreflex function.
• Be careful of white coat HTN (excited with increase of cardiac
output with non compliant arteries).
• Measure both sides take average of 3 readings in same visit.
• relative increase in systolic HTN.
• increase in pulse pressure (syst – Diast).
systolic and diastolic pulse pressure matter.
Non pharmacological therapy.
Specially among older persons, SBP is
better predictor of events (coronary
heart disease, cardiovascular disease,
heart failure, stroke, end-stage renal
disease, and all-cause mortality) than is
The goal of treatment in older patients
should be the same as in younger
patients (to below 140/90 mmHg if at
all possible), although an interim goal
of SBP below 160 mmHg may be
necessary in those patients with
marked systolic hypertension.
If goal blood pressure is not
attained with lifestyle
therapy should be initiated
Be careful in
pharmacological ttt of
• start with lower initial dose one half than younger
• lower Bp gradually in absence of emergencies.
• Orthostatic and postprandial hypotension
How to detect
Beta blockers — There is evidence that,
in the absence of a specific indication
for their use (e.g. heart failure,
myocardial infarction), beta blockers
should not be considered for primary
In general, three classes of drugs are
considered first-line therapy for the treatment
of hypertension in elderly patients: low-dose
thiazide diuretics (eg, 12.5 to
25 mg/day of chlorthalidone), long-acting
calcium channel blockers (most often
dihydropyridines), and ACE inhibitors or ARBs. A
long-acting dihydropyridine or a thiazide
diuretic is generally preferred in elderly patients
because of increased efficacy in blood pressure
• Diastolic blood pressure lowering should not be less than
60 mm Hg
The guidelines define CKD as either
kidney damage or
a decreased glomerular filtration rate (GFR) of less
than 60 mL/min/1.73 m2 for at least 3 months.
Whatever the underlying etiology, once the loss of
nephrons and reduction of functional renal mass
reaches a certain point, the remaining nephrons
begin a process of irreversible sclerosis that leads to a
progressive decline in the GFR.
Renal mass progressively declines↓↓↓ with
advancing age, and glomerulosclerosis leads
to a decrease ↓ in renal weight. Histologic
examination is notable for a decrease in
glomerular number of as much as 30-50% by
age 70 years.
The GFR peaks during the third decade
of life at approximately 120
mL/min/1.73 m2; it then undergoes
an annual mean decline of
approximately 1 mL/min/y/1.73 m2,
reaching a mean value of 70
mL/min/1.73 m2 at age 70 years.
Goal of therapy
Patients with nondiabetic and diabetic CKD should have a target
BP goal of <130/80 mmHg. Ultimately, the rationale for lowering
BP in all patients with CKD is to reduce both renal and
cardiovascular morbidity and mortality. Maintaining BP
control and minimizing proteinuria in
patients with CKD and HTN is essential for the prevention of the
progression of kidney disease and the development or worsening
Recent literature suggests that BP targets in diabetic and
nondiabetic CKD may need to be individualized based on the
presence of proteinuria.