Hypertension is highly prevalent in the elderly population. The risk of hypertension increases dramatically with age, with over 90% of people over 70 having hypertension. In the elderly, hypertension is characterized by an elevated systolic blood pressure with a normal or low diastolic blood pressure due to arterial stiffening caused by reduced elasticity of arteries with age. Multiple changes occur in the arteries with aging that result in increased systolic blood pressure and decreased diastolic blood pressure. Hypertension is the most important modifiable risk factor for cardiovascular disease in the elderly. Lifestyle modifications and medication are effective for treating hypertension in the elderly, with the goal of reducing blood pressure and cardiovascular risk.

1. HYPERTENSION IN ELDERY
PRESENTED BY--
DR MANINDERPAL SINGH
Junior Resident 1
GEN MEDICINE

2. DEFINATION
• Hypertension is defined as the presence of a
blood pressure elevation to a level that places
patients at increased risk for target organ
damage in several vascular beds including the
retina, brain , heart, kidneys and large conduit
arteries .

3. BLOOD PRESSURE CLASSIFICATIONS IN ADULTS
BLOOD PRESSURE
CATEGORY
SYSTOLIC (MMHG) DIASTOLIC (MMHG )
NORMAL <120 and <80
ELEVATED 120-129 And <80
HYPERTENSION
STAGE 1 130-139 OR 80-89
STAGE 2 >=140 OR >90
SOURCE , 2017 ACC/ AHA

4. • There is a dramatic increase in the
prevalence of hypertension with
aging ; by age 70 years, the majority
of people have hypertension .

5. EPIDEMIOLGY OF HYPERTENSION AND
AGING
• Without treatment , approximately 40% of adults
have hypertension
• HTN prevalence increases markedly with age
a) By 60 years ~ 65 % have HTN
b) By 70 years ~ 90 % have HTN ( ISH)
• In Framingham Study , HTN eventually developed in >
90% of people with normal BP at age of 55 years .

6. Recent NHANES findings

8. • In older adults , hypertension is
characterised by an elevated systolic
blood pressure with normal or low
diastolic BP , due to age associated
stiffening of the large arteries .

9. JOINT INFLUENCES OF SBP AND PULSE
PRESSURE ON CORONARY HEART DISEASE
Thus pulse pressure is the most important predictor of cardiovascular risk in the
elderly

10. PATHOPHYSIOLOGY OF HYPERTENSION IN THE
ELDERLY
• Multiple changes occur in arterial media with
aging , including reduced elastin content with
increase in non distensible collagen and calcium (
eg arterial stiffening )
• Age associated arterial stiffening results in a
gradual increase in systolic BP and a decrease in
diastolic BP
• Flow – mediated arterial dilation , primarily
mediated by endothelium derived nitric oxide,
declines markedly with aging

11. PATHOPHYSIOLOGY CONTINUES
 The changes in the vessel wall results in increased
pulse wave velocity , early return of reflected waves
from the periphery and altered contour of the pulse
waveform .
 The net effect is an elevated SBP and augmentation
index .
 DBP is also reduced due to reduced elastic recoil of stiff
arteries .
 The changes in SBP and DBP are clearly responsible for
the increased afterload , wall tension of the left
ventricle, reduced coronary perfusion pressure ,
diastolic dysfunction and left atrial enlargement

12. PATHOPHYSIOLOGY CONTINUES………
• Neurohormonal profile of older hypertensive
adults characterized by increased plasma
norepinephrine , low renin , and low
aldosterone levels
• Many so called normal aging changes in
arterial structures and function are blunted /
absent in population not chronically exposed
to high sodium/high calorie diets, low physical
activity levels , and high rates of obesity

13. Hypertension as a Risk Factor in the
Elderly
• In older adults , Hypertension is the most
prevalent modifiable CV risk factor: antecedent
HTN is estimated in :
 ~ 70 % of patients with incident myocardial
infarction
 ~ 77 % of patients with incident strokes
 ~ 74 % with chronic Heart Failure
 ~ 90 % with acute aortic syndrome
 ~ 30 % to 40 % with atrial fibrillation

14. Hypertension continues….
• HTN is also a major risk factor for conditions
directly influencing CV risk in the elderly
a) Diabetes
b) Metabolic Syndrome
c) Chronic kidney disease

15. Failure to control BP with combination of 3 or
more drugs including diuretics with adequate
dose and duration
• Unsuspected secondary cause
• Poor adherance to therapeutic plan
• Failure to modify lifestyle
• Volume overload – inadequate diuretic therapy,
progressive renal failure, high sodium intake
• Whitecoat hypertension
• Small cuff on large arm
• Too early measure after nicotine or caffiene intake
Refractory Hypertension
Reason ?

16. Hypertensive crisis
• Hypertensive emergency – critical elevation of blood
pressure (SBP >=140mmhg & DBP >=90 mmhg) associated
with features of acute or ongoing TOD as evident clinically
or by laboratory findings( Acute LVF, ARF,Encepahopathy )
• Hypertensive urgency – DBP >= 120mmhg & No features
of TOD
• Accelerated hypertension- High BP (SBP>= 140mmhg &
DBP >= 90mmhg ) with vascular damage ( retinal
hemorrhages & Exudates )
• Malignant hypertension – High BP ( SBP>=140 mmhg &
DBP >=90MMHG) with features of papilledema

17. Steps in clinical evaluation of
hypertension
• Duration and severity of elevated BP
• History of prior medications and antihypertenssive
medication use
• Use of tobacco , alcohol
• Risk factors for CAD
• Family history of hypertension, Diabetes, CVD
• Psychosocial history ( presence of stress, insomnia )
• Dietary habbits, physical activity and weight changes in
the recent past
• Features of TOD

18. Some features suggestive of secondary
HTN should be specially looked for
• Abrupt onset of hypertension
• Sudden worsening of previously well
controlled BP
• Refractory hypertension
• Episodes of hypertensive criris
• Specific symptoms and signs related to the
cause of HTN ( eg , azotemia in renal
parenchymal disease )

19. Extent of Awareness, Treatment and Control of
High Blood Pressure by Age
BP Control Rates remain suboptimal in the elderly

20. Routine Tests recommended for the
initial evaluation of a hypertensive
patient
• Serum chemistry
• glucose
• potassium
• creatinine
• sodium
• Serum Total and HDL Cholesterol
• Urinalysis
• Electrocardiogram , CBC

21. Other investigations
• Chest radiography – cardiomegaly, heart failure, CoA
• Ambulatory BP recording – to assess border line or
whitecoat HTN
• Echocardiogram – to detect or quantify LVH
• Renal ultrasound – to detect possible renal disease
• Renal angiography – to detect or confirm presence of
renal artery stenosis
• Urinary cortisol and dexamethasone suppression test – to
detect possible Cushing’s syndrome
• Plasma renin activity and aldosterone – to detect
possible primary aldosteronism

22. Lifestyle modifications that lower blood pressure
Primary lifestyle modification
 Reduction of body weight (10 kg reduces BP ~ 10/8 mmHg)
 Reduction in dietary salt consumption ( target 100 mmol/day, can
lower BP ~ 12/10 mmHg, but individual responses vary)
 Increase physical activity to 30 – 45 mins, 4 times a week ( can lower
BP 8/4 mmHg and often helps control weight)
 Increase consumption of fruits and vegetables (at least 4
servings/day, can lower BP 6/3 mmHg and often helps reduce salt
consumption)
 Moderation of alcohol consumption (target 10 -20 g ethanol for
women, 20 – 30 g for men, can lower BP up to 8/4 mmHg in those
who have more than 5 drinks/ day)
 Stress management (randomized clinical trials outside the workplace
have been unconvincing, but many psychologists still recommend
the approach despite a lack of detailed protocols that uniformely
lower BP)

23. Other lifestyle modifications that are routinely
recommended
• Tobacco avoidance (lowers cardiovascular risk
independently of any effect on BP)
• Fish consumption (improves lipid profiles and
cardiovascular risk more than expected if BP effects alone is
operative)
• Increasing dietary fibre (improves lipid profiles and cancer
risk independently of effect on BP)
• DASH (Dietry Approach to Stop Hypertension) Diet:-
• Potassium Rich fruits, Low salt and total fat, Increased
vegetable and fruits, and low Dairy Products.

24. Randomized Hypertension in the Very
Elderly Trail ( HYVET )
• In 3845 patients , > 80 years old with SBP>= 160
MMHG, AT 1.8 Year follow up, those randomized
to indapamide vs placebo had :
a) 30% non significant decrease in fatal/nonfatal
stroke
b) 39% significant decrease in fatal stroke
c) 21% significant decrease in all cause mortality
d) 23 % insignificant decrease in CV death
e) 64% significant decrease in heart failure

25. Pharmacological Management
It is based on the same principles as for younger
people with minor differences -
• The elderly have reduced body mass, reduced liver
and kidney mass. Absorption capacity is reduced
hence the pharmacokinetics of drugs are altered
• Some of the drugs commonly prescribed in the
elderly increases BP and interfere with
antihypertensive therapy. These are
corticosteroids, anabolic steroids, NSAIDS, and
erythropoietin
• All the drug classes have similar BP lowering
efficacy and CV risk reduction is largely due to BP
lowering and not due to any individual drug effect .

26. • If there are no compelling indications , start with a low
dose of any drug ( preferably a thiazide type diuretic ) .
Add a second drug if Goal BP is not achieved inspite of
maximally tolerated dose. Similarly , add a third drug
and assess for secondary hypertension if desired
response in not obtained .
• Thiazide type diuretics and dihydropyridine CCBs are
the most studied drugs in the geriatric population.
• In the presence of compelling indications, start with
drug class shown to have maximal benefit .
• Check regularly for compliance , postural hypotension
and side effects of drugs .

27. Key Message
1. Aging is associated with increased stiffness of vessels and
very high prevalence of hypertension. The prevalence is
also influneced by dietary factors( salt intake ) and other
poorly understood influences( hormonal influences )
2. All forms of hypertension are common in the elderly ;
though ISH is the commonest
3. There are no clear guidelines on different risk profile older
people, practical defination of hyperetnsion and goal BP
to be achived . Currently , 140/90mmhg is the diagnostic
threshold and also the goal BP for people in the age group
of 60-79 years of age . For octogenarians and beyond,
based on the data available, a diagnostic threshold of
160mmhg seems reasonable and a goal BP in the range of
140-145 mmhg is a reasonable target if tolerated well .

28. 4 In older people , there is no data to support the
lower BP targets in the presence of DIABETES ,
CKD &CVD
5 There is a need to identify which drugs are most
suitable and well tolerated by the elderly and
also most effective in reducing CV risk
6 Drug compliance is poor in this group because of
cost, cognitive impairment , multiple drug intake
for co-morbidities etc . Emphasis should be on
using low cost combinations

29. 7 Fundamental research should focus on
understanding the pathophysiology of
vascular stiffness to develop methods to
reverse and prevent it
8 There is a need to generate data on local
populations, specially in our country , in
different age sections within the elderly and
with different co-morbidities

30. THANK YOU