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Hypertension in Older Adults
An interview with Scott W. Bragg, PharmD, BCPS, South Carolina College of Pharmacy,
Charleston, SC.
Heart disease currently is the leading cause of death in the United States.1 This significant cause of mortality is due in no small part to the vast number of individuals who currently live with high blood pressure, also known as hypertension. Hypertension is a common and dangerous condition. Blood pressure naturally rises and falls throughout the day, often as a result of stress or exercise, but more serious health problems can occur when blood pressure remains high rather than returning to normal levels.2 Currently, 1 in 3 Americans—about 70 million people—has high blood pressure.3 However, many are entirely unaware of their condition, because high blood pressure usually presents with few or no symptoms, making it very difficult to notice and giving it the ominous moniker “the silent killer.”3
In addition to heart disease, hypertension can also lead to adverse health events including stroke, eye problems such as vision loss, and kidney failure. These can be particularly problematic in the approximately half of individuals with high blood pressure who do not have the condition under control.3 Health care providers should regularly consult with their patients to ensure that they understand their blood pressure levels and to discuss whether they need to take action to change their lifestyle and improve health outcomes.
High blood pressure is particularly dangerous for older adults. A 2012 study reported that hypertension, while already common in the general population, has a prevalence of ~66% in those 65 years of age and older.4 Older adults are more at risk of developing hypertension due to more sedentary lifestyles and a greater sensitivity to salt intake than younger adults.4
Numerous studies have been conducted to evaluate methods of controlling hypertension in older adults. A study from 2004 found that reducing sodium intake in older adults could help to improve arterial function in patients with systolic hypertension.5 More recent studies have begun using large data sets to map specific evidence-based methods for delivering the best possible care.6 This method and others seem to be paying dividends, as the number of deaths due to heart disease have fallen in recent years.7 Expanding treatment also contributed to improved outcomes. A 2013 study found that more than 70% of patients are receiving treatment for their high blood pressure,8 an increase from 51.1% of patients reported to be receiving treatment in a 1999 study.9
New findings may also help to fundamentally change and improve the way hypertension is treated in the United States. In analyzing adults over the age of 50, researchers with the National Heart, Lung and Blood Institute recently reported that the guidelines currently in use for measuring blood pressure may actually be outdated and that target blood pressure levels should be much lower than originally believed. Participants who were treated to a blood pressure goal of <120 mmHg versus <140 mmHg saw a 25% reduction in the primary endpoint, a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes.10
To gain a better clinical understanding of hypertension in older adults, Annals of Long-Term Care: Clinical Care and Aging spoke with Scott W. Bragg, PharmD, BCPS, Assistant Professor at the South Carolina College of Pharmacy.
Can you briefly tell us why hypertension is a more serious issue in older adults than in other demographic groups?
The incidence of hypertension, defined as blood pressure ≥140/90 mmHg, dramatically increases as we age. It is estimated that 75% of adults ≥70 years old are affected.11 In contrast, among adults <60 years old, only around 25% are affected.12 Hypertension is a key driver of heart attack and stroke—two of the most common causes of death in the United States.
If left untreated, what effects can this condition have on the patient?
Hypertension is known as the silent killer because few people have any symptoms with elevated blood pressures. However, people with chronically high blood pressure have a much higher rate of heart attack, stroke, chronic kidney disease, heart failure, cardiac arrhythmia, cognitive impairment, and premature death. These risks are particularly prevalent with significantly elevated pressures ≥160/100 mmHg.
What are some treatments, pharmaceutical and otherwise, a clinician can suggest after hypertension becomes apparent in a patient?
Several non-medication treatment options can significantly lower blood pressure and are reasonable strategies to try prior to starting medications or with medications. Losing weight, if overweight or obese, is one of the most helpful strategies and will help lower blood pressures approximately 1 mmHg for every 2.2 pounds lost. Patients should always try to stop smoking, because smoking elevates blood pressures and independently can cause premature death. Also, some may consider moderate alcohol intake of 1–2 drinks per day provided a patient doesn’t suffer from alcohol abuse/misuse. Lastly, the DASH diet helps many people lower blood pressures and consists of a diet high in dietary fiber, fruits, and vegetables; moderate in total fat and protein; and low in saturated fat, sodium, and cholesterol. Sodium restriction should be limited to <2300 mg/day.11
Several first line medications exist for treating hypertension as well, although it is hard to predict which medication will be most effective and have the fewest number of side effects. Experienced providers should choose a particular medicine based on good medical evidence for reducing heart attacks and strokes, patients’ comorbidities, potential medication side effects, cost considerations, and medication compliance. Some of the recommended first line medications include angiotensin-converting enzyme inhibitors (ACE inhibitors) such as lisinopril or benazepril, calcium channel blockers like amlodipine, and thiazide-like diuretics such as chlorthalidone or indapamide.11
Are there any risks involved in treating older adults for hypertension?
Yes, there are risks when treating older adults for hypertension with medications, but these are generally considered manageable by most patients. Older adults are at an increased risk of orthostatic hypotension, which is a dangerous drop in blood pressure that happens after a sudden positional shift from supine to standing position and can lead to syncope, falls, or other injury.4 A few of the more common reactions to hypertension medications include electrolyte abnormalities, such as changes in blood potassium and sodium, cough, constipation, and minor swelling. Rarely, more serious allergic reactions may occur and symptoms include shortness of breath, hives, and throat or face swelling.
Are there steps that the patient can take to reduce risk and increase quality of life?
Patients can reduce their risk of strokes, heart attacks, premature death, and other major problems by making the aforementioned lifestyle changes and by maintaining good medication adherence. Additionally, regular blood pressure monitoring to attain specific blood pressure goals, depending on the patient’s age, will help maximize benefit and minimize harm. Other strategies to minimize harm from medications include regular office visits, physical exams, and laboratory monitoring.
What preexisting conditions can increase an individual’s risk of developing hypertension?
Several preexisting conditions may increase a patient’s risk of hypertension. Common conditions include renal disease, thyroid disease, obesity, and obstructive sleep apnea. A few less common causes include Cushing disease, primary hyperaldosteronism, and pheochromocytoma.
Is there anything that long-term care facilities can do to try to lower the prevalence of hypertension among their residents?
Regular monitoring, routine physical activity, good medication compliance, and a healthy diet are the most important factors that long-term care facilities can focus on to reduce the morbidity associated with hypertension. These are all factors that should be addressed systematically by facilities. Unfortunately, with the progressive nature of hypertension as we age, it is difficult to reduce the prevalence, but we can dramatically reduce the risk of heart attacks, strokes, premature deaths, and other adverse events.
1. Leading Causes of Death. Centers for Disease Control and Prevention Website. http://1.usa.gov/1wNuvIL. Updated January 20, 2015. Accessed November 17, 2015.
2. PubMed Health. U.S. National Library of Medicine Website. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0041082/#conssmbp.s3. Published February 22, 2012. Accessed November 17, 2015.
3. High Blood Pressure. Centers for Disease Control and Prevention Website. http://www.cdc.gov/bloodpressure/. Updated February 19, 2015. Accessed November 17, 2015.
4. Nguyen QT, Anderson SR, Sanders L, Nguyen LD. Managing hypertension in the elderly: a common chronic disease with increasing age. Am Health Drug Benefits. 2015;5(3):146-153.
5. Gates PE, Tanaka H, Hiatt WR, Seals DR. Dietary sodium restriction rapidly improves large elastic artery compliance in older adults with systolic hypertension. Hypertension. 2004;44(1):35 41.
6. Go AS, Bauman MA, Colman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol. 2014;63(12):1230-1238.
7. Hoyert DL. 75 years of mortality in the United States, 1935-2010. NCHS Data Brief. 2012(88):1-8.
8. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245.
9. Psaty BM, Manolio TA, Smith NL, et al. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the Cardiovascular Health Study. Arch Intern Med. 2002;162(20):2325-2332.
10. Landmark NIH study shows intensive blood pressure management may save lives [press release]. NIH website. http://1.usa.gov/1OGHUL9. 2015. Accessed November 17, 2015.
11. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
12. Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA. 2005;294(4):466-472.
