EYE ON THE ELDERLY—Hypertension care: Striking the proper balance
How aggressive should treatment be? Which drug combinations should raise red flags? Which drugs should you avoid entirely? Here’s how to safely customize your care.
- healthy diet (such as Dietary Approaches to Stop Hypertension [DASH])
- sodium restriction (daily intake of <100 mmol/d)
- limited alcohol intake
- weight reduction (a decrease of 5-20 mm Hg for every 10 kg weight loss has been reported)
- regular physical activity (reported decrease of 4-9 mm Hg).2
No long-term trials have assessed the effects of lifestyle modification on morbidity and mortality. A subset of patients in the original DASH trial with stage 1 systolic hypertension did benefit from the diet, but the subgroup was small and the median age was 54.7 years.22 No large-scale studies have addressed the effectiveness of the diet in older patients with systolic hypertension.
Customizing therapy: What to consider
Evidence supports the use of various classes of antihypertensive medications in the treatment of high blood pressure, including thiazide diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs).10,23-27 JNC 7 recommends starting with 1 medication for patients with stage 1 hypertension (140-159/90-99 mm Hg) and 2 medications for patients with stage 2 hypertension (≥160/100 mm Hg).2 As previously noted, however, clear-cut evidence in support of treating elderly patients with stage 1 hypertension is lacking.
When you do initiate treatment for an elderly patient, begin with a low dose and titrate slowly, carefully monitoring for side effects. If 2 antihypertensive agents are needed, start 1 agent at a time in patients who are at risk for significant side effects. The type of antihypertensive agent you prescribe should be based on your patient’s health status, comorbidities, and treatment for other conditions, as well as on the known effects of the particular class of drugs (TABLE).
Thiazide diuretics. JNC 7 recommends thiazide diuretics as first-line treatment based on cost and effectiveness. Because thiazide diuretics decrease the urinary excretion of calcium, JNC 7 recommends their use in patients with osteoporosis.2
But potential side effects, such as dehydration, orthostatic hypotension, and hypokalemia, are more common in elderly patients, and may limit the use of these drugs in clinical practice. NSAIDs may reduce the antihypertensive effects of thiazide diuretics through a decrease in sodium excretion and an increase in plasma volume, and should be used with caution—if at all—in this patient population.20
Hydrochlorothiazide, a commonly used thiazide diuretic, should not be used in doses >50 mg/d because higher doses increase the risk of side effects without increasing efficacy.28 In the Systolic Hypertension in the Elderly Program (SHEP) study, the positive effects of another thiazide diuretic—chlorthalidone—were lost in elderly patients with serum potassium <3.5 mmol/L, so serum electrolytes should be routinely assessed during therapy.2,7 Thiazide diuretics lose their effectiveness in patients with a glomerular filtration rate of <30 mL/min/1.73 m2 and should not be used in this group.29
Beta-blockers. Beta-blockers are indicated in patients with a previous history of myocardial infarction, as they have been shown to decrease the rate of new coronary events.30 Other comorbidities that may be mitigated by beta-blocker administration include angina pectoris, atrial fibrillation with a rapid ventricular rate, compensated heart failure, preoperative hypertension, and essential tremor.2
Side effects of beta-blockers include sedation, depression, sexual dysfunction, bradycardia, conduction abnormalities, and exacerbation of severe reactive airway disease.2 Central nervous system effects of beta-blockers tend to be lowest in hydrophilic agents, such as atenolol, and highest in lipophilic agents, such as propranolol, which readily cross the blood-brain barrier.31
A 2007 Cochrane review looked at the effectiveness of beta-blockers as first-line agents in uncomplicated hypertension and concluded that the evidence does not support their use. The reviewers noted, however, that the majority of the trials used atenolol and cautioned that the results might not apply to other beta-blockers—or to subgroups, such as the elderly.32
ACE inhibitors and ARBs. Both ACE inhibitors and ARBs inhibit the renin-angiotensin-aldosterone pathway, and both classes are indicated in patients with diabetes, chronic kidney disease, or heart failure.2 Cough is a side effect of ACE inhibitors that affects 5% to 35% of patients,33 but angioedema—estimated to occur in 0.1% to 0.7% of patients taking ACE inhibitors—is the most serious side effect.34
An elevation in serum potassium and serum creatinine may occur after starting an ACE inhibitor in patients with heart failure, dehydration, or significant renal insufficiency, so assess serum creatinine and potassium 1 week after initiating therapy. An increase in serum creatinine >30% may require discontinuation or dose reduction.2,35
