Treatment of High Blood Pressure in the Elderly
Despite abundant evidence that elevated blood pressure is a major risk factor for heart and blood vessel disease in the elderly, and that lowering blood pressure prevents strokes, heart attacks, and heart failure, fewer than 25% of individuals with hypertension > 65 years old are being treated effectively. It is the position of the Society of Geriatric Cardiology that a major new effort is needed to increase the percentage of older individuals who are receiving appropriate treatment for high blood pressure.
Elevated Blood Pressure As a Risk Factor
Hypertension, the medical term for high blood pressure, has been identified as a major risk factor contributing to increased disability and death from heart and blood vessel diseases, including strokes, in the elderly population. Elevated blood pressure, defined as systolic blood pressure >140 mm Hg (pressure in the arteries when the heart is pumping-the upper reading), or a diastolic level < 90 mm Hg (pressure when the heart is resting between beats-the lower reading), occurs in approximately 60%-70% of all individuals > 65 years old in the U.S.
Long term studies have shown that the risk for heart attacks, strokes, and kidney failure is increased by levels of blood pressure that were once considered "normal" for older individuals. Risk correlates better with systolic blood pressure than with diastolic blood pressure. The old adage that it is "normal" for systolic blood pressure to increase with age has been abandoned. A systolic blood pressure > 140 mm Hg leads to an increased risk of cardiovascular disease, regardless of age, even if the diastolic pressure is < 90 mm Hg.
Beneficial Effects of Treatment
During the past 15-20 years, several carefully controlled long term studies in the elderly have shown that lowering blood pressure with medication reduces the number of both fatal and nonfatal strokes and heart attacks. Progression from less severe to more severe hypertension, enlargement of the heart, and heart failure are also prevented. The benefits of lowering blood pressure have been demonstrated in patients with all levels of hypertension, in both men and women, African-Americans and whites, and in people up to and including those 80 years old.
Approach to Treatment
At least two or three blood pressure readings should be taken at different times to establish a diagnosis of hypertension. Reduction in salt intake, moderation in the use of alcohol, weight reduction if appropriate, and moderate exercise are encouraged. Smoking should be avoided because it increases the risk of heart attacks, strokes, and cancer at all ages. If these lifestyle modifications do not lower blood pressure to a desirable level within 3-4 months, i.e., <140/90 mm Hg, specific blood pressure lowering medication should be given.
Even as late as the 1970s, many physicians believed that hypertension in older individuals should only be treated if the blood pressure was extremely high, i.e., >200 mm Hg systolic or 110 mm Hg diastolic, in part because of the danger of serious reactions to medication. These fears have proven to be unfounded. There are now numerous safe and effective blood pressure medications available. It has been shown that the majority of older patients adhere and respond to treatment as well as or better than younger patients. In general, medication should be started at a low dose with gradual increases in dosage if necessary. Treatment does not usually result in significant adverse effects. Some elderly patients, however, may experience dizziness, fatigue, or other symptoms, and some may not tolerate large decreases in blood pressure. In these individuals, the lowest level of blood pressure that can be achieved without symptoms should be the goal of therapy, since even a slight decrease in systolic blood pressure is likely to be beneficial.
There is good scientific evidence that:
1. High blood pressure poses an even greater risk for heart disease and strokes in the elderly patient than in the young or middle aged.
2. Studies carried out in the U.S., Europe, and Australia have clearly demonstrated that lowering blood pressure with medication in the elderly prolongs life and decreases strokes, stroke deaths, heart attacks, heart attack deaths, and heart failure.
3. In general, most elderly patients can take blood pressure lowering medication without significant or serious side effects if it is properly prescribed.
4. Despite numerous scientific studies demonstrating the benefits of treatment, fewer than 25% of older individuals with high blood pressure are being treated effectively.
Based on Available Evidence, the Society of Geriatric Cardiology Recommends that:
1. Individuals >65 years old have their blood pressure checked regularly (at least twice a year).
2. Individuals of all ages limit salt and alcohol consumption, exercise regularly, maintain a desirable weight, and avoid smoking.
3. Individuals >65 years old with high blood pressure should play an active role in their treatment by modifying their lifestyle, taking their medication as prescribed, and discussing other treatment options with their doctor if their blood pressure is not adequately controlled.