Hypertension in the Elderly

Hasyim kasim
Division hypertension and renal
Department of internal medicine
Hasanuddin University
 INTRODUCTION
• Hypertension is considered the most frequent
chronic condition
• hypertension represents the most powerful
risk factor for cardiovascular death
• blood pressure (BP) rises normally with age,
• it is not a physiological phenomenon
• hypertension is not less harmful for elderly
than for young people
 ELDERLY

> 65 YEARS
POPULATION : Notice the increase in the
elderly population as the baby – boomers age
PERCENT ELDERLY BY AGE 2000 – 2030
IN AMERICA ( U.S. CENCUS 2000 )

25

20
> 65
15
> 75
10

5 > 80

0
2000 2015 2030
21,9% 25,2% 35,1%
 INDONESIAN ELDERLY POPULATION
( > 65 YEARS )
Ind. Cencus 1971, 1980, 1990, 1995 and 2000
10
9
8
7
6 4,75%
4,25%
5 3,88%
4 3,25% >65
2,51%
3 years
2
1
0
1971 1980 1990 1995 2000 Biro Pusat Statistik
Indonesia
 Aging is NOT a disease
Aging is a universal process.
Many elderly have arthritis, or
dementia, or hypertension
But not everyone gets the same disease
Disease is not a necessary part of aging
 Principal Effects of
Aging on the Cardiovascular System
• Increased arterial stiffness
• Increased myocardial stiffness
• Impaired β-adrenergic responsiveness
• Impaired endothelial function
• Reduced sinus node function
• Decreased baroreceptor responsiveness

• Net effect: Marked reduction in CV

reserve
Systolic BP rises continuously with age
Diastolic BP rises continuously until age 60-70
years
It falls thereafter as a consequence of
increased arterial stiffness

Systolic Hypertension
Pulse pressure increases continuously
with age

Smulyan H, Safar ME. Ann Intern Med. 2000;132:233-237.

 Framingham – Study
Blood pressure and age
160
Women
150 Men
Systolic BP
140
BP (mmHg)

130
120
90

80 Men
Diastolic BP Women

70
36 41 46 51 56 61 66 71 76 81 Years age
Kannel et al 1978
 SBP, But Not DBP, Increases
Throughout Life

Blood Pressure (mm Hg)

160 SBP
With age, SBP increases,

140
while DBP tends to decline
120
100
– SBP increases in linear fashion

80 DBP
– DBP rises less steeply, plateaus, and declines
60
slightly after the seventh decade
15–24 25–34 35–44 45–54 55–64 65–74 75–84
85–99
Age Group (y)

Galarza CR et al. Hypertension. 1997;30:809-816.

 Pathophysiologic changes associated
with hypertension in the elderly (1)
Hemodynamic alterations
Increased peripheral vascular resistance
Decreased cardiac output
Decreased heart rate
Changes in cardiovascular structure and function
Decrease in vascular compliance
Increase in media-lumen ratio
Decreased myocardial contractility
Left ventricular hypertrophy
Diastolic dysfunction
 Pathophysiologic changes associated
with hypertension in the elderly (2)
Impairment of renal function
Decreased renal perfusion
Reduced glomerular filtration rate
Neurohormonal alterations
Decreased plasma renin activity
Decreased baroreceptor sensitivity
Glucose intolerance
Increased plasma catecholamine levels (decreased
adrenoreceptor sensitivity)
 O L D P A R A D I G M
Normal systolic blood pressure for older persons
was “100 plus the person’s age”.
Isolated Systolic Hypertension : wide pulse
pressure hypertension
associated with normal or low DBP
 Development of aortic pressure abnormalities due to
age-related aortic stiffening

Smulyan H, Safar ME. Ann Intern Med. 2000;132:230.

 SBP-Associated Risks: MRFIT
SBP versus DBP in Risk of CHD Mortality

CHD Death Rate

100+ 160+
90–99
80–89 140–159
75–79 120–139 Systolic BP
Diastolic BP 70–74
<70 <120 (mm Hg)
(mm Hg)

Neaton JD et al. Arch Intern Med. 1992;152:56-64.

 HYPERTENSION
Classification of blood pressure levels:
(according to the British Hypertension Society)

Category Systolic blood pressure Diastolic blood pressure

Optimal < 120 < 80
Normal < 130 < 85
High normal 130-139 85-89
Hypertension
Grade I (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) ≥180 ≥110
Isolated systolic hypertension
Grade 1 140-149 < 90
Grade 2 ≥160 < 90
 The European Society of Hypertension
and European Society of Cardiology Hypertension
(ESH/ESC) Guidelines 2003
• Optimal <120/ <80
• Normal 120–129 /80–84
• High normal 130–139/ 85–89
• Grade 1 hypertension (mild) 140–159 /90–99
• Grade 2 hypertension (moderate) 160–179/
100–109
• Grade 3 hypertension (severe) ≥180 /≥110
• Isolated systolic hypertension ≥140/ <90
pathophysiological features of hypertension in the elderly
are rather different than in younger adults

in the elderly
• cardiac output,
• heart frequency,
• ejection volume,
• intravascular volume, renal flow, and
• renin activity are decreased.
 Factors Related to Antihypertensive Treatment in the
Elderly
Factors
• Decreased activity baroreceptors
• Cerebral self-regulation alteration
• Minor intravascular volume
• Sensivity to hypokalemia
• Minor renal and hepatic function
• Polypharmacy
• Central nervous system alteration
Complications
• Orthostatic hypotension
• Cerebral ischemia under
modest systemic BP decrease
• Orthostatic hypotension
Hypovolemia ,Hyponatremia
• Arrhythmia Muscular weakness
• Drug accumulation
• Drug interactions
• Depression Confusion
 "The Goal is to Get to Goal!”

-PLUS-
Hypertension
Diabetes or Renal Disease

< 140/90 mmHg < 130/80 mmHg

 Drug-Induced Hypertension: Prescription
Medications
• Steroids • Ketamine
• Estrogens • Desflurane
• NSAIDS • Carbamazepine
• Phenylpropanolamines • Bromocryptine
• Cyclosporine/tacrolimus • Metoclopramide
• Erythropoietin • Antidepressants
• Sibutramine – Venlafaxine
• Methylphenidate • Buspirone
• Ergotamine • Clonidine
Drug-Induced Hypertension: Street Drugs
and Herbal Products
• Cocaine
• Ma huang “herbal ecstasy”
• Nicotine
• Anabolic steroids
• Narcotic withdrawal
• Methylphenidate
• Phencyclidine
• Ketamine
• Ergot-containing herbal products
• St John’s wort
 Substances Associated with HTN
• Food Substances • Chemicals
– Sodium Chloride – Lead
– Ethanol – Mercury
– Licorice – Thallium and other
– Tyramine-containing heavy metals
foods (with MAOI) – Lithium salts