Hypertension in the elderly

By Henry Olders 2017-12-04 Medicine, Teaching No Comments

References (from GitHub repo)

“At old age, mild hypertension may increase cognitive performance”1

“Results from HYVET (Hypertension in the Very Elderly Trial) showed that, at 2-year follow-up, antihypertensive drug therapy with indapamide, plus perindopril if needed, reduced fatal or nonfatal stroke by 30%, fatal stroke by 39%, all-cause mortality by 21%, cardiovascular death by 23%, and heart failure by 64%. These results indicate that hypertensive patients aged 80 years and older should be treated with antihypertensive drugs.” 2

Treatment of persons over 80 who had sustained systolic BP of 160 mm Hg or higher to a target BP of 150/80 mm Hg led to significant reductions in strokes, death, and heart failure. 3

“Cognitively normal subjects with HTN (n=19) had decreased rCBF in the putamen, globus pallidus, bilaterally, and in the left hippocampus compared with normotensives (n=22). In addition, decreased rCBF was observed in the right and left anterior cingulate gyrus with extension to the subcallosal region, left posterior cingulate gyrus and medial precuneus, left lateral inferior and superior frontal, and inferior parietal, left orbitofrontal, and left superior temporal cortices. CONCLUSIONS: rCBF is affected in normal subjects with HTN, not only in the subcortical regions, but also in limbic and paralimbic structures. We hypothesize that the HTN creates a vulnerability state for the development of neurodegenerative disorders, especially Alzheimer disease.” 4

In the Syst-Eur trial, patients over 60 with isolated systolic hypertension (blood pressure when seated of 160-219 mm Hg systolic and below 95 mm Hg diastolic) were treated with up to three drugs to reduce systolic BP by at least 20 mm Hg to reach a value below 150 mm Hg. Active treatment reduced incidence of dementia by 50%, compared to placebo, during a median followup by ITT. In the active treatment group, BP decreased by 8.3 mm Hg systolic and 3.8 mm Hg diastolic. On average, MMSE scores did not change in either group. 5

A meta-analysis of outcomes of treatment with antihypertensive drugs for patients aged 80 and over found that treatment prevented strokes and heart failure, but did not reduce mortality 6

In a study of Nigerian elderly hypertensive patients, diastolic blood pressure was found to correlate negatively with cognitive performance 7

“In the oldest old, high blood pressure is not a risk factor for mortality, irrespective of a history of hypertension. Blood pressure values below 140/70 mmHg are associated with excess mortality.” 8

“In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group.” 9

“findings support the existence of a link between low blood pressure and higher levels of depressive symptomatology, and also a range of somatic and psychosocial symptoms.” 10

Adhering to clinical practice guidelines for chronic conditions may lead to undesirable effects when caring for elderly patients with several comorbidities 11

“In men aged 75 and over low diastolic blood pressure was associated with the greatest all cause (p=0.04) and cardiovascular (p=0.02) mortality and higher diastolic blood pressure predicted survival.” 12

“Older people taking CCBs were significantly more likely than those using other agents to experience cognitive decline.” 13

“Antihypertensive treatment may increase the risk of myocardial infarction in elderly men with treated diastolic blood pressures < or = 90 mm Hg.” 14

In the HYVET study, “Antihypertensive treatment in elderly patients does not statistically reduce incidence of dementia.” 15

A study of 385 individuals (2/3 female) average age 83, looked at systolic blood pressure (SBP) and MMSE scores over 4 years of followup. A medical history of arterial hypertension was associated with lower MMSE scores and a higher prevalence of dementia and cognitive decline at baseline. However, intact cognition through the observation period was associated with higher baseline SBP. This relationship also remained when the frailty of aging subjects, indicated by remaining time to death, was taken into account. Conclusions: Lower SBP in the oldest old is associated with an increased risk of cognitive impairment even after adjustment for compromised vitality. 16

  1. Anson O, Paran E. Hypertension and cognitive functioning among the elderly: an overview. Am J Ther. 2005;12:359-365. PMID 16041200 ↩
  2. Aronow WS. Older age should not be a barrier to the treatment of hypertension. Nat Clin Pract Cardiovasc Med. 2008;5:514-515. PMID 18607394 ↩
  3. Beckett NS, Peters R, Fletcher AE et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898. PMID 18378519 ↩
  4. Dai W, Lopez OL, Carmichael OT, Becker JT, Kuller LH, Gach HM. Abnormal Regional Cerebral Blood Flow in Cognitively Normal Elderly Subjects With Hypertension. Stroke. 2008;39:349-354. PMID 18174483 ↩
  5. Forette F, Seux ML, Staessen JA et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet. 1998;352:1347-1351. PMID 9802273 ↩
  6. Gueyffier F, Bulpitt C, Boissel JP et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet. 1999;353:793-796. PMID 10459960 ↩
  7. Imarhiagbe F, Ogunrin O, Ogunniyi A. Cognitive performance of hypertensive elderly Nigerians: a case control study. Afr J Med Med Sci. 2005;34:269-273. PMID 16749360 ↩
  8. van Bemmel T, Gussekloo J, Westendorp RG, Blauw GJ. In a population-based prospective study, no association between high blood pressure and mortality after age 85 years. J Hypertens. 2006;24:287-292. PMID 16508574 ↩
  9. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc. 2007;55:383-388. PMID 17341240 ↩
  10. Stroup-Benham CA, Markides KS, Black SA, Goodwin JS. Relationship between low blood pressure and depressive symptomatology in older people. J Am Geriatr Soc. 2000;48:250-255. PMID 10733049 ↩
  11. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724. PMID 16091574 ↩
  12. Langer RD, Ganiats TG, Barrett-Connor E. Paradoxical survival of elderly men with high blood pressure. BMJ. 1989;298:1356-1357. PMID 2502252 ↩
  13. Maxwell CJ, Hogan DB, Ebly EM. Calcium-channel blockers and cognitive function in elderly people: results from the Canadian Study of Health and Aging. CMAJ. 1999;161:501-506. PMID 10497605 ↩
  14. Merlo J, Ranstam J, Liedholm H et al. Incidence of myocardial infarction in elderly men being treated with antihypertensive drugs: population based cohort study. BMJ. 1996;313:457-461. PMID 8776312 ↩
  15. Peters R, Beckett N, Forette F et al. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol. 2008;7:683-689. PMID 18614402 ↩
  16. Nilsson SE, Read S, Berg S, Johansson B, Melander A, Lindblad U. Low systolic blood pressure is associated with impaired cognitive function in the oldest old: longitudinal observations in a population-based sample 80 years and older. Aging Clin Exp Res. 2007;19:41-47. PMID 17332720 ↩

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