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hypertension in older adults

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  • hypertension is common in those aged over 60 years (elderly)
  • hypertension in the elderly is associated with an increased risk of coronary heart disease and stroke
  • treatment of elderly hypertension will reduce the risk of a major coronary event by 20% and the incidence of stroke by almost 40%
  • it is important to note that older people show greater BP variability, and thus it is particularly important that multiple measurements are taken on several occasions to confirm the diagnosis of hypertension
    • standing and seated measurements are important during the initial assessment and after initiating drug therapy, because of the high prevalence of orthostatic hypotension
  • in this age group thiazide/thiazide-like diuretics are particularly effective at lowering BP in older people, as are dihydropyridine calcium channel blockers
  • NICE have recommended that (2):
    • a clinician should offer patients over 80 years of age the same treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use
    • the guidance notes that patients over 80 years of age are poorly represented in clinical trials and the effectiveness of treatment in this group is less certain. However, it is reasonable to assume that older patients will receive worthwhile benefits from drug treatment, particularly in terms of reduced risk of stroke

Notes:

  • a meta-analysis from the Blood Pressure Lowering Treatment Trialists' Collaboration indicated that reducing blood pressure with antihypertensive drugs reduces CV risk to a similar degree in both younger (<65 years) and older (>65 years) people irrespective of which drug regimen is used (3)
  • HYVET study was a large double-blind, randomised, placebo-controlled trial, which showed that antihypertensive treatment with a thiazide-like diuretic (indapamide) and/or an ACE inhibitor (perindopril) reduced the risk of death from stroke or any cause in patients aged 80 years or older (4)
    • note though that the study sample was a relatively healthy group with low prevalence of diabetes mellitus and coronary artery disease. Patients with heart failure or dermentia and those requiring nursing care were excluded - thus the relative benefits and risks of treating frail elderly people with multiple comorbid conditions were not addressed by this trial (and may never be known) (5)

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