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Can Fam Physician. 2010 November; 56(11): 1141.
PMCID: PMC2980430

Treating hypertension in the very elderly

G. Michael Allan, MD CCFP
Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton
Laurie Mallery, MD FRCPC
Head of the Division of Geriatric Medicine at Dalhousie University and Director of the Centre for Health Care of the Elderly in Halifax, NS
Noah Ivers, MD CCFP

Clinical question

What are the risks and benefits of treating hypertension in patients older than 80 years of age?

Evidence

  • HYVET,1 an RCT, included 3845 patients older than 80 (mean 83.5) years; 60% female; systolic blood pressure (SBP) > 160 mm Hg; mean follow-up of 2.1 years.
    • -Placebo or indapamide (1.5 mg) with or without perindopril (2 to 4 mg); target BP was < 150/80 mm Hg.
    • -Outcomes: mortality—number needed to treat (NNT) 47 (treatment 10% vs 12%), P = .02; any cardiovascular disease (CVD)—NNT 34 (treatment 7.1% vs 10.1%), P < .001.
    • -Potential limitations:
      • —HYVET was stopped early (might exaggerate benefit2);
      • —Healthy elderly population (≤12% CVD history, < 7% diabetes, no dementia) limits generalization;
      • —Patients with standing SBP < 140 mm Hg were not included; few subjects had orthostasis (7.9% to 8.8%).

Context

  • A systematic review of data on patients 80 years or older from 7 trials (N = 1670, mean age 83 years) found antihypertensive therapy significantly reduced CVD events (P < .01) but left uncertainty about effects on mortality.3
  • In patients older than 60 years, BP treatment reduces mortality (NNT 84, P < .001) and CVD outcomes (NNT 24, range 29–21) over 4.5 years.4
    • -Lower-risk patients get slightly less benefit.4,5
    • -Updated meta-analysis4 of older-than-80 age sub-groups3 with HYVET1 found improved CVD outcomes but no clear mortality benefit.4
  • HYVET was specifically designed to address hypertension in the healthy very elderly and for that population would be more reliable than pooled subgroup data.
    • -Target BP was higher than that of most guidelines.
    • -In secondary analysis of another trial, target SBP < 150 mm Hg was as good as lower targets in older patients.6
    • -A 2010 trial7 of 3260 patients aged 70 to 84 found no difference in CVD outcomes between SBP targets <150 and <140 mm Hg.
    • -Patients in HYVET1 and most patients in the meta-analysis4 used thiazide diuretics as first-line therapy.

Bottom line

Treating hypertension in healthy patients older than 80 years of age is effective. Exact targets are uncertain, but the primary trial aimed for 150/80 mm Hg. Benefits are uncertain for the frail elderly or those with orthostasis or standing systolic BP below 140 mm Hg.

Implementation

Managing hypertension in the elderly is important to reduce cardiovascular risk, but targets should be patient-specific, accounting for comorbidities.8 Consider monitoring standing BP to avoid orthostatic hypotension in the very elderly. Drug side effects or interactions are common and difficult to manage, even in dedicated clinics.9 Treatment adherence is a considerable barrier for achieving targets10; simplifying dosing is an easy way to improve adherence.11 Self-management programs can also improve BP control.12 Hypertension Canada has patient resources13 and a list of approved home BP monitors,14 which might facilitate self-management and improve adherence.15

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published twice monthly on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician. Feedback is welcome and can be sent to ac.cpfc@ecitcarprofsloot. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

References

1. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98. [PubMed]
2. Montori VM, Devereaux PJ, Adhikari NK, Burns KE, Eggert CH, Briel M, et al. Randomized trials stopped early for benefit: a systematic review. JAMA. 2005;294:2203–9. [PubMed]
3. Gueyffier F, Bulpitt C, Boissel JP, Schron E, Ekbom T, Fagard R, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet. 1999;353:793–96. [PubMed]
4. Musini VM, Tejani AM, Bassett K, Wright JM. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev. 2009;(4):CD000028. [PubMed]
5. Ferrucci L, Furberg CD, Penninx BW, DiBari M, Williamson JD, Guralnik JM, et al. Treatment of isolated systolic hypertension is most effective in older patients with high-risk profile. Circulation. 2001;104:1923–6. [PubMed]
6. Ogihara T, Nakao K, Fukui T, Fukiyama K, Fujimoto A, Ueshima K, et al. The optimal target blood pressure for antihypertensive treatment in Japanese elderly patients with high-risk hypertension: a subanalysis of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial. Hypertens Res. 2008;31:1595–601. [PubMed]
7. Ogihara T, Saruta T, Rakugi H, Matsuoka H, Shimamoto K, Shimada K, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56(2):196–202. [PubMed]
8. Krakoff LR. Older patients need better guidelines for optimal treatment of high blood pressure: 1 size fits few. Hypertension. 2008;51(4):817–8. Epub 2008 Mar 10. [PubMed]
9. Butt TF, Branch RL, Beesley L, Martin U. Managing hypertension in the very elderly: effect of adverse drug reactions (ADRs) on achieving targets. J Hum Hypertens. 2010;24(8):514–8. [PubMed]
10. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes. A meta-analysis. Med Care. 2002;40:794–811. [PubMed]
11. Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev. 2004;(3):CD004804. [PubMed]
12. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143(6):427–38. [PubMed]
13. Hypertension Canada . MyBP [pamphlet] Calgary, AB: Hypertension Canada; 2010. Available from: http://hypertension.ca/bpc/wp-content/uploads/2010/03/Brochure_2010.pdf. Accessed 2010 Sep 10.
14. Hypertension Canada [website] Devices endorsed by Hypertension Canada. Calgary, AB: Hypertension Canada; Available from: http://hypertension.ca/chs/deviceendorsements/devices-endorsed-by-chs/. Accessed 2010 Sep 10.
15. Allan GM, Hegan K. Home in the range—home blood pressure monitoring. In: Allen GM, editor. Tools for practice. Edmonton, AB: Alberta College of Family Physicians; 2009. Available from: www.acfp.ca/docs09/Home%20BP%20_final%20TFP_.pdf. Accessed 2010 Sep 10.

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada