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For Student

Mrs. K
Mrs. K is a 90-year-old woman who has moved to the community recently. She feels well except
for pain in both knees while walking, for which she takes acetaminophen. She has also taken baby
aspirin once daily for many years. She denied a history of hypertension, diabetes, or heart disease,
and has never smoked. On physical examination, she is a slender, healthy appearing woman. Her
blood pressure is 165/80, heart rate is 78 beats per minute, and regular, respiratory rate is 12; lung,
heart and abdominal examinations are unremarkable. Examination of the lower extremities reveals
strong peripheral pulses and no edema. Blood tests including blood count, creatinine, glucose, and
thyroid-stimulating hormone (TSH) are all normal. Electrocardiogram shows left ventricular
hypertrophy (LVH) by voltage criteria, without other abnormalities. You tell her that her blood
pressure is high and she expresses doubt, saying, “I have never had high blood pressure!”

Tasks:
1. What criteria should be used in elderly patients to determine if blood pressure is high enough to
be treated?
2. How should you approach the management of blood pressure in Mr. G and Mrs. K?
3. What pharmacologic agents should be used in older adults with hypertension?
4. What lifestyle modifications should be recommended?
Student’s name
For examiner
Mrs. K
Mrs. K is a 90-year-old woman who has moved to the community recently. She feels well except
for pain in both knees while walking, for which she takes acetaminophen. She has also taken baby
aspirin once daily for many years. She denied a history of hypertension, diabetes, or heart disease,
and has never smoked. On physical examination, she is a slender, healthy appearing woman. Her
blood pressure is 165/80, heart rate is 78 beats per minute, and regular, respiratory rate is 12; lung,
heart and abdominal examinations are unremarkable. Examination of the lower extremities reveals
strong peripheral pulses and no edema. Blood tests including blood count, creatinine, glucose, and
thyroid-stimulating hormone (TSH) are all normal. Electrocardiogram shows left ventricular
hypertrophy (LVH) by voltage criteria, without other abnormalities. You tell her that her blood
pressure is high and she expresses doubt, saying, “I have never had high blood pressure!”
Task 1 (3.0) Hypertension (HTN) is generally defined as systolic blood pressure (SBP) 140 mm
Hg or diastolic blood pressure (DBP) 90 mm Hg. Isolated systolic hypertension (ISH) is defined
as SBP 140 mm Hg or greater and DBP less than 90 mm Hg. According to recent guidelines, these
criteria apply to all adults, regardless of age (Chobanian et al., 2003), and, using these criteria,
about two-thirds of hypertensive patients between the ages of 65 and 89 have isolated systolic
hypertension. These guidelines are based on a doubling of cardiovascular mortality risk for each
20/10 increment in blood pressure over 115/75, labeling systolic pressure greater than 120 as
“prehypertension.” Before treating or counseling and possibly unnecessarily upsetting a 90-year-
old patient, it would be important to place these recommendations in perspective. SBP elevation
in late life has long been considered an inevitable consequence of advancing age, due to decreased
compliance of the arterial wall, and was considered unimportant, in contrast to diastolic
hypertension, which was thought to reflect increased peripheral vascular resistance and to be
harmful. The differing age distribution of ISH and diastolic hypertension is illustrated in Figure 6.
Longitudinal and prospective data have demonstrated clearly that SBP is a better independent
predictor for cardiovascular events than DBP, even in subjects with mildly elevated SBP. More
recently, large, double-blind, controlled studies of people 65 years of age and older with SBP 160
mm Hg demonstrated that lowering SBP significantly reduces the incidence of stroke,
cardiovascular events, and all-cause of mortality. The mean age of “elderly” subjects in most
clinical trials is about 70, and, official guidelines notwithstanding, the benefits of treatment in
elderly patients with SBP between 140 to 159 are yet to be proved.
Both of our patients satisfied the criteria for ISH. However, official criteria can only be used as a
general guide. The approach to a patient meeting the criteria of hypertension, especially those older
than 80 years with SBP between 140 and 160 without evidence of target organ damage, requires
careful consideration (see below).
Task 2 (3.0) Mr. G’s blood pressure is elevated, despite antihypertensive medications, and he has
several additional cardiac risk factors. There is ample evidence that blood pressure lowering delays
and prevents nephropathy and reduces cardiovascular events, even in patients over 65, and a target
blood pressure less than 130/85 is recommended in diabetes. Because the patient also has
proteinuria, the target might be even stricter (125/75). Although these recommendations are based
on data in patients younger than 70 years, there is currently no evidence that this target should not
be applied to Mr. G., who has compelling reasons for aggressive treatment. However, successful
treatment will depend on his ability to adhere to and tolerate the recommended regimen.
There are additional caveats to consider before treating Mrs. K, who is 90 years old. Information
on people in their nineties is sparse, and it is legitimate to ask if reducing this woman’s SBP would
benefit her in any way. Her projected life span is about 4–5 years. In two major studies of
hypertension in the elderly (see SHEP Cooperative Research Group, 1991; Staessen JAet al.,
1997), the average age of subjects was almost 20 years younger than Mrs. K. In these studies, 100
patients with ISH (SBP 160 in both studies) need to be treated with antihypertensive medications
for 2–5 years in order to achieve a reduction of stroke and major cardiovascular events by three
and five episodes, respectively. Pharmacologic treatment of hypertension can reduce the severity
of or reverse LVH, which is an independent factor for congestive heart failure. Even if Mrs. K’s
LVH were confirmed by echocardiography, any projected benefit of treatment would still be based
on the extrapolation of data from younger individuals. It will also be important to confirm whether
Mrs. K has sustained hypertension. Systolic pressure is more labile than diastolic pressure. Blood
pressure in general varies from day to day, at different times during the day, and from minute to
minute. The “white coat effect,” an elevation in blood pressure associated with measurement in
the doctor’s office, occurs in adults of all ages but the difference between office and ambulatory
blood pressure may increase with age (see Wiinberg et al., 1995). “Pseudohypertension,” or
elevated cuff pressure in the face of normal intra-arterial pressure, is another problem that should
be considered in elderly patients whose blood pressure seems hard to control. Falsely elevated cuff
pressure occurs when arteries lack distensibility or are calcified, requiring greater extrinsic
pressure before they can be compressed. The frequency of this problem is uncertain because
confirmation requires monitoring that is invasive or impractical. Nonetheless, it should be
considered, especially when patients undergoing treatment seem to develop symptoms of
hypotension in the face of normal or elevated cuff pressure. Despite these caveats, Mrs. K’s general
good health and functional status makes her an appropriate candidate for treatment. However,
vigilance is required for symptoms that might occur if blood pressure were lowered to youthful
target levels. Mrs. K preferred not to receive any antihypertensive medication, but she continued
to take coated baby aspirin and wanted to hear more about lifestyle modification. She comes to the
office periodically and her SBP has varied between 145 and 170.
Task 3 (2.0) Most antihypertensive drugs, alone or in combination, are effective in reducing SBP
and decreasing cardiovascular morbidity and mortality in elderly patients with ISH. There is no
“drug of choice” for the elderly hypertensive. Rather, the initial drug choice should be based on
the patient’s profile, comorbidity, potential side effects, and physician’s experience.
Recommendations to initiate treatment with thiazide diuretics or beta-blockers in combination with
thiazides are based on the earliest studies of ISH that used these agents and not others (SHEP
Cooperative Research 92 Case studies in geriatric medicine Group, 1991), and more recent studies
do not consistently demonstrate the benefit of one agent over another. In fact, many geriatric
patients cannot tolerate diuretics because of bladder problems (see Case 33). Specific agents
should be selected when common comorbid conditions exist for which these agents are known to
be effective – e.g. angiotensin-converting enzyme (ACE) inhibitors in diabetes or heart failure,
and beta-blockers or ACE inhibitors in myocardial infarction. Conversely, elderly patients
commonly experience certain symptoms with specific agents, such as constipation or leg edema
with calcium channel blockers (CCBs); when these effects occur, they may sometimes be
mistakenly attributed to other causes and lead to unnecessary evaluation and erroneous treatment.
Owing to pharmacokinetic changes that occur in late life (see Case 20), an increased incidence of
adverse drug reactions, and occasional heightened sensitivity to blood pressure-lowering effects,
the starting dose should be lower than, usually about one-half of, the dose for younger patients,
and the dose gradually increased if necessary. Delayed elimination of renally eliminated drugs,
such as ACE inhibitors, can sometimes be harnessed so shorter-acting agents, such as captopril,
can be given less often.
Task 3 (2.0) . Like younger adults, elderly patients with hypertension should attempt lifestyle
modification, such as weight loss if obese, exercise, smoking cessation, and avoidance of excessive
alcohol use, because the benefits of these interventions are broader than merely blood pressure
reduction. High dietary potassium intake may improve blood pressure control and an adequate
intake of potassium in foods like fruits and vegetables are recommended along with other lifestyle
modifications. Salt restriction remains somewhat controversial for elderly hypertensives, however.
Controlled studies have shown the effectiveness of dietary sodium restriction in reducing blood
pressure in hypertensive and normotensive adults. However, before recommending a salt-restricted
diet for an elderly patient, several caveats should be considered. First, evidence of benefit comes
from studies of community residing “older” adults (e.g. Johnson et al., 2001), but not in very old
or frail patients, who may already be malnourished and would possibly be harmed rather than
helped by enforced dietary restriction. Second, nonmodifiable genetic factors may determine
whether hypertensive patients are salt sensitive or salt insensitive. Third, most studies of the effects
of salt restriction employed very severe restriction of sodium, which is difficult to achieve in
clinical practice. Finally, there is a decline in renal solute conservation with age; the clinical
implications of this physiologic change with regard to salt restriction, blood pressure, or
intravascular volume are not known. Many exercises are impractical in patients with physical
limitations who are unable to increase aerobic physical activity sufficiently, if at all. In these cases,
creative interventions should be considered, including movement therapy, or a 93 Two patients
with hypertension physical therapy program tailored to the needs of the particular patient. Mrs. K
should be counseled to participate in moderate exercise, such as walking, because of overall
benefits to her well being. Mr. G requires more intensive intervention and counseling regarding
the importance of controlling blood glucose, hypertension, lipids, and weight, and might benefit
from progressive resistance training if aerobic exercises are difficult or impractical.
Final score: