Geriatric refers to age ≥ 65 years, and the prevalence of hypertension in the elderly population is as high as 49%. Early on, it was thought that hypertension in the elderly is a physiological phenomenon that blood pressure increases with age and does not need to be treated, but long-term studies have shown that hypertension in the elderly is an important factor that jeopardizes the survival.
Qquality of life of the elderly, and active treatment can significantly reduce the risk of stroke and other important cardiovascular events. Regardless of age, blood pressure should be controlled under the guidance of a physician to bring it down to as normal a range as possible.
◈ Etiology and pathophysiology
The pathogenesis of hypertension in the elderly has not been fully elucidated. It is generally believed that with increasing age, the intima and middle layers of the aortic wall thicken, the middle elastic fibers break and decrease, collagen, lipid and calcium salt deposition, undifferentiated vascular smooth muscle cells (VSMC) migrate through the elastic layer to proliferate, and connective tissue production increases, which can lead to narrowing of the arterial lumen, increased stiffness, reduced elasticity and self compliance of the large arteries, and decreased elastic dilatation capacity.
The vascular pressure is not buffered and increases significantly. In addition to structural changes in the aorta (large vessels), endothelial cell dysfunction, changes in neurohumoral factors, hemodynamic changes, environmental and genetic factors play an important role in the development of hypertension in the elderly.
◈ Clinical manifestations
Age ≥ 65 years. All but a fraction of patients evolve from pre-geriatric diastolic hypertension, which manifests as elevated systolic and diastolic blood pressure. More than half of hypertension in the elderly is simple systolic hypertension (ISH), a specific type of hypertension characterized by increased systolic blood pressure and increased pulse pressure difference. It has a high rate of death and disability, and has become a hot spot for research.
1. Simple systolic hypertension is common: In the elderly, due to atherosclerosis, the elasticity and stretch of the arterial wall is reduced, the elastic expansion in systole and elastic retraction in diastole are weakened, and the buffering capacity is reduced, resulting in higher systolic pressure, lower diastolic pressure, and increased pulse pressure difference. Therefore, elderly people are often purely systolic hypertension.
2. Blood pressure fluctuation, blood pressure circadian fluctuation rhythm abnormal, the target organs such as the heart, brain and kidney damage; susceptible to environmental changes and stress response to make the office blood pressure is much higher than the self-measured blood pressure.
Prone to morning peak blood pressure increase, that is, the average value of systolic blood pressure within 2h after waking up – the lowest value of systolic blood pressure during sleep at night (including the lowest value of the average value of 1h), ≥ 35mmHg for morning peak blood pressure increase . It is recommended to measure 24-hour ambulatory blood pressure in order to clarify blood pressure fluctuations and adjust medication regimen; advocate home self-measurement of blood pressure.
3. Prone to postural hypotension and postprandial hypotension.
4. Older people have reduced taste sensitivity and tend to eat very salty food. And the kidney’s ability to regulate water and salt has decreased, and blood pressure is more sensitive to salt. Excessive salt intake will raise blood pressure, reduce the efficacy of antihypertensive drugs and make it difficult to control blood pressure.
5. Often combined with other cardiovascular risk factors, more likely to occur target organ damage and cardiovascular disease; because of the coexistence of a variety of diseases and the number of drug species, easy to occur between the drug interactions, prone to adverse drug reactions.
1. Laboratory tests
(1) Blood test Check serum lipid, blood sugar, uric acid, creatinine; serum potassium, sodium, etc. and complete blood cell count to understand whether there are risk factors associated with cardiovascular disease.
(2) Urine tests: urine routine, urine albumin-creatinine ratio, 24-hour urine protein, urine electrolytes and other evidence of primary disease and target organ damage secondary to systolic hypertension.
2. Other ancillary tests
(1) Electrocardiogram and ambulatory electrocardiogram can promptly detect the presence of left ventricular hypertrophy, arrhythmia and concomitant myocardial ischemia in patients with systolic hypertension, which is beneficial to the assessment and treatment of the condition.
(2) Echocardiography is of high value in understanding the left ventricular structure and the presence of impaired diastolic function in elderly patients with simple systolic hypertension.
(3) Routine chest radiography To understand the size of the heart and lung condition and the presence of respiratory system diseases.
Examination concerning target organ damage and complications of heart, brain and kidney, and comorbidities.
Age ≥ 65 years, systolic blood pressure (SBP) ≥ 140 mmHg, if also diastolic blood pressure (DBP) < 90 mmHg for simple systolic hypertension (ISH).
1. Initially elevated readings were reviewed at least three times, with the average of >2 readings taken each time.
2. Some diseases with increased cardiac output, such as aortic closure insufficiency, aortic fistula, arteriovenous catheterization, severe anemia, and hyperthyroidism, are not included in the elevated SBP.
3. The blood pressure of the elderly is more unstable and easily affected by emotions, position and activities, and the blood pressure varies greatly over 24 hours, so the blood pressure should be measured repeatedly in different positions and must be quiet for more than 5 minutes before measurement.
In addition, a comprehensive diagnostic evaluation should be made based on the patient’s medical history, family history, physical examination and laboratory tests to understand the causes of hypertension, assessment of cardiovascular risk factors and the degree of target organ damage, so as to guide diagnostic and treatment measures and prognosis.
1.The goal of lowering blood pressure
The goal of hypertension treatment is not only to lower the blood pressure, but also to delay the reduction of atherosclerosis and reduce the damage to target organs. The treatment of elderly hypertension should be smooth and safe, starting with small doses, taking care that the target blood pressure value is not too low to prevent insufficient blood supply to vital organs.
In elderly hypertensive patients, the standard of blood pressure lowering can be relaxed to below 150/90mmHg, or to below 140/90mmHg if tolerated. The rate of blood pressure lowering should be slow to prevent postural hypotension, and sit-to-stand blood pressure should be measured before and after medication. 2013 European Hypertension Guidelines recommend the following blood pressure lowering targets.
(1) For elderly people younger than 80 years old, systolic blood pressure should be controlled at 140-150 mmHg. If the patient is in good general condition and can tolerate it, the systolic blood pressure can be further reduced to less than 140 mmHg.
(2) If the general condition and mental state of the patient is better than 80 years old, the systolic blood pressure can be controlled at 140-150mmHg.
(3) For frail elderly, the need for antihypertensive therapy is determined by the clinician based on his or her monitoring of the treatment effect.
(4) For all older adults, diastolic blood pressure should be controlled to less than 90 mmHg, and further reduced to less than 85 mmHg if diabetes is present. For the elderly, a diastolic blood pressure between 80 and 85 mmHg is safer and can be tolerated by the patient.
2. Improvement of lifestyle and diet structure
For elderly patients with hypertension, regular physical exercise, weight reduction, increased intake of vegetables and fruits, reduced salt and alcohol intake, and smoking cessation are needed.
3. Drug treatment
(1) Various antihypertensive drugs should be used according to different situations. All five drugs are available. Low renin, elderly ISH more diuretics or long-acting CCBs, with heart failure and renal disease (such as diabetic nephropathy) is appropriate to use ACEI or ARB, for those with myocardial infarction can be used β-blockers and ACEI.
(2) The combination of different classes of antihypertensive drugs can lower blood pressure more sharply than one drug alone, and the range of blood pressure reduction is about twice that of one drug alone, i.e., 8% to 15%. For many hypertensive patients, single drug therapy does not bring blood pressure down to the ideal level, and the increase in the dose of a single drug is often accompanied by an increase in adverse reactions, which often makes it difficult for patients to tolerate, so the best choice is to use a combination of drugs.
(3) There are often pharmacokinetic changes in the elderly. In general, as age increases, the amount of body fat increases, while water, plasma volume and total muscle mass decrease, resulting in a decrease in the volume of distribution of fat-soluble drugs. Drug metabolism and excretion rates are reduced in elderly patients with hypertension due to often reduced liver and kidney function. Therefore, dose reduction should be considered when using the following drugs, such as thiazide diuretics, aminopterin, verapamil, angiotensin-converting enzyme inhibitors, water-soluble beta-blockers, colistin, methyldopa, etc.
(4) The clearance of calcium antagonists by the liver is low in the elderly. The pharmacokinetics of α-blockers and labetalol are not reduced in the elderly, while the sensitivity of β-blockers is reduced, but the function of α-blockers is normal. With regard to the rate of blood pressure lowering, it is not advisable to lower blood pressure rapidly. The main reason is that the cerebral circulation and other circulatory system functions in the elderly need to be maintained normally at higher circulatory pressures, and although self-regulation and adaptation to antihypertensive therapy can occur, it often takes several days to adapt. Therefore, even in elderly people who need rapid blood pressure lowering, the initial blood pressure lowering rate should not exceed 25%.
(5) In addition to antihypertensive treatment, the elderly generally have more target organ damage and complications, and need to focus on multiple interventions and individualized treatment.
1. For the elderly, attention should be paid to eliminating risk factors for cardiovascular disease, avoiding emotional excitement, quitting smoking, drinking less alcohol, and keeping body weight close to the normal range is beneficial to health.
2. In daily life, pay attention to limit the intake of sodium and salt, adhere to moderate physical exercise.
3. Once you start antihypertensive treatment for senile hypertension, you should adhere to the regular medication treatment and do not reduce or stop the medication at will.