Download Quality Outpatient Care of Older Persons

Quality Outpatient Care of Older Persons
Department of Family Medicine and Program on Aging – University of North Carolina at Chapel Hill
Evidence-Based Geriatric Module: Hypertension
Rationale
Hypertension is one of the most common medical diagnoses in persons over the age of 65. At least two-thirds of people in the US aged 70+ have
hypertension (defined as a systolic BP ≥ 140 mm Hg and/or a diastolic BP ≥ 90 mmHg), and the prevalence of hypertension increases further with
advancing age. (1-3) Among elderly hypertensives, 60-87% have isolated systolic hypertension (ISH), and ISH has been found to be associated with
mortality, cardiovascular disease, and stroke. (4-9) Unfortunately, ISH is the least likely form of hypertension to be treated. (4, 10,11) Diastolic
hypertension is also a risk factor for cardiovascular disease in the elderly, but between ages 50 and 60, systolic hypertension assumes a superior
role over diastolic blood pressure as a predictor of adverse cardiovascular outcomes. (5, 12-16) A widened pulse pressure (>50 mm Hg) is often seen
in the setting of ISH, and thus may be a marker of increased cardiovascular risk and the need for hypertension treatment. (1) (See “III. Treatment:
…J-Curve Hypothesis” for information regarding management of another cause of a widened pulse pressure: a low diastolic blood pressure.)
In the US, the elderly account for the group with the largest relative risk of uncontrolled hypertension, despite having the most frequent contact
with the medical system. (1) One study suggests this may be because of lack of awareness of the issue and lack of adequate control with current
treatment strategies. (17). Aside from the burden of morbidity and mortality, the financial costs of untreated hypertension can be staggering. In 1999
alone the estimated direct and indirect cost of hypertensive disease was above $33.3 billion. (1)
Numerous large-scale placebo-controlled trials of hypertension treatment in elderly patients have shown that successful reductions in blood
pressure are associated with significant reductions in cardiovascular events and mortality. (18-23) The evidence is most compelling for patients aged
65-79, since this population figured prominently in the trials. It is more difficult to extrapolate benefit to patients aged 80+, since not as many
people in this age group were featured in each trial. In fact, no large scale trials of hypertension treatment in octo- or nonagenarians have been
completed as yet, although the Hypertension in the Very Elderly Trial (HYVET) is ongoing. (24) Therefore, for now, we must rely on secondary
analyses of data from existing trials: one meta-analysis of 1670 octogenarians involved in several large-scale placebo-controlled trials of
antihypertensive treatment showed a relative risk reduction in stroke, cardiovascular events, and heart failure of 34%, 22%, and 39% respectively.
However, there was a non-significant 6% increase in all-cause mortality. (25) It is hoped that the results of the HYVET trial will more directly
address benefits vs. risks of hypertension treatment in the very elderly. For now, however, given the cardiovascular risks associated with age and
with hypertension, and given the evidence of cardiovascular event reduction with hypertension treatment, limits on attempts at treatment should
not be based upon age alone. Conversely, it is acceptable to individualize treatment decisions for very elderly hypertensives based upon the
assessment of risk vs. benefit of treatment in the person.
Any decision to treat an asymptomatic condition must consider the impact of treatment on quality of life. In most cases quality of life is enhanced
by measures that maintain activities of daily living and cognitive function – i.e. by measures which prevent strokes and heart attacks. Hence,
hypertensive therapy in older persons is usually worthwhile. However, for some individuals, particularly the very frail or the very old, the adverse
effects of medication may outweigh the benefits. Setting a goal blood pressure of <140/90 may be inappropriate and dangerous for a frail older
person with risks for orthostasis and other adverse treatment effects. In these situations, decisions regarding treatment must be left to the
discretion of physician and patient. (26,27, 28)
Recommended Quality of Care Indicators
I. Screening
Recommendation
All older persons should be screened for
hypertension using a sphygmomanometer at
each health examination.
Rationale
Screening is low-cost. Identification and treatment of hypertension can lead to
reductions in morbidity and mortality from cardiovascular events.
Hypertension in older persons is defined as a
systolic pressure ≥ 140 mmHg or a diastolic
pressure ≥ 90 mmHg on three or more
separate occasions.
Conversely, not following criteria for diagnosis can lead to a mistake in
diagnosis, resulting in unnecessary use of medications, increase in risk of
adverse effects, and increased cost.The burden of false labeling can include
negative psychological, social, and economic effects.
References
1, 29, 30
II. Initial Assessment
Recommendation
Rationale
References
A baseline electrocardiogram (ECG) should
be considered when a new diagnosis of
hypertension is made in the older patient.
No studies exist that assess the relationship between the performance of an
ECG and either prognosis or treatment outcome. However, there is indirect
evidence linking the performance of an ECG with better outcomes from
hypertensive treatment. This may be due to risk stratification and subsequent
aggressiveness of treatment if ventricular hypertrophy is identified.
1, 31-36
Blood urea nitrogen (BUN), creatinine, basic
electrolytes, fasting lipid panel, glucose, and
microalbuminuria or proteinuria should be
measured.
Measurement of renal function (including proteinuria/microalbuminuria),
lipids, and glucose allows for risk stratification. Measurement of renal function
and electrolytes also provide information necessary for making safe and
effective treatment choices.
Older patients with a new diagnosis of
hypertension should be assessed for evidence
of target organ damage and for
cardiovascular risk factors (smoking,
dyslipidemia, diabetes, male gender, and
family history of cardiovascular disease).
Older patients have a higher prevalence of target organ damage and higher
rates of additional risk factors for cardiovascular disease. Although there is no
direct evidence that documentation of target organ damage and cardiovascular
risk factors will result in improved patient outcomes, awareness of these
factors may lead to more aggressive hypertension control, thus reducing the
risk of future adverse events. Targeting additional risk factors may further
decrease the risk of cardiovascular events.
1, 31-34
III. Treatment: Threshold for Initiation of Treatment
Recommendation
In most elderly patients, treatment
(nonpharmacologic and/or pharmacologic)
for hypertension should be initiated if SBP ≥
140 mmHg and/or DBP ≥ 90 mmHg.
However, treatment decisions need to be
individualized to the patient: advanced age
and/or frailty may create a situation in which
the risk of treatment outweighs the benefit.
The strongest benefit in treatment is seen if
the initial SBP > 160 mmHg, or if there are
multiple cardiac risk factors or evidence of
target organ damage.
Rationale
For persons aged 40-70 years, starting at a BP of 115/75 mmHg, there is a doubling
in the risk of cardiovascular disease for each rise in SBP of 20 mmHg or DBP of 10
mmHg. The Framingham Study has shown a significantly higher age-adjusted risk
ratio for cardio- and cerebrovascular events and sudden death among hypertensive
elders. A treatment threshold of BP ≥140/90 allows blood pressure lowering to be
started before further vascular damage occurs.
See “Treatment: Age-based Recommendations and Rationale” (next page) for
evidence regarding treatment of hypertension in ages 80+.
A review of 36 studies of hypertension treatment in the elderly found that the
strongest evidence for treatment effect occurred with an initial SBP > 160 mmHg,
with weaker data to guide therapy if the SBP was lower than this.
References
1, 7, 37, 38
(see next
page)
39
III. Treatment: Goal Blood Pressure Reduction
Recommendation
Non-diabetic and non-proteinuric elders:
< 140/90 mmHg and no orthostasis or
significant side-effects.
diabetics: < 130/80 mm Hg.
proteinuric patients: < 125/75 mmHg
(and no orthostasis or significant sideeffects for either group)
If these goals cannot be achieved, a
sustained reduction in systolic blood pressure
should still be made, especially if initial
systolic blood pressure is > 160 mmHg.
Rationale
Numerous large-scale placebo-controlled trials of hypertension treatment in elderly
patients have shown that successful reductions in blood pressure are associated with
significant reductions in cardiovascular events and mortality. More aggressive blood
pressure reduction in diabetics and in those with renal disease is associated with
more favorable outcomes.
References
1, 18-23,
32, 33
Expert opinion has not established a less aggressive treatment goal in older
patients, but orthostasis and other harmful side-effects of treatment should be
minimized. Therefore, it is mandatory to check for orthostasis and to alter
treatment means/goals if this is occurring.
A meta-analysis of 15, 693 older patients with ISH showed that just a 10 point
reduction in systolic blood pressure, even if SBP remained greater than 140 mmHg,
was associated with a 30% reduction in strokes, 26% reduction in cardiovascular
event-related deaths, 23% reduction in myocardial infarctions, and a 13% reduction
in all-cause deaths.
8
III. Treatment: Age-based Recommendations and Rationale
Type of Hypertension
Age 65-79
Age ≥ 80
Isolated Diastolic
(DBP ≥ 90 mm Hg)
RCT’s suggest that treatment lowers risk of
stroke, cardiac events, and death.
(1, 19, 21,23)
Insufficient evidence, due to lack of large numbers of octogenarians
in each RCT.(19,21,23) Expert opinion suggests treatment.(1) Decision
must be individualized to the patient, assessing expected life span,
comorbidities, and risks vs. benefits of treatment.
RCT’s show that treatment significantly lowers
risk of stroke, cardiac events, congestive heart
failure, and cardiovascular mortality. (1, 18-23)
Benefit is more conclusive in patients with SBP
>160 mmHg. (39)
RCT's involving broad age ranges (6th-9th decades) support treatment,
but extrapolation should be done carefully as there are fewer numbers
of patients aged 80+ in these trials. (18-23) Expert opinion and
secondary analyses of trials suggests treatment. (1, 41,42) Benefit of
treatment is more conclusive in patients with SBP >160 mmHg. (39)
Isolated Systolic
( SBP ≥ 140 mm Hg)
A dedicated double-blinded RCT is needed to conclusively address
mortality effect of treatment. Therefore, decision to treat must be
individualized to the patient, assessing expected life span,
comorbidities, and risks vs. benefits of treatment.
Notes:
Range of event reduction in 3 large trials: (18-20)
36-47%  in stroke, 13-30%  in MI's, 29-51%,
 in CHF.
Meta-analysis of 8 ISH trials: (40)
30%  in stroke, 26%  in cardiac events, 13%
 in total mortality
Notes:
One meta-analysis of 7 RCT’s suggested caution with treatment: (25)
Subjects: 1,670 patients, age 80+, most with ISH
Results: Among treated group, 33%  in strokes (NNT = 30), 23% 
in cardiovascular events (NNT = 21), and a 40%  in CHF (NNT =
48). No reduction in all-cause or cardiovascular mortality. However,
restricting analysis to double-blind trials would have produced a nonsignificant 6% increase in all-cause mortality.
Hypertension in the Very Elderly Trial (HYVET): (24)
RCT specifically designed to evaluate the benefit of HTN treatment
in age 80+. Primary endpoint: stroke incidence. Secondary endpoints:
cardiovascular events and mortality. Results not available yet.
Systolic/Diastolic
(BP ≥ 140/90 mmHg)
RCT's: treatment significantly lowers risk of
stroke, cardiac events, and cardiovascular
mortality. (19,21,23)
Insufficient evidence, but expert opinion suggests treatment.(1)
Decision must be individualized to the patient, assessing expected life
span, comorbidities, and risks vs. benefits of treatment.
III. Treatment: Considerations Regarding Blood Pressure Reduction: J-Curve Hypothesis
Recommendation
The presence of a “J curve phenomenon”
(higher cardiovascular morbidity and
mortality associated with lower DBP’s) is
not well-established: it is not clear that there
is a cause and effect relationship between
low DBP’s and mortality.
Rationale
Some clinical trials have shown a J-shaped relationship between DBP and risk of
coronary events. It is hypothesized that lowering DBP excessively may affect
coronary perfusion, thus leading to an increased risk of myocardial events and death.
However, a J-shaped relationship between DBP and morbidity/mortality is not wellestablished, as some studies have failed to demonstrate this phenomenon.
References
Therefore, a low DBP is not a contraindication to trying to treat isolated systolic
hypertension. However, during treatment, it
is advisable to monitor the degree of DBP
reduction in patients with existing
cardiovascular disease.
Other studies have suggested that the increased risk of coronary events seen in
people with lower DBP’s may be due to the presence of underlying existing cardiac
disease or chronic disease (i.e. the low DBP is a proxy measure for higher risk).
49, 50
One meta-analysis of seven RCT’s involving hypertension treatment of 40, 233
patients found a J-shaped relationship between diastolic blood pressure and risk for
total and cardiovascular deaths for both treated and untreated patients, suggesting
that the increased death risk was not related to hypertension treatment, but perhaps
was related to underlying health conditions causing a low DBP.
51
21, 43-47
18, 48
III. Treatment:
Nonpharmacologic Interventions
Intervention
Reduction in Sodium
Intake
Recommendation
Limit sodium to less than 2.4 gm/day.
Rationale
RCT's and well-designed clinical studies support
effect of sodium intake limitations on clinically
significant BP reductions. Although individuals vary
in their sodium sensitivity, older patients tend to be
more salt-sensitive than younger hypertensives.
Limitations should be modified per patient’s overall
nutritional status or quality of life issues.
References
1, 40, 52, 53
Increased Intake of
Calcium/Potassium
Diet should be rich in grains, fruits and
vegetables, and low-fat dairy products.
Trials involving the use of the DASH diet in treating
hypertension showed moderate reductions in BP in
older hypertensives.
54-56
If overweight (BMI > 25), reduce weight to at
least within 10% of ideal body weight. For
starters, encourage at least 10 kg of weight
loss. Individualize recommendations to
patient’s other health concerns, as well.
Excess weight is correlated with elevated BP's, and a
weight loss of only 10 kg can lower systolic BP by 520 mmHg.
1, 52, 57
(“Dietary Approaches
to Stopping
Hypertension” Diet:
DASH Diet)
Weight Loss
III. Treatment: Guidelines on Selection of Therapeutic Agents, per Compelling Indication
Compelling Indication
Obesity
Recommendation
All older obese persons should be educated
about the benefits of weight loss and
decreasing sodium intake
Rationale
Trial of Antihypertensive Interventions and
Management (TAIM) suggests that effective weight
loss of 4.5 kg or more lowers blood pressure similarly
to low-dose drug therapy and potentiates drug effects.
References
1, 52, 57
Trial of Nonpharmacologic Interventions in the
Elderly (TONE) suggests that weight loss and reduced
sodium intake was a feasible, effective, and safe
nonpharmacologic therapy of hypertension in older
persons.
Note: Neither of these trials demonstrated a reduction
in cardiovascular morbidity/mortality.
Isolated Systolic
Hypertension
Consider using a thiazide diuretic as first line
agent.
Predominance of ISH RCT’s showing treatment
benefit used thiazide diuretics (usually
chlorthalidone). A meta-analysis of 42 trials involving
192,478 adults with all forms of hypertension showed
that low-dose diuretics, compared to multiple other
classes of anti-hypertensives, were the most effective
first-line agents for preventing the occurrence of
cardiovascular disease morbidity and mortality.
1, 18-20,
23, 58
Diabetes mellitus
ACE Inhibitors or angiotensin receptor
blockers (ARB’s) should be considered as
first line agents. Watch serum glucose if using
thiazide diuretics.
Due to renoprotective effects and neutral effects on
glucose and lipids, ACE Inhibitors and ARB’s are
preferred agents. Cost must be considered when
choosing which agent to use among these categories.
1, 26, 28,
59, 60
First line treatment with chlorthalidone is not
associated with any adverse effects on quality of life,
including cognitive performance. However, one may
see mild elevations in serum glucose with thiazide
diuretics, so glucose monitoring is encouraged.
III. Treatment: Guidelines on Selection of Therapeutic Agents, per Compelling indication
Compelling Indication
Recommendation
Rationale
References
Congestive Heart
Failure
Use ACE Inhibitors or ARB’s as first-line
agents. B-blockers are also beneficial.
ACE Inhibitors and ARB’s have been found to have
benefits on left ventricular remodeling and systolic
function in patients with CHF. These agents and Bblockers have a positive effect on reducing mortality
in patients with CHF.
1, 32 ,
61-64
Myocardial Infarction
Beta-blockers and/or ACE inhibitors (or
ARB’s) should be considered as first-line
agents. If an anti-anginal is necessary, the
use of calcium channel blockers can be
considered.
B-blockers and ACE Inhibitor’s are associated with
decreased mortality after myocardial infarctions.
1, 32,
65-67
Nephropathy
Use ACE inhibitors ( or ARB’s) when the
serum creatinine is greater than 1.5 mg/dL or
the 24-hour urine protein is greater than 1
gram.
Meta-analyses have shown that in “non-vulnerable
elders,” ACE inhibitors slow the progression toward
end stage renal disease and dialysis in the setting of
hypertensive nephropathy.
Gout
Avoid thiazide diuretics in patients with gout.
Patients predisposed to acute attacks of gout may be
susceptible to the increased resorption or decreased
secretion of serum uric acid when taking thiazide
diuretics.
1, 60
Hyperlipidemia
Use calcium channel blockers or ACE
inhibitors
Effects of calcium channel blockers or ACE inhibitors
tend to be neutral on blood glucose and lipids;
therefore, there may be an advantage over the use of
thiazide diuretics or B-blockers.
59, 69
Erectile dysfunction
Use chlorthalidone with caution.
Chlorthalidone is associated with erectile dysfunction
in 10-15% of middle aged men.
26, 28
1, 68
IV. Treatment: Therapies Not Recommended
Recommendation
Short-acting calcium channel blockers should be avoided.
Rationale
Short-acting calcium channel blockers (sublingual
nifedipine) have been associated with rapid and
excessive drops in blood pressure. Expert opinion
does not advocate use of these agents, as observational
studies and meta-analyses have shown higher
mortality in groups receiving these agents.
References
32, 70-72
IV. Treatment: Additional Information Regarding Treatment Strategies
See Teaching Card and Slide Shows which accompany this module. (Evidence-Based Geriatric Module: Hypertension)
V. Quality of Care Indicators for Continuous Quality Improvement Activities
-
See Quicksheet and Audit form which accompany this module. (Evidence-Based Geriatric Module: Hypertension)
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Authorship
These guidelines were developed by the Geriatric Education Guidelines development group of the Department of Family Medicine, University of
North Carolina at Chapel Hill. Members of the guidelines group include: Amrit Singh, MD (chair), John Harrington MD. Julie Price, MD; Bron
Skinner, PhD; Philip Sloane, MD, MPH, and Sam Weir, MD, MPH. Primary author of this guideline was Dr. Singh.
This work was supported by funding from HRSA grant #5 D22 HP 00167-02 and from the Donald W. Reynolds Foundation.
© 2006 The University of North Carolina at Chapel Hill Program on Aging