For hypertension in the elderly, the systolic value for cerebrovascular and cardiovascular mortality is the key factor.
Hypertension in the elderly is a very common phenomenon. From about the age of 50, the diastolic value decreases, so that almost 2/3 of all over-60s have isolated systolic blood pressure values in excess of 140 mmHg and thus represent the most important cardiovascular risk factor in this age group. Blood pressure values> 140mmHg systolic to <90mmHg diastolic increase the risk of left ventricular hypertrophy, myocardial infarction, renal disorder, stroke and cardiovascular death by 2-4 fold.
With weight reduction, reduced salt intake, restriction of alcohol consumption and exercise - endurance exercise and strength training - are primary to use as a blood pressure regulating measures.In the treatment of hypertension in the elderly, it is important that endothelial dysfunction, altered sodium sensitivity, structural changes of the major arteries, left ventricular hypertrophy, diastolic dysfunction, heart failure, or atrial fibrillation are also found The risk of a cardiovascular event due to concomitant diseases and complications is naturally highest.
Diagnosis of hypertension in the elderly
According to expert recommendations - in contrast to the one-time blood pressure measurement by the doctor - 30 measurements - ideally made by the patient - necessary to be able to estimate the correct level of blood pressure.
If the blood pressure values of more than seven of the 30 measurements exceed 135 / 85mmHg, hypertension is independent of age. Especially in the elderly, the blood pressure values can vary more due to the higher wall stiffness of the vessels, which is why even more frequent measurements are required.
Elderly persons should also be aware of blood pressure fluctuations due to lower blood volume or baroreceptor dysfunction, which may clinically present as increased blood pressure response during stress or after isometric effort, and on the other hand as orthostatic and postprandial blood pressure drop.
Also, antihypertensive drugs can lead to increased hypotension, which is why dizziness and falls should be queried in an anamnestic manner and, if necessary, blood pressure controls should be used more frequently.
Hypertension in the elderly and risk assessment
Both the causes of secondary hypertension in old patients and other cardiovascular risk factors as well as existing organ consequences and complications are to be clarified in the anamnesis and physical examination.
Myocardial infarction and left ventricular hypertrophy can be detected by ECG, while echocardiography also supports the detection of hypertrophy and ventricular function. It is also important to consider blood glucose, lipid status, potassium, serum creatinine and urinary findings, and to detect vascular changes such as PAOD or kidney impairment (proteinuria).
Therapeutic options of hypertension in the elderly
The benefit of lowering blood pressure is undisputed, and large studies have proven it in older patients too: the reduction of systolic blood pressure by 2 mmHg reduced the coronary risk by 7% and the incidence of strokes even by 10%.
Therefore, primarily weight reduction, reduced saline intake and restriction of alcohol consumption together with more exercise - especially endurance exercise - as blood pressure regulating measures to use in smaller studies so a reduction in systolic value by 5mm Hg and diastolic pressure by 4mmHg can be achieved.
Pharmacological blood pressure lowering of hypertension in the elderly
If the effects are only minor and, in particular, in the presence of risky concomitant diseases, a drug-induced regulation of blood pressure should be sought. The primary goal of the therapy is to achieve optimal blood pressure values below 140mmHg and below 90mmHg, with a maximum of seven out of 30 self-measurements above 135 / 85mmHg.
Basically, always start with the lowest dose, a dose increase must be slow. Since orthostatic reactions can occur in older people - up to 30% of cases exceeding 20mmHg - blood pressure measurements must be made both lying and standing, and a dose increase must be adjusted to the standing blood pressure.
For the same efficacy, the individual active ingredients should always be selected according to the comorbidities. Essentially, the four substance groups ACE inhibitors, AT1 receptor blockers, calcium antagonists and diuretics are available for initial monotherapy. When using several drugs, the combination of ACE inhibitors / AT1 receptor blockers and diuretics is favorable; alternatively, ACE inhibitors or betablockers, administered together with calcium antagonists, show advantages in elderly patients.
Diuretics or calcium antagonists can be used especially in hypertensives without comorbidities, ACE inhibitors / AT1 receptor blockers and calcium antagonists are the combination of choice in left ventricular hypertrophy.
In patients with angina pectoris therapy with beta-blockers is an advantage, which should be extended in status post myocardial infarction by ACE inhibitors / AT1-blocker. Cardiac insufficiency requires the administration of ACE inhibitors, diuretics and beta-blockers. If the patient has obstructive pulmonary disease, calcium antagonists and ACE inhibitor / AT1 receptor blockers are the treatment of choice. Alpha blockers are a therapeutic option in prostate hypertrophy with micturition disorder, but they are contraindicated in concomitant heart failure.
In most cases, hypertension in the elderly requires combinations of active ingredients in order to achieve the blood pressure targets - this can be a particularly difficult task, especially for very old, multimorbid, frail patients.
These patients may therefore be expected to have a higher target of less than 150 / 90mmHg. With regard to compliance with hypertension in the elderly, patients should be aware of cognitive deficits and include family members in the treatment plan from the beginning. The daily dose should possibly be provided by helpers and thus guaranteed.