Hypertension in the Elderly: Pocketbook

As will be noted later, almost all who are hypertensive before treatment will become hypertensive again if treatment is stopped. There are three possible relationships between the levels of blood pressure achieved by therapy and the risk 55 Figure 26 Three models of hypothetical relationships between levels of blood pressure and risk of cardiovascular disease.

Line A implies the lower the blood pressure, the less the risk, in keeping with the straight-line relationship between untreated levels of blood pressure and risk shown in Figure However, the results of the multiple RCTs described earlier have suggested that the consequences of therapy are more accurately portrayed as either line B, wherein little if any additional benefit is derived from increasingly greater reduction in blood pressure, or line C, wherein additional risks appear as the pressure is reduced below some initial level.

From the time in when the English practitioner I. Stewart reported a fivefold increase in heart attacks among patients whose diastolic blood pressure fourth Korotkoff phase was reduced below 90 mmHg, considerable arguments have either defended or denied the presence of a J-curve. The reason for so much discussion is the implication that therapy beyond a certain level could have serious adverse consequences.

The HOT trial involved almost hypertensives aged 50—80 years mean They were randomly divided into three groups to receive drug therapy adequate to lower their diastolic blood pressure to either 90, 85 or 80 mmHg. From Hansson et al. Therefore, the existence of a J-curve could be neither denied nor documented because of the small degree of blood pressure differences. No additional benefit was seen at lower pressures.

The authors of the HOT trial paper provide arguments against the J-curve. However, a closer look at Figure 27 shows a rise—slight but definite—in cardiovascular event and mortality at diastolic pressures below 85 mmHg. Evidence for a J-curve for diastolic pressure The patients enrolled in the HOT trial had combined systolic and diastolic hypertension. As previously noted, the largest part of the elderly hypertensive population has isolated systolic hypertension ISH , starting with diastolic BP below 90 mmHg.

As also previously noted, the pressure fall in diastolic BP typically occurring over age 55 is, in itself, a risk factor. There is some evidence that further inadvertent reductions in diastolic BP by drug therapy of ISH may increase the risk of stroke. However, subsequent analysis found an increase in stroke events in those whose diastolic BP was reduced more than 5 mmHg and to below 65 mmHg, compared to those with a lesser fall in diastolic levels Somes et al.

Reference category is the second lowest category of diastolic blood pressure.

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Values are plotted on a logarithmic scale. Varying goals Based on these data, the goal for the elderly with ISH should be a systolic of mmHg, as long as the diastolic does not fall to below 65 mmHg Staessen et al. We will now turn to the therapies that will be needed to reach these goals, starting with lifestyle modifications and then drug therapy. Not all of these have been studied in elderly patients, but their benefits almost certainly apply to them equally as much or even more. For instance, elderly people respond better to a lower sodium intake, i.

Avoidance of tobacco Nicotine has an acute and often dramatic pressor effect that does not lessen with continued exposure. Tolerance to Table 13 Lifestyle modifications for hypertension 61 Figure 29 Changes in systolic blood pressure over 15 minutes after smoking the first cigarette of the day in 10 normotensive smokers. From Groppelli et al. The pressor effect noted in addicted smokers from the cigarette smoked for 2 minutes is shown to persist for 15 minutes in Figure 29, but is gone by 30 minutes. Therefore, the effect may not be recognized, as smoking is not allowed in clinics or offices where blood pressure is measured.

Therefore, if possible, smokers should take their blood pressure while smoking. That reading should be the basis for deciding on therapy and the goal of therapy. Regardless of age or duration of smoking, every effort should be made to get the patient to stop smoking. Weight loss Weight gain is the most common direct environmental cause of hypertension. Even relatively small amounts of weight gain increase the incidence of hypertension, as 62 shown in the report by Huang et al. Those who gained as little as 5 kg 11 lb from their weight at age 18 had twice as much hypertension as those whose weight did not change; with a 10kg 22 lb weight gain the incidence tripled.

These data clearly indicate the major contribution of even modest weight gain to the risk for hypertension. Furthermore, those who lost weight had less hypertension, in keeping with a large body of data showing falls in blood pressure with weight loss Figure Difficult as it may be, particularly for the elderly, weight loss must be constantly Figure 30 Systolic and diastolic blood pressure before and after body weight reduction. The short-term use of diet pills may be of some help, but caution is needed as most can raise blood pressure. Sodium restriction Despite a claim based on flawed data by Alderman et al.

Modified from Cutler et al. The elderly are more sodium sensitive and therefore more likely to respond favorably to sodium reduction. However, two factors may make it more difficult for them to reduce sodium: The effort to reduce dietary sodium moderately is worthwhile and success can be achieved with counseling, the avoidance of processed foods with more than mg of sodium per portion as indicated on the label a major boon to sodium avoidance , and occasional checks of urinary sodium excretion. The TONE trial Perhaps the best documentation of the benefits and safety of modest sodium restriction, alone or combined with weight loss, in elderly hypertensives comes from the randomized controlled Trial of Nonpharmacologic Interventions in the Elderly TONE reported by Whelton et al.

Are hypertensive elderly patients treated differently?

The trial involved men and women aged 60—80 years with hypertension that was being well controlled on one or two medications. The patients agreed to discontinue their drugs and were then randomly allocated to four groups: From Whelton et al. Despite these modest changes, the number whose hypertension reappeared the primary end-point and who developed cardiovascular complications was far greater among the usual care group than among those who reduced either sodium intake or body weight.

Those who did both were protected even more. Subsequent analysis of the TONE data showed that, compared to those on usual care, those assigned to sodium reduction achieved a 4. The appropriate amount, i. Those who drink more than two portions on average per day must be strongly advised to cut back. Small amounts of daily alcohol consumption protect against coronary mortality, as shown in numerous surveys, including that of Thun et al.

Occ, occasional; light, one to two daily; Mod, moderate, three to six daily; Heavy, more than six daily. From Shaper et al. As expected, mortality from alcohol-related diseases increased with excessive consumption. The lower recommendation for women should circumvent any threat of stimulation of breast cancer by alcohol. Maintain adequate dietary potassium, calcium and magnesium Intake of these three minerals should be well maintained in the elderly, preferably by a diet containing adequate amounts of fresh fruits, vegetables and dairy products; if not, by mineral and vitamin supplements.

On the other hand, as reviewed by Sacks et al. More fresh fruits and vegetables reduce BP Sacks et al. These benefits may reflect many effects of such a diet: As shown by Hakim et al. The longer the walk, the lower the mortality. Such low-intensity activity will also lower blood pressure, probably contributing to the overall reduction in mortality. Higher-intensity activity may be even better, both to aid in weight loss and to lower blood pressure. Pure isometric exercise weightlifting only raises blood pressure acutely; during aerobic or isotonic activity running, swimming systolic blood pressure increases and diastolic goes down.

Afterwards both systolic and diastolic levels tend to remain lower. Those elderly hypertensives who cannot walk, run or swim should be encouraged to use whatever exercise devices they can that are available at health clubs and retirement centers. Reduce dietary saturated fat and cholesterol There is very likely some benefit on the blood pressure when diet or statin drug therapy lowers serum LDL cholesterol.

The effect is mediated by improvements in endothelial function, with increased synthesis of vasodilatory nitric oxide. In most trials of lipid-lowering agents a slight but significant fall in blood pressure has been observed Goode et al. Other modalities Increased amounts of fiber, omega-3 fatty acids, garlic or oral antioxidants, as well as various relaxation techniques, have been claimed to lower blood pressure, but most of the trials are small, short and poorly 69 controlled Kaplan, None of these should have adverse effects, but do not expect them to lower blood pressure.

Two additional drugs are widely used among elderly hypertensives: Aspirin, 75 mg daily, was shown in the HOT trial to reduce coronary events but to increase nonfatal bleeding episodes. ERT, unlike oral contraceptives, does not raise blood pressure and can be given to hypertensive women without concern about their blood pressure. After these lifestyle changes have been attempted, the blood pressure may remain above the goal, making drug therapy compulsory.

Because the elderly may have sluggish baroreceptor and sympathetic nervous responsiveness as well as impaired cerebral autoregulation, therapy should be gentle and gradual, avoiding drugs that are likely to cause postural hypotension or to exacerbate other common problems often seen among the elderly Table Table 14 Factors that might contribute to increased risk of pharmacological treatment of hypertension in the elderly 71 These cautions should not however, interfere with the well-documented need to treat the overwhelming majority of elderly hypertensives. The benefits they have been shown to receive from antihypertensive drug therapy, detailed earlier, are quantitatively greater than those provided to younger patients.

No longer should age alone interfere with the provision of appropriate therapy. General guidelines The treatment algorithm shown in Figure 34 is well suited to the elderly hypertensive, with the caveat that most will Figure 34 Treatment algorithm based upon the use of a low dose of diuretic as the first choice and, if BP control is not achieved, the addition of a second drug determined by the presence of compelling indications.

As the majority of the elderly will have isolated systolic hypertension, attention will be directed to the compelling indications for diuretics as the preferred initial therapy, and the use of long-acting dihydropyridine DHP calcium antagonists as an appropriate second drug or, rarely, an alternative. Diuretics for initial therapy As shown earlier, a low-dose diuretic was the first drug used in most of the major randomized controlled trials in the elderly.

A large amount of data from the Systolic Hypertension in the Elderly SHEP trial has confirmed the efficacy and safety of the step 1 drug chlorthalidone, started at As reported by Savage et al. Biochemical changes were relatively minimal over the 3 years of active therapy Table These data, along with those from the other RCTs described earlier, strongly support the preference given to low-dose diuretics for the elderly.

Emphasis should be given to the low doses, equivalent to Long-acting dihydropyridine calcium antagonists As described earlier, four RCTs have been completed comparing one of these agents against placebo in elderly patients with isolated systolic hypertension ISH. All three showed excellent protection from both stroke and coronary disease with either longacting nitrendipine or nifedipine. The cardioprotection provided by these long-acting DHP calcium antagonists should allay any concerns about the danger noted with very large doses of short-acting nifedipine in the highly vulnerable post myocardial infarction period Brown et al.

Long-acting antagonists do not lower blood pressure abruptly, thereby avoiding the activation of sympathetic activity that is seen with short-acting agents Grossman and Messerli, Another concern about short-acting calcium antagonists— their promotion of cancer—as reported in 74 retrospectiveuncontrolled observations has also been clearly documented not to apply to the long-acting agents. In the Syst-Eur trial Staessen et al. Numerous large surveys have documented the absence of any relationship between calcium antagonists and cancer Kizer and Kimmel, These include amlodipine, felodipine, nicardipine, nifedipine XL and nisoldipine.

One conclusion seems obvious: Certainly, calcium antagonist-based therapy protected better against stroke and less well against CHD and CHF, but the two forms of therapy were identical in their effects on overall morbidity and mortality rates. Furthermore, a good deal of admixture occurred in these trials. In one Estacio et al. Table 16 shows data from the two trials that directly compared an ACEI with a calcium antagonist Estacio et al.

The results of the trials completed since are by no means definitive. As He and Whelton noted: Fortunately, many trials are in progress, so that more definitive data to guide our choices of therapy will soon be available. Of course, the playing field keeps growing. By the time we know whether ARBs are as good as ACEIs, vasopeptidase inhibitors will probably be available, so the process of finding out what is best will probably never end.

In one sense the process is irrelevant. As the need to achieve lower goals of therapy has become obvious, the need to use more than one drug in the majority of hypertensive patients has also become obvious. This is nowhere better seen than among elderly diabetic hypertensive patients, who will be considered in the next section. Therefore, the best combination of agents, almost always to include a low dose of diuretic, will be a more pertinent object of trials in the future.

Drugs for specific indications A variety of comorbid conditions that are often seen in elderly hypertensives may be favorably influenced by oneclass of drug or another, whereas others may be adversely affected by certain drugs. However, the wisdom of using an a-blocker to relieve the symptoms of prostatism while also lowering the blood pressure is obvious. As noted by Lieber , ablockade is now the accepted initial therapy for most patients with urinary obstructive symptoms, so that only one drug will often manage the two conditions, hypertension and BPH, which occur together in as many as 25 of elderly men.

Concerns about a-blockers arising from the termination of that arm of the ALLHAT trial because of an apparent increased incidence of heart failure compared to the diuretic arm ALLHAT, should not deny their use along with a low dose of diuretic when indicated. If the blood pressure is still too high, a calcium antagonist may be required. Patients with renal insufficiency, defined as a serum creatinine above 1. ACEIs are always indicated. If diabetic nephropathy is the cause of renal damage, an ARB may be chosen instead.

Most will require a third drug, and a calcium antagonist is often the best choice to control hypertension. Special guidelines for the elderly These recommendations should be helpful in controlling hypertension in the elderly, in addition to those described later that are aimed at improving overall compliance with therapy Kaplan, Always check for postural and postprandial hypotension before starting antihypertensive drug therapy to avoid even more precipitous falls in blood pressure.

If present, utilize the various maneuvers described earlier to overcome the postural and postprandial falls in blood pressure. Start with a low dose of a thiazide diuretic, preferably in combination with a potassiumsparing agent; if the serum creatinine is above 1. If the diuretic is inadequate or poorly tolerated, add or substitute a long-acting DHP calcium antagonist, again starting with a dose one-half the usual starting dose. Titrate slowly, every 4—8 weeks, until control is attained. Use agents in addition to diuretics or DHP calcium antagonists that provide favorable influences on comorbid conditions, as noted in Figure If a b-blocker is indicated, as with angina or post myocardial infarction, or an alpha-blocker for prostatism, always add a low dose of thiazide diuretic.

Always use once-a-day dosing with long-acting agents that provide full hour efficacy. Agents such as amlodipine and trandolapril, with inherently longer durations of action, are particularly attractive to cover the days when doses are skipped—a common occurrence. Some, such as grapefruit juice, potentiate antihypertensive effects, but the most common interaction is with non-steroidal anti-inflammatory agents NSAIDs , which will antagonize the effects of all agents save calcium antagonists Harris and Brater, Johnson recommends the use of physical therapy and other analgesics such as acetaminophen, which do not interfere with antihypertensive drug efficacy.

Erectile dysfunction Erectile dysfunction is common in elderly men, usually a consequence of atherosclerotic impairment of penile blood flow.

Hypertension may add to the problem, which may be further aggravated by antihypertensive therapy. As reported by Grimm et al.

Only 15 mg of chlorthalidone was used, so the problem can obviously be exacerbated by low doses of diuretics. Now the best course, if the antihypertensive therapy is otherwise effective and well tolerated, may be to simply give sildenafil, which should have no interaction with any antihypertensive drug. Caution is obviously needed to avoid the use of sildenafil with nitrates that may induce profound hypotension.

Even if all the guidelines are followed, compliance with therapy may be poor. Advice to improve compliance is provided next. According to a survey of over hypertensives in England reported by Jones et al. On the other hand, Monane et al. Compliance worsened when multiple drugs were prescribed and improved with more physician visits. Unfortunately, hypertension and its treatment fulfill many of the criteria that are known to reduce adherence to any therapy Table As hypertension is an asymptomatic, Table 17 Factors that reduce adherence to therapy 82 Table 18 General guidelines to improve patient adherence to antihypertensive therapy 83 chronic incurable condition whose treatment requires daily therapy that may cause side effects and which provides no obvious benefit, it is easy to see why so few patients adhere closely to their therapy.

Table 18 provides general guidelines to improve patient compliance with therapy. Unfortunately, few of these have been documented to be successful. In their review of all published randomized trials of interventions to improve compliance Haynes et al. Five of these involved hypertensives. Improved adherence to antihypertensive therapy was noted with these interventions.

Are hypertensive elderly patients treated differently?

The elderly often have additional impediments to adherence to therapy, ranging from difficulty in opening childproof containers to an inability to pay for expensive drugs, to difficulty in reaching their healthcare providers. Hopefully, the guidelines provided in Table 18 and elsewhere in this book will help physicians and their patients to achieve the true goal of antihypertensive therapy: Dietary sodium intake and mortality: Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone.

Effects of reduced sodium intake on hypertension control in older individuals. Arch Intern Med ; Fetal origins of coronary heart disease.

Essential Hypertension in the Elderly

Br Med J ; Factors common to all techniques. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: Congenital oligonephropathy and the etiology of adult hypertension and progressive renal injury. Am J Kidney Dis ; Technique of blood pressure measurement. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: The prognosis of hypertension according to age at onset. Prevalence of hypertension in theUS adult population.

Randomized trials of sodium reduction: Am J Clin Nutr ; 65 Suppl: J Hum Hypertens ; Primary prevention of coronary heart disease. Excerpta Med ; 1: The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulindependent diabetes and hypertension. N Engl J Med ; Prevention of dementia in randomised double-blind placebo-controlled systolic hypertension in Europe Syst-Eur trial.

Does the relation of blood pressureto coronary heart disease risk change with aging? The Framingham Heart Study. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: J Hypertens ; Hyperlipidaemia, hypertension, and , coronary heart disease. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Ambulatory blood pressure monitoring and postprandial hypotension in elderly patients with isolated systolic hypertension.

Persistent blood pressure increase induced by heavy smoking. Grossman E, Messerli FH. Effect of calcium antagonists on plasma norepinephrine levels, heart rate, and blood pressure. Am J Cardiol ; Antihypertensive drugs in very old people: Effects of walking on mortality among nonsmoking retired men. Home blood pressure recording in mild hypertension: J Hum Hypertens ; 4: Hallock P, Benson IC. Studies of the elastic properties of human isolated aorta. J Clin Invest ; Benefits of intensive blood pressure lowering and acetylsalicylic acid in hypertensive patients: Randomized trial of old and new antihypertensive drugs in elderly patients: Renal effects of cyclooxygenase-2 selective inhibitors.

Curr Opin Nephrol Hypertens ; Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Selection of initial antihypertensive drug therapy.


Biochemical changes were relatively minimal over the 3 years of active therapy Table However, we believe this is appropriate for comparing the prescription of antihypertensives in older and younger adult populations, and for considering adherence with JNC 6. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. This study shows that CCBs were preferentially prescribed more often than BBs to all hypertensive patients, regardless of age. Unfortunately, few of these have been documented to be successful. Multiple and more accurate blood pressure measurements are needed, primarily because of the marked variability of the blood pressure, as shown in the hour readings taken by an automatic recorder on a single patient taking no medication and performing his usual daily activities Figure Figure 14 Technique of blood pressure measurement recommended by the British Hypertension Society.

Beneficial effects of potassium. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on death from cardiovascular causes, myocardial infarction, and stroke in high-risk patients. Prevention of end-stage renal disease due to type 2 diabetes. Body weight, weight change and risk for hypertension in women. Ann Intern Med ; Management of raised blood pressure in New Zealand: Drugs Aging ; Discontinuation of and changes in treatment after start of new courses of antihypertensive drugs: Fruit and vegetable intake in relation to risk of ischemic stroke.

Prospects for prevention of cardiovascular disease in the elderly. Prev Cardiol ; 1: Elevated systolic blood pressure as a cardiovascular risk factor. Clinical hypertension, 8th edn. Some different types of essential hypertension: Am J Med Sci ; Epidemiologic review of the calcium channel blockerdrugs. An up-to-date perspective on the proposed hazards. Lavie P, Hoffstein V. Pharmacologic therapy for prostatism. Mayo Clin Proc ; Intra-individual variability in postural BP in the elderly.

Clin Sci ; Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Blood pressure, stroke, and coronary heart disease, Part 1: Prolonged differences in blood pressure. Blood pressure control in the hypertensive population. The effects of initial drug choice and comorbidity on antihypertensive therapy compliance. Am J Hypertens ; ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Neaton JD, Wentworth D.

Serum cholesterol blood pressure, cigarette smoking and death from coronary heart disease. Overall findings and differences by age for , white men. Vrain JA et al. Effect of treatment of isolated systolic hypertension on left ventricular mass. Mechanical principles in arterial disease. Blood pressure monitoring outside the office for the evaluation of patients with resistant hypertension. Hypertension ; 11 Suppl II: Randomised trial of a perindopril-based blood-pressure-lowering regimen among individuals with previous stroke or transient ischaemic attack. Health outcomes associated with antihypertensive therapies used as first-line agents.

British Hypertension Society guidelines for hypertension management Optimizing drug treatment for elderly people: Effect on blood pressure of potassium, calcium and magnesium in women with low habitual intake. The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc ; Influence of long-term, low-dose, diuretic-based, antihypertension therapy on glucose, lipid, uric acid, and potassium levels in older men and women with isolated systolic hypertension.

Schwartz SM, Ross R. Cellular proliferation in atherosclerosis and hypertension. Prog Cardiovasc Dis ; Alcohol and blood pressure in middle aged British men. J Hum Hypertens ; 2: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. The role of diastolic blood pressure when treating isolated systolic hypertension. Body weight, sodium intake and blood pressure. J Hypertens ; 7 Suppl 1: Randomized double-blind comparison of placebo and active treatment of older patients with isolated systolic hypertension.

Risks of untreated and treated isolated systolic hypertension in the elderly: Cardiovascular protection and blood pressure reduction. The increased prescription of A2Ags likely reflects long-term usage of these medications, which nonetheless may be hazardous due to their potential for causing increased cognitive dysfunction in the aged. Hypertension is commonly encountered in the aging population. Randomized, controlled trial data demonstrate that antihypertensive therapy reduces morbidity and mortality in the elderly SHEP ; Staessen et al ; Neal et al Collectively, these observations suggest that a high proportion of the elderly population will receive antihypertensive therapy.

The means whereby clinicians develop a treatment plan for elderly patients with hypertension is unknown. The aging process is known to be associated with physiologic changes which raise blood pressure including increased arterial vessel stiffness, decreased arterial compliance, reduced beta-adrenergic function, and decreased plasma renin activity Weber et al ; Furmaga et al ; Lakatta and Levy The aged population frequently has co-morbid disease and limited financial resources which may impact provider decision-making.

Several studies have compared the efficacy of antihypertensive agents in the elderly and therapeutic recommendations based on these studies have been promulgated by different groups, most prominently by the 5th through 7th Joint National Committees on the Detection, Evaluation, and Treatment of High Blood Pressure JNC 5—7 JNC , ; Chobanian et al However, there is limited information on existing patterns of antihypertensive treatment in the elderly.

The present study was therefore undertaken to ascertain the current patterns of antihypertensive therapy in an older as compared with a younger population. We also desired to compare patterns of antihypertensive therapy with recommendations of national committees. For the timeframe of this study, JNC 7 was not yet available and diuretics and beta-blockers BBs were the recommended first-line agents by JNC 5 and 6. It has been conducted annually since In the NAMCS database, the diagnoses are noted according to their ICD-9 codes and the medications have specific numeric codes by which they are listed.

Based on the geographic and population data, each site center is designated as urban or non-urban, and its region is designated as Northeast, South, Midwest, or West.

We identified the encounters with an ICD-9 code for essential hypertension eg, NAMCS data sets were combined to produce reliable estimates regarding medication usage of the essential hypertensive patient population. We then analyzed the antihypertensive medications listed for these encounters and classified them into the appropriate therapeutic class.

For combination antihypertensives, we noted the patient was on both classes of medications eg, lotrel, which is a combination of amlodipine and benazepril, was classified as both a CCB and an ACEI. Proportional comparisons were made using the chi-square test of association. Since the chi-square test determined unadjusted general associations between geriatric age of patient and region, pairwise comparisons were also performed to determine the specific regional differences. Mantel-Haenszel chi-square tests were performed to determine the associations between geriatric age and the demographic variables of gender, race, insurance type, urban status, and region as stratified by survey year.

The results of the stratified analysis indicated similar associations between geriatric age and the demographic variables. Within each year strata, the association between geriatric age and the demographic variables were the same. Bivariate analyses were first performed to determine unadjusted associations between antihypertensive class and geriatric age. Each analysis controlled for patient gender, race white or non-white , insurance type self-pay, all other , urban status metropolitan area, non-metropolitan area , geographic region Northeast, Midwest, South, or West , and NAMCS year — Prescribing time patterns of each antihypertensive medication class were also explored.

First, unadjusted chi-squared analyses determined general associations between year — and each of the antihypertensive medication classes. This analysis determined if the time trend associations remained when the essential hypertensive population was restricted by age less than 65 years, 65 years of age or older. These analyses were performed only for hypertensive classes with sample sizes large enough to produce reliable estimates according to National Center for Health Statistics NCHS standards number of sampled patient visits is at least 30 and the relative standard error is less than 0.

Multivariate logistic regression analysis determined adjusted association between antihypertensive class and prescribing year while controlling for demographic variables discussed above. Statistical associations were determined at the alpha level of 0. All estimates reported are reliable by NCHS standards. Per the NAMCS database, an estimated essential hypertension patient visits occurred during — Of these hypertensive patients, Hypertensive patients 65 years and older were more likely female All other p-values indicate pairwise differences between geriatric age category for each region category.

Hypertensive patients who were 65 years of age or older were more likely to be prescribed or already using diuretics adjusted odds ratio [adj OR] — 65 yrs or older: The proportion of essential hypertensive patients prescribed BBs appear to decrease between and ; whereas the proportion of essential hypertensive patients prescribed ARBs appear to increase. Our results demonstrate that hypertensive patients aged 65 and over were treated differently than their younger counterparts in the US from — However, the prescription of diuretics, CCBs, A1Bs, and A2Ags was significantly more frequent in the older population than in younger hypertensives.

Our theories regarding this discrepant prescribing are detailed below. Their preferential use in the group aged 65 and older may reflect adherence to evidence-based guidelines such as JNC 6. This study shows that CCBs were preferentially prescribed more often than BBs to all hypertensive patients, regardless of age. At best, physicians were following the evidence in some ways eg, by prescribing diuretics frequently while eschewing them in others.

Possibly, physician perceptions of frequent BB side effects led to this behavior Ubel et al Publicity for CCBs by drug representatives may have led to more frequent prescription for the general population, but this does not explain their preferential use in the geriatric population. Caution is urged in the prescription of A1Bs to the elderly due to potential orthostatic hypotension, and yet these agents were preferentially used in the elderly population.

One can surmise this is likely due to the frequent co-morbidity of benign prostatic hyperplasia BPH in elderly men.

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However, it is interesting to note that these medications were specifically noted in a visit coded for hypertension, so some practitioners may have considered these to be good medications for high blood pressure in their elderly male patients regardless of the degree of BPH which was present. A2Ags were also prescribed preferentially to the geriatric population despite concerns that cognitive dysfunction, notably sedation, may occur when used in this group JNC We hypothesize that these medications were prescribed years ago when there were few alternatives and if they were well-tolerated, they were continued by practitioners.

Simply put, the longer that someone has been hypertensive, the more likely they are taking an older medication. Clearly, the geriatric population would be more likely to have been hypertensive for a longer period of time than younger adults. One other theory is that the convenience of once-weekly topical dosing options with clonidine patches leads to greater use in older adults who may suffer from memory impairment or difficulties in swallowing pills.

There are several caveats to consider in reviewing our results.