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PRESENTATION
 81-YEAR-OLD FEMALE NON-SMOKER-DIAGNOSED
  WITH STAGE 2 HYPERTENSION, BY ANOTHER
  PRACTIONER 1 MONTH AGO AND ABPM DONE
 HER CLINIC BLOOD PRESSURE WAS 174/102
  mmHG AND HER ABPM AVERAGE WAS 170/100
  mmHG
 CUT OFF FOR ABPM?


MEDICAL HISTORY
  NO SIGNIFICANT MEDICAL HISTORY.
  NON-DIABETIC
POINTS TO PONDER OVER…


   WHAT TESTS TO ORDER NOW?

   WHAT IS INITIAL TREATMENT?

   WHAT IS THE CV RISK?

   WHAT IS THE DIFFERENCE IN YOUNG AND

    ELDERLY IN HTN TREATMENT?
QUESTION
WHAT TESTS YOU ORDER NOW? WHAT IS INITIAL
TREATMENT?

 APPROPRIATE TESTS FOR TARGET ORGAN
  DAMAGE AND CARDIOVASCULAR RISK
  ASSESSMENT
 GIVEN HER AGE, SHE WILL SCORE VERY
  HIGHLY IN ALL CARDIOVASCULAR RISK
  ASSESSMENTS
 INITIAL APPROPRIATE TREATMENT IS WITH A
  CALCIUM-CHANNEL BLOCKER
• Offer people aged 80 years and over the same

 antihypertensive drug treatment as people aged

 55—80 years, taking into account any

 comorbidities. [New 2011]
RECOMMENDATIONS

1. OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO
  PEOPLE AGED UNDER 80 YEARS WITH STAGE 1
  HYPERTENSION WHO HAVE ONE OR MORE OF THE
  FOLLOWING:
 TARGET ORGAN DAMAGE
 ESTABLISHED CARDIOVASCULAR DISEASE
 RENAL DISEASE
 DIABETES
 A 10-YEAR CARDIOVASCULAR RISK EQUIVALENT TO 20%
  OR GREATER.                       [NEW 2011]

2.OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO PEOPLE
  OF ANY AGE WITH STAGE 2 HYPERTENSION. [NEW 2011]
RECOMMENDATIONS

   Use clinic blood pressure measurements to monitor

    the response to antihypertensive treatment with

    lifestyle modifications or drugs. [New 2011]
WHAT DRUG/S IF HEART FAILURE +

   If a CCB is not suitable, for example because of

    oedema or intolerance, or if there is evidence of

    heart failure or a high risk of heart failure, offer a

    thiazide-like diuretic. [New 2011]
   If diuretic treatment is to be initiated or changed,
    offer a thiazide-like diuretic, such as chlortalidone
    (12.5—25.0 mg once daily) or indapamide (1.5 mg
    modified-release or 2.5 mg once daily) in
    preference to a conventional thiazide diuretic such
    as bendroflumethiazide or hydrochlorothiazide.
    [New 2011]
   ONE MONTH LATER
    Patient’s total cholesterol is 148 mg/dland her HDL is 50
    mg/dl.Glucose is normal.
   There is no left ventricular hypertrophy or atrial fibrillation on
    ECG.
   Her 10-year cardiovascular risk is 27%.(Using QRISK2)
   You measure her clinic blood pressure and it is 165/100
    mmhg.
   What would you do next?
   BLOOD PRESSURE IS NOT CONTROLLED.

   CHECK ADHERENCE WITH STEP 1 TREATMENT.
    IDENTIFY IF YOU CAN HELP ENHANCE ADHERENCE

   -   MODIFY DOSING REGIMEN,

   -   PROVIDE A RECORD FOR HER TO MONITOR HER
    MEDICINE TAKING).
   Aim for a target clinic blood pressure below 150/90
    mmhg in people aged 80 years and over, with
    treated hypertension. [New
    2011]
   IF BLOOD PRESSURE IS NOT CONTROLLED BY

    STEP 1 TREATMENT, OFFER STEP 2

   TREATMENT WITH A CCB IN COMBINATION

    WITH EITHER AN ACE INHIBITOR OR AN ARB.

    [NEW 2011]
   SHE RETURNS TO THE CLINIC AFTER A

    MONTH.

    HER CLINIC BLOOD PRESSURE IS

    154/90 mmHG. WHAT NEXT?
    Review her antihypertensive medications and
    ensure optimal or best tolerated dose.
   Ensure adherence to the drug regimen and review
    any factors that may reduce her compliance
    A blood test to check her electrolytes around 2
    weeks after starting the ace inhibitor and to return
    to the clinician after 1 month
   Follow the results of the electrolyte test and a
    further review of her blood pressure.
USEFUL INTERVENTIONS
 RECORDING THE MEDICINE-TAKING BY
  PATIENT
 ENCOURAGING PATIENTS TO MONITOR THEIR
  CONDITION
 SIMPLIFYING THE DOSING REGIMEN

 USING ALTERNATIVE PACKAGING

 USING A MULTI-COMPARTMENT MEDICINES
  SYSTEM.
3 MONTHS LATER

   CLINIC APPOINTMENT BLOOD PRESSURE IS
    145/85 MMHG.

   AN ACCEPTABLE BLOOD PRESSURE FOR A
    PERSON OVER 80.

   SHE CAN STAY ON CURRENT TREATMENT.
RECOMMENDATIONS

   AIM FOR A TARGET CLINIC BLOOD PRESSURE
    BELOW 150/90 MMHG IN PEOPLE AGED 80 YEARS
    AND OVER, WITH TREATED HYPERTENSION. [NEW
    2011]
   BEFORE CONSIDERING STEP 3 TREATMENT,
    REVIEW MEDICATION TO ENSURE STEP 2
    TREATMENT IS AT OPTIMAL OR BEST TOLERATED
    DOSES. [NEW 2011]
   USE INTERVENTIONS TO OVERCOME PRACTICAL
    PROBLEMS ASSOCIATED WITH NON-ADHERENCE
    IF A SPECIFIC NEED IS IDENTIFIED.
< 79 yrs, achieved SBP values <140 mm Hg are appropriate goals

>80 yrs, 140 to 145 mm Hg, if tolerated, can be acceptable.

SBP <130 and DBP <65 mm Hg should be avoided

Low-dose thiazides, CAs, and RAAS blockers are preferred,.

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Management of hypertension in elderly person.

  • 1. PRESENTATION  81-YEAR-OLD FEMALE NON-SMOKER-DIAGNOSED WITH STAGE 2 HYPERTENSION, BY ANOTHER PRACTIONER 1 MONTH AGO AND ABPM DONE  HER CLINIC BLOOD PRESSURE WAS 174/102 mmHG AND HER ABPM AVERAGE WAS 170/100 mmHG  CUT OFF FOR ABPM? MEDICAL HISTORY NO SIGNIFICANT MEDICAL HISTORY. NON-DIABETIC
  • 2. POINTS TO PONDER OVER…  WHAT TESTS TO ORDER NOW?  WHAT IS INITIAL TREATMENT?  WHAT IS THE CV RISK?  WHAT IS THE DIFFERENCE IN YOUNG AND ELDERLY IN HTN TREATMENT?
  • 3. QUESTION WHAT TESTS YOU ORDER NOW? WHAT IS INITIAL TREATMENT?  APPROPRIATE TESTS FOR TARGET ORGAN DAMAGE AND CARDIOVASCULAR RISK ASSESSMENT  GIVEN HER AGE, SHE WILL SCORE VERY HIGHLY IN ALL CARDIOVASCULAR RISK ASSESSMENTS  INITIAL APPROPRIATE TREATMENT IS WITH A CALCIUM-CHANNEL BLOCKER
  • 4. • Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55—80 years, taking into account any comorbidities. [New 2011]
  • 5. RECOMMENDATIONS 1. OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO PEOPLE AGED UNDER 80 YEARS WITH STAGE 1 HYPERTENSION WHO HAVE ONE OR MORE OF THE FOLLOWING:  TARGET ORGAN DAMAGE  ESTABLISHED CARDIOVASCULAR DISEASE  RENAL DISEASE  DIABETES  A 10-YEAR CARDIOVASCULAR RISK EQUIVALENT TO 20% OR GREATER. [NEW 2011] 2.OFFER ANTIHYPERTENSIVE DRUG TREATMENT TO PEOPLE OF ANY AGE WITH STAGE 2 HYPERTENSION. [NEW 2011]
  • 6. RECOMMENDATIONS  Use clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modifications or drugs. [New 2011]
  • 7. WHAT DRUG/S IF HEART FAILURE +  If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [New 2011]
  • 8.  If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5—25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [New 2011]
  • 9.  ONE MONTH LATER Patient’s total cholesterol is 148 mg/dland her HDL is 50 mg/dl.Glucose is normal.  There is no left ventricular hypertrophy or atrial fibrillation on ECG.  Her 10-year cardiovascular risk is 27%.(Using QRISK2)  You measure her clinic blood pressure and it is 165/100 mmhg.  What would you do next?
  • 10.  BLOOD PRESSURE IS NOT CONTROLLED.  CHECK ADHERENCE WITH STEP 1 TREATMENT. IDENTIFY IF YOU CAN HELP ENHANCE ADHERENCE  - MODIFY DOSING REGIMEN,  - PROVIDE A RECORD FOR HER TO MONITOR HER MEDICINE TAKING).
  • 11.  Aim for a target clinic blood pressure below 150/90 mmhg in people aged 80 years and over, with treated hypertension. [New 2011]
  • 12.  IF BLOOD PRESSURE IS NOT CONTROLLED BY STEP 1 TREATMENT, OFFER STEP 2  TREATMENT WITH A CCB IN COMBINATION WITH EITHER AN ACE INHIBITOR OR AN ARB. [NEW 2011]
  • 13.  SHE RETURNS TO THE CLINIC AFTER A MONTH. HER CLINIC BLOOD PRESSURE IS 154/90 mmHG. WHAT NEXT?
  • 14.  Review her antihypertensive medications and ensure optimal or best tolerated dose.  Ensure adherence to the drug regimen and review any factors that may reduce her compliance  A blood test to check her electrolytes around 2 weeks after starting the ace inhibitor and to return to the clinician after 1 month  Follow the results of the electrolyte test and a further review of her blood pressure.
  • 15. USEFUL INTERVENTIONS  RECORDING THE MEDICINE-TAKING BY PATIENT  ENCOURAGING PATIENTS TO MONITOR THEIR CONDITION  SIMPLIFYING THE DOSING REGIMEN  USING ALTERNATIVE PACKAGING  USING A MULTI-COMPARTMENT MEDICINES SYSTEM.
  • 16. 3 MONTHS LATER  CLINIC APPOINTMENT BLOOD PRESSURE IS 145/85 MMHG.  AN ACCEPTABLE BLOOD PRESSURE FOR A PERSON OVER 80.  SHE CAN STAY ON CURRENT TREATMENT.
  • 17. RECOMMENDATIONS  AIM FOR A TARGET CLINIC BLOOD PRESSURE BELOW 150/90 MMHG IN PEOPLE AGED 80 YEARS AND OVER, WITH TREATED HYPERTENSION. [NEW 2011]  BEFORE CONSIDERING STEP 3 TREATMENT, REVIEW MEDICATION TO ENSURE STEP 2 TREATMENT IS AT OPTIMAL OR BEST TOLERATED DOSES. [NEW 2011]  USE INTERVENTIONS TO OVERCOME PRACTICAL PROBLEMS ASSOCIATED WITH NON-ADHERENCE IF A SPECIFIC NEED IS IDENTIFIED.
  • 18. < 79 yrs, achieved SBP values <140 mm Hg are appropriate goals >80 yrs, 140 to 145 mm Hg, if tolerated, can be acceptable. SBP <130 and DBP <65 mm Hg should be avoided Low-dose thiazides, CAs, and RAAS blockers are preferred,.

Hinweis der Redaktion

  1. Elderly &gt; 65 yrs