There are however two major issues with hypertension screening in older adults. A first issue is the weak discriminative power of elevated BP for having or not CVD later in life [ 28 ]. This is especially problematic for patients with BP close to the threshold above which a treatment is recommended, and many older adults have BP close to such threshold.
To overcome this issue, two approaches are possible.
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The first approach is a high-CVD risk prevention strategy, where the decision to treat hypertension is not based on BP level, but rather on an estimated absolute CVD risk [ 29 ]. The idea is that, for the same BP reduction, the absolute benefit will be much higher among patients at high absolute CVD risk compared with patients at relatively low absolute CVD risk.
In a simulation study, Karmali et al. The second approach would be a population-based prevention strategy shifting the distribution of BP toward lower levels in the entire population, instead of lowering BP only in high-risk populations with high BP or high risk of CVD [ 23 , 31 ]. Apart from the weak discriminative power of elevated BP, a second issue with BP screening among older adults is that the benefit of lowering BP among the oldest-old is disputable.
While these patients are at very high risk for CVD, there are doubts about a true benefit of BP lowering drugs on mortality and other health outcomes. Instead of being beneficial, a low BP might indeed be detrimental among oldest-old patients [ 10 ]. The relationship between BP and mortality and other health outcomes in older age and the decision to treat or not oldest-old adults for hypertension is highly debated. In middle-aged adults, the risk for cardiovascular events, cardiovascular mortality, and all-cause mortality increases with increasing BP [ 5 ]. In oldest-old adults, however, evidence about the predictive value of BP and the benefit-harm balance of treating hypertension is inconsistent [ 6 , 7 , 8 , 9 ].
Epidemiology of hypertension in the elderly
These findings suggest that lowering BP among the oldest-old might be harmful. Several cohort studies have also shown that low BP was associated with a decline in cognitive and physical abilities [ 51 , 52 , 53 , 54 ]. First, the association between BP and CVD risk may be modified by poor health, such as frailty [ 11 ].
For instance, in a study by Van Hateren et al. In another study by Odden et al. Among slow walkers, high BP was not associated with higher cardiovascular mortality rates, while high BP was associated with higher CVD mortality rates among fast walkers. Other studies have shown that the relationship between BP and both mortality and adverse health outcomes could be modified by poor health, such as physical and mental impairment [ 45 , 48 ]. The modification of the association between BP and health outcomes in case of frailty or poor health may be explained by physiological reasons.
Low BP in old and frail individuals might indeed cause hypo-perfusion of vital organs and accelerate physical and mental decline [ 11 ], a state of physiological weakness, which is often worsened by the presence of polypharmacy and comorbidity [ 10 , 53 ].
Second, the association of a lower BP with worse health outcomes in cohort studies may be due to confounding and reverse causality Fig. On the one hand, the association between BP and any adverse health outcomes may be confounded by some unmeasured factors. On the other hand, in a case of reverse causality, some conditions, which can be initially caused by high BP, evolve to become the cause of low BP. For example, high BP is a cause of heart failure [ 61 ], but in an advanced stage, heart failure becomes the cause of a lower BP.
In this case, there is an association between low BP and the condition, as well as between low BP and mortality, but both these associations are the result of a reverse causality. This situation is frequent in circumstances of end-of-life care [ 42 ]. Finally, the selection of relatively healthy patients in randomized trials compared with cohorts may be a third explanation of the discrepancies between RCTs and cohort studies [ 10 ].
Post-randomization confounding may also bias results of RCTs [ 62 ]. The hypothetical causal relationship between blood pressure BP and related adverse health outcomes or mortality according to different scenarios is depicted in these graphs. II The relationship can be confounded by unmeasured factors C , which have an effect on both BP and the risk of adverse health outcomes.
III In a situation of reverse causality, some conditions, which can be initially caused by high BP, evolve to become the cause of low BP. To disentangle these complex controversies on the association between BP and health outcomes among older adults, hypertension trials targeting specifically frail or multimorbid older adults are needed. Most guidelines recommend higher BP targets among older adults compared with middle-aged adults [ 6 , 7 , 8 , 9 ]. Further, some of these guidelines recommend taking into account health status to set the targeted BP [ 6 , 8 ].
For frail patients, the decision whether or not to treat has to be evaluated by the physician, with a close monitoring of clinical effects of treatment [ 8 ]. However, a close BP monitoring in older persons with high comorbidity is recommended. Some experts consider that these guidelines downplay the adverse effects of antihypertensive treatment, such as falls due to hypotension [ 65 ] and the risk for overtreatment and polypharmacy [ 10 , 66 ], especially in frail oldest-old patients [ 65 ].
In reaction, some experts have developed their own guidelines with more conservative treatment recommendations accounting for detrimental effects of low BP reported in cohort studies [ 67 ]. In summary, while international guidelines give clear recommendations about screening for and treatment of hypertension in middle-aged adults, the recommendations in older adults are much less clear, with large inconsistencies across different guidelines. This reflects the lack of clear evidence on the risks and benefits of BP treatment and on the optimal BP targets in older adults, especially for the frail and oldest-old patients.
Due to population aging, hypertension in older adults is a major and growing burden for the health care system. Screening and treatment of hypertension in older adults, and especially in the oldest-old, is still a matter of intense debate notably due to the lack of high quality evidence. While screening and treatment strategies accounting for general health status or frailty are appealing, it raises the question of how to assess these clinical features with confidence [ 56 ].
More broadly, various screening and treatment strategies should be evaluated and compared with a population-based approach aiming to find the most appropriate way of managing hypertension in older adults. Census Bureau. Global burden of hypertension and systolic blood pressure of at least to mm hg, Cardiovascular disease statistics. Accessed Hypertension prevalence and control among adults: United States, — NCHS data brief, no Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
Hypertension in adults: diagnosis and management.
London: NICE; Blood Press. Siu AL.
Hypertension in the elderly
Screening for high blood pressure in adults: U. Preventive Services Task Force recommendation statement. Ann Intern Med. Polypharmacy in the aging patient: management of hypertension in octogenarians. Treatment of hypertension in the oldest old: a critical role for frailty? Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur J Clin Invest. Frailty in older adults: evidence for a phenotype.
Blood pressure targets for hypertension in older adults
J Am Coll Cardiol. Prevalence of hypertension in the US adult population. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States.
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Franklin SS. Elderly hypertensives: how are they different? J Clin Hypertens Greenwich. Global burden of blood-pressure-related disease, Kaplan RM, Ong M.
Rationale and public health implications of changing CHD risk factor definitions. Annu Rev Public Health. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1. Results of several large randomized trials of the treatment of diastolic hypertension in elderly patients indicate that treatment is beneficial, at least up to age Data from well-designed studies are not available to make a definitive statement about the treatment of isolated systolic hypertension.
Conclusion: The cardiovascular risk reduction from treating mild to moderate diastolic hypertension in the elderly is significant, but the magnitude of absolute risk reduction is not so great that treatment should invariably be pursued if serious side effects cannot be avoided. Applegate WB. Hypertension in Elderly Patients. Ann Intern Med. Results provided by:. Sign In Set Up Account. You will be directed to acponline.
Open Athens Shibboleth Log In. Subscribe to Annals of Internal Medicine. Advanced Search. Reviews 1 June William B. Abstract Purpose: To synthesize and analyze new information on the epidemiology, pathophysiology, and management of hypertension in the elderly to guide physicians making treatment decisions. In November I had to be hospitalized again. That time the ER doctor said they were not going to release me back to the same situation and added Amlodipine Besylate.
My blood pressure has been normal with one brief spike since. Problem now are medication side effects: edema of feet and legs, hearing loss from fluid retention, bloating and constipation and generally not feeling well.
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