Silver Age Health | Several common strategies for treating hypertension in the elderly

Mastering and understanding the characteristics and clinical diagnosis and treatment processes of different types of elderly hypertension is of great significance for improving the level of diagnosis and treatment and improving the compliance rate. Recently, the "Expert Consensus on the Characteristics and Clinical Diagnosis and Treatment Process of Elderly Hypertension (2024)" was released, providing us with recommendations on the characteristics, evaluation and treatment of several common types of elderly hypertension. In view of the characteristics of these types, we should conduct individualized evaluation and treatment according to the specific circumstances to minimize the occurrence of complications and improve the quality of life of the elderly.

▏Definition of Hypertension

Hypertension, also known as "arterial hypertension" or "primary hypertension" in medicine, is a common cardiovascular disease. It refers to the phenomenon that the pressure exerted on the blood vessel wall by blood flowing in the blood vessels is continuously higher than the normal level. Normal blood pressure levels are usually defined as systolic pressure (the pressure of blood on the blood vessel wall when the heart contracts) less than 120 mmHg and diastolic pressure (the pressure of blood on the blood vessel wall when the heart relaxes) less than 80 mmHg. If the systolic pressure is higher than 140 mmHg or the diastolic pressure is higher than 90 mmHg, it is considered high blood pressure.

Epidemiological surveys in my country show that the prevalence of hypertension in people aged 65 and above is nearly 60%, and the prevalence of hypertension in people aged 70 and above is >90%.

▏Early morning hypertension in the elderly

If the blood pressure measured at home within 1 hour after waking up in the morning, before taking medicine and breakfast, or dynamic blood pressure within 2 hours after waking up, reaches or exceeds 135/85 mmHg, regardless of the blood pressure level at other times, it can be considered as morning hypertension. It is worth noting that if the blood pressure reaches or exceeds 140/90 mmHg when visiting the doctor between 8 and 10 o'clock, further dynamic blood pressure measurement is required to confirm the diagnosis.

There are two main manifestations of morning hypertension: non-dipping and reverse dipping nighttime hypertension continuing into morning hypertension, and dipping hypertension with a sudden increase in blood pressure in the morning. This morning hypertension is particularly common in elderly patients with salt-sensitive hypertension.

1. Diagnostic methods:

Home blood pressure measurement, 24-hour ambulatory blood pressure, and office blood pressure measurement can all be used to diagnose morning hypertension. The specific methods have been detailed in relevant guidelines. Considering the convenience and daily operability of home blood pressure monitoring, we recommend giving priority to this method.

2. Treatment method:

First, we can take lifestyle interventions. In terms of diet, quitting smoking and limiting alcohol consumption, and a low-salt diet can help control the morning blood pressure of patients with salt-sensitive hypertension. At the same time, improving sleep at night can also help lower morning blood pressure. Drug treatment is also an important means. Choosing long-acting drugs, such as the combined use of adequate doses of long-acting drugs or combined medications, can effectively prevent the increase in blood pressure 18 to 24 hours (the last 6 hours) after taking the medicine, and reduce the increase in morning blood pressure caused by failure to take the medicine on time or missing it. For non-dipper and reverse dipper patients, we recommend the use of long-acting drugs that can reduce nocturnal hypertension and restore normal physiological rhythms, and give priority to drugs that have outstanding efficacy in controlling nocturnal hypertension. For patients with dipper-type morning hypertension, we recommend taking antihypertensive drugs in the morning, or dividing the morning combination of medication into morning and evening.

As for latent morning hypertension, there is currently no specific treatment recommendation, but if it meets the above definition and diagnostic criteria, treatment should be considered by adjusting the dosing time or combining medications.

▏Nocturnal hypertension in the elderly

Nocturnal hypertension refers to a state of hypertension in which the average blood pressure reaches or exceeds 120/70 mmHg during sleep. This type of hypertension manifests itself in various ways in the elderly population, and may be manifested as increased blood pressure during both the day and night, or simply increased blood pressure at night, with dynamic blood pressure monitoring showing a non-dipping or reverse dipping blood pressure morphology. It is worth noting that some elderly patients may also experience nocturnal supine hypertension, or supine hypertension combined with orthostatic hypotension.

1. Treatment: First of all, relevant factors should be screened and eliminated as much as possible, such as sleep disorders, obstructive sleep apnea syndrome, excessive salt intake, etc., and the causes should be treated. At the same time, for patients with chronic kidney disease, diabetes, etc., volume assessment should be performed and diuresis should be used as appropriate to reduce volume load.

2. Medication: Patients with high sympathetic activity at night can be treated with sympathetic nerve antagonists. In order to achieve the goal of stable control of 24-hour blood pressure, it is recommended to take long-acting antihypertensive drugs once a day, alone or in combination, including drugs with long-term antihypertensive effects and promoting sodium ion excretion, such as long-half-life drugs. These drugs not only play a hypotensive role, but also help to lower nighttime blood pressure.

For patients with simple supine hypertension or elevated blood pressure only during sleep at night, medium- and short-acting antihypertensive drugs can be taken before bedtime to control nocturnal hypertension if necessary. During treatment, special attention should be paid to orthostatic hypotension, which is more common in elderly patients, and appropriate preventive measures should be taken. For elderly patients with supine hypertension and orthostatic hypotension, blood pressure reduction should be individualized, and a moderate and gentle blood pressure management strategy should be adopted.

▏ Hypertension and multiple diseases coexist in the elderly

1. Definition

Elderly hypertension refers to a disease in which blood pressure in the elderly aged 60 years and above is continuously or repeatedly elevated. Multi-disease coexistence refers to the elderly suffering from two or more chronic diseases at the same time. These chronic diseases may include diabetes, coronary heart disease, stroke, chronic lung disease, etc. They affect each other and are mutually causal, making the health of the elderly more complicated.

In the case of elderly hypertension and multiple diseases coexisting, blood pressure management in the elderly becomes particularly complicated. On the one hand, hypertension itself increases the risk of cardiovascular disease and affects the quality of life of the elderly; on the other hand, the coexistence of multiple diseases requires the elderly to consider the impact of other diseases when receiving antihypertensive treatment to avoid drug interactions and adverse reactions.

2. Diagnosis

For the diagnosis of hypertension and multiple diseases in the elderly, accurate blood pressure measurement is required first. Due to physiological changes such as arteriosclerosis in the elderly, there may be certain errors in the measurement of blood pressure. Therefore, when measuring blood pressure, appropriate measurement methods and equipment should be selected to ensure the accuracy of the measurement results.

Secondly, doctors need to understand the elderly's medical history and medication in detail. By asking about the medical history and conducting necessary examinations, doctors can understand whether the elderly have other chronic diseases and the impact of these diseases on blood pressure. At the same time, doctors also need to understand the drugs currently used by the elderly in order to avoid drug interactions during antihypertensive treatment.
Finally, doctors need to develop personalized treatment plans based on the specific conditions of the elderly. Because the physiological functions of the elderly decline and their ability to metabolize and excrete drugs weakens, when developing treatment plans, they need to fully consider the physical characteristics of the elderly and the safety of the drugs.

3. Processing

In view of the coexistence of hypertension and multiple diseases in the elderly, the treatment strategy needs to take into account multiple aspects. First of all, lifestyle intervention is the basis. The elderly should maintain good eating habits, limit sodium intake, and increase the intake of foods rich in trace elements such as potassium, magnesium, and calcium. At the same time, proper exercise is also essential, which can improve the cardiopulmonary function of the elderly and help control blood pressure.

Secondly, drug treatment is an important means of controlling hypertension in the elderly. Doctors should reasonably select antihypertensive drugs based on factors such as the elderly's blood pressure level, disease type and severity, comorbidities, and drug tolerance. During drug treatment, the elderly's blood pressure changes should be closely monitored, and the drug dosage and type should be adjusted in a timely manner to achieve the best antihypertensive effect.
In addition, multidisciplinary collaboration is particularly important in the treatment of hypertension and coexisting multiple diseases in the elderly. Since coexisting multiple diseases is common in the elderly, doctors from multiple disciplines such as cardiovascular, endocrine, respiratory, and neurological departments need to participate in the development of a comprehensive treatment plan. Through multidisciplinary collaboration, blood pressure and other chronic diseases in the elderly can be better managed, and treatment effects and quality of life can be improved.

▏ Refractory hypertension in the elderly

1. Definition

When elderly hypertensive patients use three antihypertensive drugs with different mechanisms in sufficient doses for at least 4 weeks, and their blood pressure still does not reach the target level either in the clinic or outside the clinic (including home and dynamic blood pressure monitoring), or when four drugs are needed to bring their blood pressure to the target level, we define it as elderly refractory hypertension.

2. Diagnostic criteria and methods

According to the requirements of the "Guidelines for the Prevention and Treatment of Hypertension in China", under normal circumstances, the target blood pressure control value for hypertensive patients is 140/90 mmHg, but if other risk factors are combined, the recommended blood pressure reduction target value is 130/80 mmHg. Before diagnosing refractory hypertension, we need to judge some issues.

(1) First, we need to determine whether it is pseudo-refractory hypertension. This may be caused by improper blood pressure measurement methods, such as incorrect posture, or the cuff is too large or too small. In addition, simple white coat hypertension needs to be ruled out.

(2) Are there any predisposing factors or other coexisting disease factors for high blood pressure? This may include poor treatment compliance, improper combination or use of antihypertensive drugs, and continued use of antihypertensive drugs, such as adrenal steroids, nonsteroidal anti-inflammatory drugs, cyclosporine A, erythropoietin, cocaine, licorice, ephedra, etc.; failure to change unhealthy lifestyles or failure to change, such as weight gain or obesity, smoking, excessive drinking; excessive volume load (such as inadequate diuretic treatment, high salt intake, progressive renal insufficiency); insomnia, prostatic hypertrophy (frequent nocturia affecting sleep), chronic pain and long-term anxiety, etc.

(3) Has secondary hypertension been ruled out? Such as sleep apnea syndrome, renal artery stenosis, etc.

3. Treatment After eliminating the above factors, we can optimize the original three-drug combination regimen. The specific principles and methods for optimizing the combination regimen include:

(1) Before optimizing the combination regimen, we will communicate more with patients to improve medication compliance and strictly limit sodium salt intake.

(2) If the combined antihypertensive effect is still not ideal at adequate therapeutic doses of the three drugs, we can use a combination of four drugs and add an aldosterone antagonist after evaluating renal function and potential risk of hyperkalemia.

(3) If the treatment effect is still not good, we can try a combination of 5 drugs, or stop using the current antihypertensive drugs under close observation and restart another treatment plan. For patients who have failed to achieve optimal combined antihypertensive therapy, whether to give device therapy is still under study, so it is not recommended for the time being.

▏Principles of diagnosis and treatment of hypertension in the elderly

1. Monitoring

There are three common methods of blood pressure monitoring: office blood pressure, dynamic blood pressure and home self-measurement. At the same time, a new method of office blood pressure measurement - unattended automatic office blood pressure, is also worthy of our attention. For elderly patients with hypertension, we encourage them to perform home self-measurement and dynamic blood pressure monitoring, and regularly measure blood pressure in both upper limbs and in different body positions. Pay special attention to blood pressure monitoring before going to bed, in the early morning and before taking medication.

2. Principles of diagnosis and treatment

To deal with hypertension in the elderly, we need to clarify the assessment and treatment process. After a risk stratification assessment of other cardiovascular risk factors, subclinical target organ damage, and clinical diseases, elderly patients with hypertension who are newly diagnosed should start regular antihypertensive treatment as soon as possible. The type of acute target organ damage is the main determinant of the preferred treatment plan. The purpose of treatment is to improve the patient's quality of life and reduce the occurrence of cardiovascular, cerebrorenal, and vascular complications, and reduce the overall risk of death.
In terms of treatment timing and target values, we recommend that patients at high risk of cardiovascular disease start drug treatment when they are 65 to 79 years old and their blood pressure is ≥150/90mmHg or ≥140/90mmHg. It is recommended to lower blood pressure to <140/90mmHg, and if tolerated, it can be further lowered to <130/80mmHg. For patients over 80 years old, it is recommended to start drug treatment when systolic blood pressure is ≥150mmHg, and first lower it to <150/90mmHg. For frail hypertensive patients, if the systolic blood pressure is ≥160mmHg, antihypertensive drug treatment should be considered, and the blood pressure target value should be individualized, but the systolic blood pressure should be kept as high as possible. Not lower than 130mmHg.

As for the specific value of the target value, it needs to be adjusted appropriately according to individual differences and tolerance. During dynamic blood pressure monitoring, we must also pay attention to various special circumstances, such as changes in body position, which may affect blood pressure changes and require careful observation and recording. Hypertension management requires us to comprehensively consider various factors and develop personalized treatment plans to achieve the best management effect.

(Picture from the Internet)

Author | Han Mei is a practicing pharmacist who has worked in a well-known national tertiary hospital for more than 30 years and has rich medical care experience. She has represented the hospital on many occasions to go out for exchanges and study. She is an expert in food hygiene and nutrition, has a national nutritionist qualification, and is a science enthusiast.