michigan hypertension core curriculum - State of Michigan

individuals. 2, 5 The risk of AD increases with increasing age. 6, 7 Clinically, this is manifest as orthostatic
blood pressures (SBP drops > 10 mmHg or DBP > 5 mmHg going from sitting to standing), which can
complicate management. The effect of orthostatic BP drops is that individuals under treatment are at
increased risk of symptomatic hypotension, increased medication side effects and a not insignificant
increase in risk of falling. Appropriate management requires first that seated and standing measures
of BP are done and second that recommendations for home monitoring specify standing BP’s and third
that the target BP goal is focused on control of the standing BP. For many patients this may translate
into the need for larger doses of anti-hypertensive medications in the evening (when the person will be
supine for several hours) compared to the morning doses.
Elderly patients are far more likely than younger individuals to have isolated systolic HTN (ISH). 8
Isolated systolic HTN may account for as much as 80% of the HTN seen in the elderly population. As
a consequence, the particular choices of medication may need to be specialized. A practitioner must
also keep in mind the relatively low control rates found in the elderly. Part of the issue is the relative
unawareness many patients have about their diagnoses, with only about 50% of individuals aware they
are hypertensive. Despite awareness of the high frequency of multiple cardiovascular co-morbidities
in the elderly population, HTN is frequently uncontrolled. In fact, elderly patients are up to five times
more likely to have uncontrolled blood pressure than their younger counterparts. 9 A major reason for
the lack of SBP control in the elderly has to do with the magnitude of the SBP elevation that is often far
above goal levels. Also, co-morbidities such as obesity, diabetes mellitus, CKD (both depressed GFR
and albuminuria), and the presence of pressure-related target-organ injury are more common in elderly
than non-elderly hypertensives. All of these conditions have been shown to confer resistance to the BP
lowering effect to anti-hypertensive agents.
Co-morbid illnesses increase the difficulty of appropriately treating elderly individuals with HTN.
A significant number of individuals will have DM, coronary heart disease (CHD), congestive heart
failure (CHF) or be on chronic anticoagulation therapy. Each of these conditions requires sensitivity
to the recommended medication classes for each disease. Elderly individuals may have physical
limitations to home BP monitoring, such as poor vision or difficulty standing for prolonged periods of
time. In addition, individuals may be particularly sensitive to the effects of BP lowering or not tolerate
NKFM & MDCH 51