michigan hypertension core curriculum - State of Michigan

side effects particularly well. A holistic and integrated approach to HTN management in this population
is necessary for the best outcomes and should include coordination of management by what are often
multiple care providers.
A non-medical, but real concern is the cost of medication. 10, 11 Elderly individuals are less likely
to be working and more likely to be on fixed incomes than their younger counterparts. In addition,
as elderly patients may have co-morbid medical conditions, their out of pocket medical costs may
be substantial prior to starting anti-hypertensive therapy. The financial issue also impacts access to
health care and BP monitoring which must be considered. In assessing elderly individuals, a provider
needs to be comfortable with having frank and open discussions about the financial realities of care
and design a treatment plan that minimizes the economic burden to the treated individual. Such an
approach must involve aggressive and deliberate use of generic medications, minimize polypharmacy
and encourage consistent feedback from the treated individual to ensure that the HTN treatment is not
placing an undue burden on the individual.
Hypertension treatment is covered in a separate section of the book, but there are a few issues
worth noting. The first is that several studies have demonstrated the effectiveness and utility of treating
HTN in older and elderly individuals. 12-14 Cardiovascular events, most notable stroke and heart failure,
can be reduced and treated individuals experience reduced morbidity and in many cases, reduced
mortality. Secondly, the treatment goals for older and elderly individuals are no different from those in
the general population. Specifically, using the JNC-7 recommendations as a guide, BP should be less
than 140 mmHg over less than 90 mmHg in most individuals and less than 130 mmHg over less than
80 mmHg in individuals with DM or CKD. Third, an appreciation for cultural differences is necessary to
achieve optimal results. 15 In regards to specific medications, the thiazide diuretics have shown great
efficacy in the elderly population, as have ACE-I and calcium channel blockers. 13,16,17 Nevertheless,
thiazide diuretics and calcium channel blockers will lower BP more as monotherapy than other
antihypertensive drug classes; however, single drug therapy with any drug class is unlikely to control
BP, especially SBP to below goal levels in most elderly antihypertensives. Thus, in most situations the
practitioner will be using combination drug therapy, typically a diuretic or calcium channel blocker, in
combination with a RAAS inhibitor in a slow, deliberate approach to BP lowering in the elder population.
52 Hypertension Core Curriculum