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