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. 2001 Dec;47:2520–2525.

Office management of elderly hypertensive patients. Focusing on cognition and function.

K Rockwood 1, S H Freter 1
PMCID: PMC2018477  PMID: 11785283

Abstract

OBJECTIVE: To review office management of elderly hypertensive patients and to focus on cognition and function both as ways to stratify who gets treated and as end points for treatment. QUALITY OF EVIDENCE: Relevant papers were identified through a MEDLINE search from January 1994 to March 2000, using the MeSH terms hypertension, aged, aged 80 and over, cognition, activities of daily living, therapeutics, hypotension orthostatic, and dementia. Many well conducted randomized controlled trials were found and are included. MAIN MESSAGE: Treatment of combined and systolic hypertension up to age 80 is clearly worthwhile; beyond age 85, other factors (chiefly cognitive and functional impairment) mitigate most routine recommendations. Successful treatment is individualized, taking into account comorbid conditions and their effect on cognition and function. Age is useful for thinking about groups, not individuals: as people age, risk of cognitive and functional impairment increases, but even very elderly people (> 85 years) with no impairment should be treated as younger patients are. Elderly people with signs of having a "brain at risk" should be managed with special vigilance. CONCLUSION: Good evidence supports treating elderly people, who are otherwise well and are cognitively and functionally intact, when their blood pressure is > 160 mm Hg systolic or > 105 mm Hg diastolic. There is insufficient evidence for carrying out routine recommendations for frail elderly people. Treatment of comorbid illnesses dictates choice of therapeutic agent.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Auseon A., Ooi W. L., Hossain M., Lipsitz L. A. Blood pressure behavior in the nursing home: implications for diagnosis and treatment of hypertension. J Am Geriatr Soc. 1999 Mar;47(3):285–290. doi: 10.1111/j.1532-5415.1999.tb02990.x. [DOI] [PubMed] [Google Scholar]
  2. Bender R., Jöckel K. H., Trautner C., Spraul M., Berger M. Effect of age on excess mortality in obesity. JAMA. 1999 Apr 28;281(16):1498–1504. doi: 10.1001/jama.281.16.1498. [DOI] [PubMed] [Google Scholar]
  3. Brown M. J., Palmer C. R., Castaigne A., de Leeuw P. W., Mancia G., Rosenthal T., Ruilope L. M. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT). Lancet. 2000 Jul 29;356(9227):366–372. doi: 10.1016/S0140-6736(00)02527-7. [DOI] [PubMed] [Google Scholar]
  4. Choinière R., Lafontaine P., Edwards A. C. Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults. CMAJ. 2000;162(9 Suppl):S13–S24. [PMC free article] [PubMed] [Google Scholar]
  5. Cléroux J., Feldman R. D., Petrella R. J. Lifestyle modifications to prevent and control hypertension. 4. Recommendations on physical exercise training. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada. CMAJ. 1999 May 4;160(9 Suppl):S21–S28. [PMC free article] [PubMed] [Google Scholar]
  6. Curb J. D., Pressel S. L., Cutler J. A., Savage P. J., Applegate W. B., Black H., Camel G., Davis B. R., Frost P. H., Gonzalez N. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA. 1996 Dec 18;276(23):1886–1892. [PubMed] [Google Scholar]
  7. Feldman R. D., Campbell N., Larochelle P., Bolli P., Burgess E. D., Carruthers S. G., Floras J. S., Haynes R. B., Honos G., Leenen F. H. 1999 Canadian recommendations for the management of hypertension. Task Force for the Development of the 1999 Canadian Recommendations for the Management of Hypertension. CMAJ. 1999;161 (Suppl 12):S1–17. [PMC free article] [PubMed] [Google Scholar]
  8. Forette F., Seux M. L., Staessen J. A., Thijs L., Birkenhäger W. H., Babarskiene M. R., Babeanu S., Bossini A., Gil-Extremera B., Girerd X. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet. 1998 Oct 24;352(9137):1347–1351. doi: 10.1016/s0140-6736(98)03086-4. [DOI] [PubMed] [Google Scholar]
  9. Fotherby M. D., Iqbal P. Antihypertensive therapy and orthostatic responses in elderly hospital in-patients. J Hum Hypertens. 1997 May;11(5):291–294. doi: 10.1038/sj.jhh.1000430. [DOI] [PubMed] [Google Scholar]
  10. Gillman M. W., Ross-Degnan D., McLaughlin T. J., Gao X., Spiegelman D., Hertzmark E., Goldman L., Soumerai S. B. Effects of long-acting versus short-acting calcium channel blockers among older survivors of acute myocardial infarction. J Am Geriatr Soc. 1999 May;47(5):512–517. doi: 10.1111/j.1532-5415.1999.tb02562.x. [DOI] [PubMed] [Google Scholar]
  11. Glynn R. J., Beckett L. A., Hebert L. E., Morris M. C., Scherr P. A., Evans D. A. Current and remote blood pressure and cognitive decline. JAMA. 1999 Feb 3;281(5):438–445. doi: 10.1001/jama.281.5.438. [DOI] [PubMed] [Google Scholar]
  12. Gueyffier F., Bulpitt C., Boissel J. P., Schron E., Ekbom T., Fagard R., Casiglia E., Kerlikowske K., Coope J. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet. 1999 Mar 6;353(9155):793–796. doi: 10.1016/s0140-6736(98)08127-6. [DOI] [PubMed] [Google Scholar]
  13. Guo Z., Fratiglioni L., Zhu L., Fastbom J., Winblad B., Viitanen M. Occurrence and progression of dementia in a community population aged 75 years and older: relationship of antihypertensive medication use. Arch Neurol. 1999 Aug;56(8):991–996. doi: 10.1001/archneur.56.8.991. [DOI] [PubMed] [Google Scholar]
  14. Guo Z., Viitanen M., Fratiglioni L., Winbland B. Low blood pressure and early death of elderly people with dementia. Lancet. 1998 Sep 26;352(9133):1035–1036. doi: 10.1016/S0140-6736(05)60078-5. [DOI] [PubMed] [Google Scholar]
  15. Hansson L., Hedner T., Lund-Johansen P., Kjeldsen S. E., Lindholm L. H., Syvertsen J. O., Lanke J., de Faire U., Dahlöf B., Karlberg B. E. Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet. 2000 Jul 29;356(9227):359–365. doi: 10.1016/s0140-6736(00)02526-5. [DOI] [PubMed] [Google Scholar]
  16. Hogan D. B., Ebly E. M., Rockwood K. Weight, blood pressure, osmolarity, and glucose levels across various stages of Alzheimer's disease and vascular dementia. Dement Geriatr Cogn Disord. 1997 May-Jun;8(3):147–151. doi: 10.1159/000106623. [DOI] [PubMed] [Google Scholar]
  17. Januszewicz W., Chodakowska J., Styczyński G. Secondary hypertension in the elderly. J Hum Hypertens. 1998 Sep;12(9):603–606. doi: 10.1038/sj.jhh.1000673. [DOI] [PubMed] [Google Scholar]
  18. Lindholm L. H., Hansson L., Ekbom T., Dahlöf B., Lanke J., Linjer E., Scherstén B., Wester P. O., Hedner T., de Faire U. Comparison of antihypertensive treatments in preventing cardiovascular events in elderly diabetic patients: results from the Swedish Trial in Old Patients with Hypertension-2. STOP Hypertension-2 Study Group. J Hypertens. 2000 Nov;18(11):1671–1675. doi: 10.1097/00004872-200018110-00020. [DOI] [PubMed] [Google Scholar]
  19. Lipsitz L. A. Orthostatic hypotension in the elderly. N Engl J Med. 1989 Oct 5;321(14):952–957. doi: 10.1056/NEJM198910053211407. [DOI] [PubMed] [Google Scholar]
  20. Maxwell C. J., Hogan D. B., Ebly E. M. Calcium-channel blockers and cognitive function in elderly people: results from the Canadian Study of Health and Aging. CMAJ. 1999 Sep 7;161(5):501–506. [PMC free article] [PubMed] [Google Scholar]
  21. Messerli F. H., Grossman E., Goldbourt U. Are beta-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA. 1998 Jun 17;279(23):1903–1907. doi: 10.1001/jama.279.23.1903. [DOI] [PubMed] [Google Scholar]
  22. Nilsson P., Gullberg G., Ekesbo R., Von Schenck H., Gustafson L. No impaired cognitive function in treated patients with mild-moderate hypertension compared to normotensive controls. Blood Press. 1998 Jul;7(4):209–213. doi: 10.1080/080370598437231. [DOI] [PubMed] [Google Scholar]
  23. Okumiya K., Matsubayashi K., Wada T., Fujisawa M., Osaki Y., Doi Y., Yasuda N., Ozawa T. A U-shaped association between home systolic blood pressure and four-year mortality in community-dwelling older men. J Am Geriatr Soc. 1999 Dec;47(12):1415–1421. doi: 10.1111/j.1532-5415.1999.tb01559.x. [DOI] [PubMed] [Google Scholar]
  24. Pahor M., Psaty B. M., Alderman M. H., Applegate W. B., Williamson J. D., Cavazzini C., Furberg C. D. Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials. Lancet. 2000 Dec 9;356(9246):1949–1954. doi: 10.1016/S0140-6736(00)03306-7. [DOI] [PubMed] [Google Scholar]
  25. Pahor M., Shorr R. I., Somes G. W., Cushman W. C., Ferrucci L., Bailey J. E., Elam J. T., Applegate W. B. Diuretic-based treatment and cardiovascular events in patients with mild renal dysfunction enrolled in the systolic hypertension in the elderly program. Arch Intern Med. 1998 Jun 22;158(12):1340–1345. doi: 10.1001/archinte.158.12.1340. [DOI] [PubMed] [Google Scholar]
  26. Port S., Demer L., Jennrich R., Walter D., Garfinkel A. Systolic blood pressure and mortality. Lancet. 2000 Jan 15;355(9199):175–180. doi: 10.1016/S0140-6736(99)07051-8. [DOI] [PubMed] [Google Scholar]
  27. Rockwood K., Ebly E., Hachinski V., Hogan D. Presence and treatment of vascular risk factors in patients with vascular cognitive impairment. Arch Neurol. 1997 Jan;54(1):33–39. doi: 10.1001/archneur.1997.00550130019010. [DOI] [PubMed] [Google Scholar]
  28. Rockwood K., Silvius J. L., Fox R. A. Comprehensive geriatric assessment. Helping your elderly patients maintain functional well-being. Postgrad Med. 1998 Mar;103(3):247-9, 254-8, 264. doi: 10.3810/pgm.1998.03.424. [DOI] [PubMed] [Google Scholar]
  29. Rockwood K., Stadnyk K., MacKnight C., McDowell I., Hébert R., Hogan D. B. A brief clinical instrument to classify frailty in elderly people. Lancet. 1999 Jan 16;353(9148):205–206. doi: 10.1016/S0140-6736(98)04402-X. [DOI] [PubMed] [Google Scholar]
  30. Rockwood K., Wentzel C., Hachinski V., Hogan D. B., MacKnight C., McDowell I. Prevalence and outcomes of vascular cognitive impairment. Vascular Cognitive Impairment Investigators of the Canadian Study of Health and Aging. Neurology. 2000 Jan 25;54(2):447–451. doi: 10.1212/wnl.54.2.447. [DOI] [PubMed] [Google Scholar]
  31. Skoog I., Kalaria R. N., Breteler M. M. Vascular factors and Alzheimer disease. Alzheimer Dis Assoc Disord. 1999 Oct-Dec;13 (Suppl 3):S106–S114. doi: 10.1097/00002093-199912003-00016. [DOI] [PubMed] [Google Scholar]
  32. Staessen J. A., Gasowski J., Wang J. G., Thijs L., Den Hond E., Boissel J. P., Coope J., Ekbom T., Gueyffier F., Liu L. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet. 2000 Mar 11;355(9207):865–872. doi: 10.1016/s0140-6736(99)07330-4. [DOI] [PubMed] [Google Scholar]
  33. Staessen J. A., Thijs L., Fagard R., O'Brien E. T., Clement D., de Leeuw P. W., Mancia G., Nachev C., Palatini P., Parati G. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA. 1999 Aug 11;282(6):539–546. doi: 10.1001/jama.282.6.539. [DOI] [PubMed] [Google Scholar]
  34. Stroup-Benham C. A., Markides K. S., Black S. A., Goodwin J. S. Relationship between low blood pressure and depressive symptomatology in older people. J Am Geriatr Soc. 2000 Mar;48(3):250–255. doi: 10.1111/j.1532-5415.2000.tb02642.x. [DOI] [PubMed] [Google Scholar]
  35. Whelton P. K., Appel L. J., Espeland M. A., Applegate W. B., Ettinger W. H., Jr, Kostis J. B., Kumanyika S., Lacy C. R., Johnson K. C., Folmar S. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA. 1998 Mar 18;279(11):839–846. doi: 10.1001/jama.279.11.839. [DOI] [PubMed] [Google Scholar]
  36. van den Hoogen P. C., Feskens E. J., Nagelkerke N. J., Menotti A., Nissinen A., Kromhout D. The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. Seven Countries Study Research Group. N Engl J Med. 2000 Jan 6;342(1):1–8. doi: 10.1056/NEJM200001063420101. [DOI] [PubMed] [Google Scholar]

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