Hypertension: How Low to Go When Treating Older Adults

Abstract

Recent changes to guidelines for diagnosing and managing hypertension (HTN) in adults provide an opportunity for nurse practitioners to re-examine how they treat older adults with elevated blood pressure. This paper will review the revised definition of hypertension based on 2017 treatment guidelines, what age is considered “older” for adults with hypertension, what the treatment goal is for this population, and recommendations for getting blood pressure to desired goals.

Hypertension (HTN) is the most modifiable cardiovascular risk factor affecting more than two thirds of adults in the United States (U.S).¹ The prevalence of HTN is higher for adults over the age of 64 years compared to their younger adults. Moreover, based on data from NHANES (2011–2014) approximately three-quarters (73%) of men and slightly more (81 %) of women age 75 or older have HTN.¹ Thus, primary care and specialty nurse practitioners (NPs) have a high likelihood of encountering older adults with HTN in their daily clinical practice. Yet some NPs have reservations in prescribing antihypertensives to older adults, especially the very elderly, despite having good evidence from landmark clinical trials that HTN should be treated in this vulnerable population. Namely, two seminal trials -the Systolic Hypertension in the Elderly Program (SHEP) trial² and the Systolic Hypertension in Europe (Syst-Eur) trials,³ in addition to data from a more recent meta-analysis⁴ support the need to treat isolated systolic hypertension (ISH) in patients 60 years of age and older based on improved clinical outcomes (e.g. stroke and other cardiovascular events) associated with lower blood pressure (BP). In addition, studies have shown benefit in treating HTN in the very elderly. For example, the Hypertension in the Very Elderly Trial (HYVET)⁵ that enrolled adults 80 years old and older who had a baseline systolic blood pressure (SBP) of 160–199 mm Hg demonstrated that treatment with a thiazide-like diuretic indapamide (with the option of adding an ACE-inhibitor [perindopril] as additional therapy to reach the target BP of < 150/80 mm Hg) resulted in a lower risk of stroke and all-cause death compared to those in the placebo group. Specifically, at the 2-year mark of the study, nearly twice of patients in the treatment group versus patients in the placebo group achieved the target BP (48% versus 20% respectively). This study showed that, not only was it possible to achieve the target BP of < 150/80 mm Hg, there was also an overwhelming benefit to reducing BP in this population. In fact, the study was stopped early due to a larger than expected reduction in clinical endpoints (21% relative risk reduction in all-cause death (p = 0.02), 30% non-significant relative risk reduction in fatal or non-fatal stroke (p = 0.06), and 39% relative risk reduction in fatal stroke (p = 0.05) in the treatment group. Important to note, the benefits of therapy in HYVET were seen within the first year of treatment. Notably, serious side effects from medications were less common in the treatment group in this very elderly population as compared to placebo. Although the HYVET study was published a decade ago, the findings provide evidence to NPs for the beneficial effects of treating HTN in adults 80 years and older to reduce morbidity (stroke) and mortality.

Diagnosis of Hypertension in Elders

Beyond reservations about whether to treat older patients with HTN is the question of whether the diagnosis threshold for HTN should be different for older adults. The answer can be found by examining the definition of HTN in scientific statements and guidelines that inform NP practice. Previously, based on 2014 guidelines, the diagnostic cut-point for the HTN was a SBP of ≥ 140 mm Hg and/or diastolic BP (DBP) of ≥ 90 mm Hg.⁶ However, the 2017 American Heart Association/American College of Cardiology (AHA/ACC) treatment guidelines for HTN recategorized the definition of stage one HTN as SBP of 130–139 mm Hg and/or a DBP of 80–89 mm Hg, which is applicable to adults of all ages.⁷ As in the past, the diagnosis of HTN in the 2017 treatment guidelines is based on an average of 2 or more BP readings on 2 or more occasions to estimate the level of BP - which does not differ based on age of the adult. Thus, the diagnostic threshold for HTN is the same for older adults as compared to their younger counterparts.

In addition, the 2017 guideline recommendations included a call for action to NPs and other providers to use out-of-office BP measurements (i.e. ambulatory BP monitoring or self-measured BP) to confirm the diagnosis of HTN and to help NPs with up-titration of medication therapy.⁷ The additional readings, beyond in-office readings, provide additional BP measurements to guide diagnosis and treatment. Refer to Table 1 for categories of BP based on the 2017 AHA/ACC guidelines.

Table 1.

Blood Pressure Classification based on 2017 AHA/ACC Guidelines7

Blood Pressure (BP) Category	Systolic BP		Diastolic BP
Normal	< 120 mm Hg	and	< 80 mm Hg
Elevated	120–129 mm Hg	and	< 80 mm Hg
Hypertension (HTN)
Stage 1 HTN	130 – 139 mm Hg	or	80 – 90 mm Hg
Stage 2 HTN	≥ 140 mm Hg	or	≥ 90 mm Hg

Hypertension Treatment Goals for Elders

Although the diagnostic categories for HTN do not differ according to age, treatment goals do. So, the next question NPs may ask is: at what age should the treatment goal become less stringent? The answer depends on who you ask based on the various guidelines and scientific statements that have been published over the past several years. For example, in 2008, the HYVET authors recommended a less stringent (higher) target BP of < 150/80 mm Hg in patients ≥ 80 years receiving treatment.⁵ Then in 2011, the ACCF/AHA 2011 expert consensus document on HTN in the elderly recommended a BP treatment goal of <140/90 for adults age 65–79 years for those with uncomplicated HTN⁸ with less stringent (higher) goals for those ≥ 80. Later, the 2014 evidence-based guideline for the management of high BP in adults (the report from the panel appointed for JNC 8) established an age threshold of ≥ 60 years for a less stringent BP goal of < 150/90 mm Hg⁹ in the general population. However, this recommendation, using the age cut-point of 60 years for less stringent BP goals, was accompanied with some controversy by the cardiovascular community. Notably, a year later, in their 2015 scientific statement on treatment of HTN for patients with coronary artery disease, the AHA/ACC recommended the less stringent BP treatment goal (< 150/90 mm Hg) be reserved for the very elderly patients (> 80 years of age).¹⁰ The authors of the 2015 scientific statement advocated for raising the age threshold (to 80) for the less stringent BP treatment goal because lowering the age to an age cut-point (below 80) would place a significant number of patients, with an established cardiovascular risk, at a higher risk for complications from HTN.¹⁰ More recently (2017) the American College of Physicians and the American Academy of Family Physicians published as a joint scientific statement based on a systematic review and meta-analysis of 21 randomized clinical trials and 3 observational studies on the benefits and harms of intensive SBP treatment goals in adults ≥ 60 years of age.¹¹ Recommendations from authors of this joint scientific statement included starting pharmacological therapy in adults ≥ 60 years if the SBP is persistently ≥ 150 for a target SBP of < 150 mm Hg in an effort to decrease stroke and other cardiovascular events. However, authors noted that a stricter SBP goal (< 140 mm Hg) was recommended for persons at higher risk of stroke and other cardiovascular events (namely patients with a history of a stroke or transient ischemic attack or those at a high cardiovascular risk). Authors indicated that, regardless, in all situations, clinicians should have periodic discussions with patients and family to discuss the benefits and harms of specific BP targets. In particular, for older adults with multiple comorbid conditions, shared decision making, with or without decision aids, often becomes very complicated.¹² For example, as noted in the systematic review and meta-analysis, potential harms of the more intensive SBP target (< 140 mm Hg) in those 60 years and older include an increased likelihood of discontinuation of BP medication due to side effects such as cough, hypotension, and/or syncope.¹¹ Thus, engaging family members and other less formal caregivers in conversations with older patients may be helpful when determining priorities of care and treatment strategies. If multiple comorbidities exist and polypharmacy is a concern, the benefit-harm of treatment options including cost should be openly discussed to solicit patient preferences. Furthermore, because decision aids are not typically designed for older adults who have multiple comorbidities, these discussions should be personalized.¹²

Furthermore the latest (2017) AHA/ACC treatment guidelines for HTN recommended use of one of the lowest SBP treatment goals (< 130 mm Hg) for non-institutionalized ambulatory community dwelling older adults (defined as ≥ 65 years of age) in order to prevent cardiovascular disease and cognitive decline (including dementia).⁷ However, as with the other 2017 meta-analysis, authors noted that clinical judgement should prevail when determining an appropriate treatment goal for adults ≥ 65 who have multiple comorbidities (with or without a limited life expectancy). Thus, as recommended by the American College of Physicians and the American Academy of Family Physicians, NPs should take into consideration patient preferences and past intolerances to weigh the risks/benefits of the best approach.⁷ Refer to Table 2 for various BP treatment goals based on age.

Table 2.

Treatment Goals for Older Adults Based on Various Guideline Statements

Guideline/Statement	Age Cut-point in Years	Treatment Goal in mm Hg
HYVET (2008)	Age > 80	<150/80
AHA/ACC Statement on HTN in the Elderly (2011)	Age 65–79	< 140/90
	Age ≥ 80	< 150/90
JNC-8 (2014)	Age ≥ 60 (general population)	< 150/90
AHA/ACC Statement in CAD Patients with HTN (2015)	Age ≥ 80	< 150/90
American College of Physician/ American Academy of Family Physicians (2017)	Age ≥ 60	< 150/90
	Age ≥ 60 and a history of stroke, TIA, or at high risk for cardiovascular event	< 140/90
AHA/ACC Statement in Patients with HTN (2017)	Noninstitutionalized adults Age ≥ 65	< 130/80
	Institutionalized adults or those > 65 with multiple comorbidities with or without a limited life expectancy	< 140/90

ACC = American College of Cardiology; AHA = American Heart Association; CAD = Coronary Artery Disease; HTN = Hypertension; HYVET – Hypertension in the Very Elderly Trial; JNC-8 = Joint National Committee.

Achieving Stricter Treatment Goals

Achieving these more strict treatment goals may require additional time and resources, including scheduling more frequent patient visits to add or up-titrate antihypertensive medications, to monitor the patient for side effects, and to provide education related to self-care (such as the implementation of home BP self-monitoring).¹³ Better treatment algorithms are also needed, including those which incorporate enhanced electronic health record information, along with the use of team-based care (NPs, physician assistants, and clinical pharmacists) to help get patients to goal.¹³ In addition, if stricter treatment goals are to be achieved adherence to the treatment regimen is paramount. Nonadherence may occur in three different time periods: at initiation of the treatment strategy (patient does not start the medication of life-style change), actual implementation of the treatment (patient delays taking a dose or starting the life-style change, misses a dose all together, or takes an extra dose), or in maintaining the treatment (patient does not persistently maintain the regimen).¹⁴ In addition to personalized education about the benefits of starting and maintaining prescribed therapies, more attention is being given to the impact of reminder packaging available from pharmacies.¹⁴ Examples include: top opening easy access containers, intake reminders inside the box of the prescribed therapy, instant daily availability so the patient is more aware of a missed dose sooner, and blister packaging.¹⁴ Collaboration with local pharmacies would determine which options are available for use in a particular location.

Treatment Options

Non-pharmacological Treatment Options

Regardless of the age of the patient (or the recommended BP target) NPs should encourage all patients diagnosed with HTN to adopt a healthy lifestyle to reach (and maintain) their BP goal. Therapeutic life style modifications include weight loss (for overweight and obese patients), a heart healthy diet such as the DASH Diet, decrease in sodium intake along with an increase in potassium intake (unless contraindicated), increase in structured physical activity or exercise, moderation in alcohol intake (up to two servings per day for men and one serving per day in women or light weight men), and cessation of all tobacco products.⁷ Importantly, in addition to the direct BP lowering effect of the life style modifications themselves, these changes also help the antihypertensive mediations work better. In addition, NPs should discourage the use of non-steroidal anti-inflammatory agents (NSAIDs), including excess aspirin, by patients which interfere with antihypertensive medications (such as ACE inhibitors or ARBs). Patients should also be screened for obstructive sleep apnea since treatment with continuous positive airway pressure may help improve BP control.⁷ Thus patients with a history of snoring, witnessed apnea, and/or excessive sleepiness should be referred for polysomnography.

Pharmacological Treatment Options

Regardless of the treatment goal, if patients do not reach their treatment goal, it is important to know which drug classes are recommended for which patients. These four classes of medications include renin-angiotensin-aldosterone system (RAAS) blockers (including ACE-I or ARBs), calcium channel blockers, and diuretics. Notably, patients should not be on more than one type of RAAS blocker to avoid worsening kidney function, including hyperkalemia. Diuretics generally start with thiazide (or thiazide-like) diuretics moving on to loop diuretics if the patient’s kidney function starts to decline. Calcium channel blockers are excellent antihypertensive agents, with fewer side effects as compared to other antihypertensive drug classes. However, elders taking calcium channel blockers may experience ankle swelling which can generally be offset by lowering the dose of the calcium channel blocker initiation or by adding a small dose (or an increased dose) of a diuretic. Furthermore, aldosterone antagonists (such as spironolactone) may be used for further BP reduction (~20/10 mm Hg), in patients with resistant HTN. However, caution should be taken to monitor the patient for worsening kidney function (specifically hyperkalemia) in patients taking both an ACE-I or ARB plus an aldosterone antagonist. For these patients, monitoring laboratory findings within 2 weeks of any dosage change for a medication and every six months thereafter is generally the timeframe to have patients return to the clinic.

Benefits of Home BP Monitoring

While home BP monitoring is recommended for all patients with elevated BP, it is especially important for older adults who have been diagnosed with HTN to place confidence in the accuracy of BP recordings in the office. Home BP monitoring can determine whether BP readings in the office are higher than out-of-office readings (indicating white coat HTN) or lower than out-of-office readings (indicating masked HTN). Furthermore, home BP monitoring has also been shown to increase patient engagement in their own care while increasing adherence to the treatment regimen. Several resources and references about self-measured BP monitoring (another name for home BP monitoring) are available on the Million Hearts® website, including a guide specifically written to help clinicians implement self-measured BP monitoring in their practices.¹⁵

Conclusion

Older adults, especially the very elderly (> 80 years of age), diagnosed with HTN benefit from BP reduction. The most recent guidelines suggest that adults ~ 60 years and older should aim for the BP to be < 140/90, with the most recent 2017 AHA/ACC guidelines calling for BP to be < 130/80 in this age group. It will generally take more than one medication class to get older adult patients to goal, with the most common drug classes being ACE-inhibitors, ARBs, CCBs, and/or diuretics. It is important for NPs to use shared decision making to discuss with older adults the pros and cons of more intensive BP targets when trying to determine the right combination of medications at the right doses. Home BP monitoring is useful in detecting differences in BP readings in and out of the office, as well as, potentially improving treatment adherence.

Highlights:

• Older adults benefit from blood pressure lowering to reduce morbidity and mortality.

• Age cut-points for less stringent BP treatment goals varies across scientific statements.

• Home blood pressure monitoring helps confirm diagnosis of hypertension.

• Patient engagement is important when determining pros/cons of more intensive BP targets.