Using a practical approach when treating and monitoring hypertension is essential for optimal management of the condition. A BEGIN algorithm was developed to assist prescribers in initiating hypertensive therapy and guide safe medication use in older adults with hypertension.
By the year 2025, it is predicted that 1.56 billion people worldwide will be living with hypertension (high blood pressure).Hypertension is a common condition in which the force of blood against the artery wall is too high. Symptoms that are associated with the chronic form of this condition are rare and include light headaches, dizziness, and frequent nosebleeds. Though hypertension has few or no true symptoms, if it is left untreated it can cause severe conditions, such as stroke or cardiovascular disease.The BEGIN algorithm is a tool used which combines geriatric and pharmacy expertise to best support prescribers of hypertensive medications in their consideration of when to begin pharmacological therapy.In order to prevent severe progression of hypertension, treatment is necessary and usually includes antihypertensive drugs. The drug classes found to be most effective in lowering blood pressure are calcium-channel blockers and ACE-inhibitors. Though Beta blockers are not the first line of treatment, these drugs may be prescribed to hypertensive patients who have a pre-existing cardiovascular condition.Regardless of the chosen therapeutic path to treat this condition, the “start low, go slow” is an important approach to prescribing medications for older adults with hypertension.
The use of antihypertensives is relatively high and the guidelines between countries vary in regards to who to treat, the stage to treat them, and the most appropriate class of drug to prescribe. Determining when to prescribe medications and how best to proceed with treatment in relation to other conditions that older hypertensive patients have involves practical approaches and much consideration. Several large placebo-controlled, randomized trials have been performed in order to investigate optimal management of hypertension. The international hypertensive guidelines show that over the last 35 years, these trials have shown that lowering hypertension in older adults can reduce cardiovascular disease risk and mortality. These trials have also contributed to the implementation of the varied guidelines for treating hypertension in Europe and America. In Europe, pharmacological treatment is recommended to begin when systolic blood pressure (SBP)is greater than 160 mmHg. However, American guidelines recommend the initiation of pharmacological treatment when SBP is greater than 150 mmHg. With the goal to lower blood pressure, the collection of data showed that the relative risk of cardiovascular events and stroke are reduced when systolic blood pressure have been lowered by 10 mmHg or diastolic blood pressure has been lowered by 5 mmHg.The optimal blood pressure for hypertensive adults aged 65 years and older is seen as the patient’s specific decision; which needs to be made based on therapeutic benefits and patient tolerance of antihypertensive therapy. It is known that there is a benefit for intensive lowering of blood pressure, however, the target number that blood pressure should be lowered to remains to be decided on. Though a lowered systolic or diastolic blood pressure is known to reduce all-cause mortality, the answer for how low to go remains to be determined.
Management of hypertension in older adults is complex due to the multiple pathologies that are associated with ageing. Proper management involves consideration of multimorbidity challenges that older hypertensive patients face, such as frailty, orthostatic hypotension, falls, and cognitive impairment. To investigate this matter randomized trials were performed to compare antihypertension medications in older adults. Because many older hypertensive patients suffer from other conditions, managing blood pressure cannot be done in isolation. However, though other conditions must be considered in the process, limited evidence is available to support its management within a multimorbidity framework. Polypharmacy, or subscribing multiple medications for this single condition has been associated with poor health outcomes, including falls, heart failure, raised blood pressure, and increased mortality. Therefore, it is important to consider patient health care goals, the role of the medication, and its risk-to-benefit profile.Clinical experts with a special interest in older adults, such as geriatricians or general practitioners are thought to deliver the best holistic and tailored care plan to these patients.
Even though the management of hypertension is essential, treating this condition without considering how management may affect other conditions is not suggested. Common conditions in elderly individuals such as frailty, orthostatic hypotension (OH), proneness to falls, and dementia contribute to the multimorbidity framework when considering optimal management of hypertension. As another common condition associated with ageing, frailty is characterized as having increased vulnerability due to physical stressors. Studies have found that taking action to lower blood pressure is a potential risk for frail older people. A drop in SBP ⩾ 20 mmHg or drop in DBP ⩾10 mmHg within three minutes of standing from sitting or supine position is referred to as an OHcondition usually seen in older people. The symptoms of OH, dizziness or light-headedness, was found to lead to falls in older adults; and was, therefore, determined to be best managed with medications. Because some antihypertensive medications have been found to cause OH, and the symptoms of OH can lead to dizziness, light headedness, and falls, medication management of this condition was found to be essential. Due to the fact they are less likely to cause OH, renin-angiotensin system blockers and a selection of calcium channel blockers were found to be the medication of choice. The management of this condition is important because uncontrolled orthostatic hypertension, BP > 140/90, was associated with a 2.5times greater risk of falls than in those who did not suffer from OH but had uncontrolled hypertension.
Falls can be the result of impaired balance, OH, or polypharmacy. A direct association between the use of hypertensive medications and falls has been found to be directly related. In fact, it was determined that the risk of falls and injuries with the use of hypertensives depends on how long the patient has been taking the medication. However, when researchers investigated the preference of older hypertensive patients and their risk of falls, they found that half of the people that were surveyed preferred to take hypertensives regardless of their increased risk for falls.
As a chronic disorder of mental processes, dementia is another condition to consider when prescribing hypertensive therapy. Because older adults with dementia have a higher risk of OH, polypharmacy, and frailty, prescribing hypertensives to those suffering from this mental condition is done so in a cautious manner. In fact, more clinical trials are needed to see the benefit of treating hypertension in older adults with dementia.
Using clinical evidence and determining patient preferences allows for shared decision making between the patient and the clinician for selecting tests, treatments, and optimal management of hypertension. Though more research is needed to determine the optimal target to which blood pressure should be lowered, the consideration of the BEGIN algorithm, and multimorbidity factors, aid practitioners in making the best decisions for treating and monitoring hypertension in older adults.
A practical approach to the pharmacological management of hypertension in older people, Nikesh Parekh, Amy Page, Khalid Ali, Kevin Davies and ChakravarthiRajkumar,Therapeutic Advances in Drug Safety,2017, Vol. 8(4) 117–132
Written By: Viola Lanier, Ph. D., M. Sc.