Review article 59
Blood pressure measurement in the geriatric population Arun K. Reddya,b, Mather R.D. Jogendraa,b and Clive Rosendorffa,b As the population above 60 years of age is the fastest growing and hypertension is highly prevalent in this group, accurate blood pressure (BP) measurement in the elderly is a very important and widely applicable subject. As with any other population, an accurate measurement of BP is essential to plan therapy and this remains an important consideration in the elderly as well. There are some unique problems of BP measurement in the elderly, including drug-induced orthostatic hypotension, white-coat hypertension, and advanced atherosclerotic disease with stiff arteries. For clinical use, home blood pressure monitoring (HBPM), office measurement, and ambulatory blood pressure monitoring all play a role in patient management. In the office setting, aneroid devices, hybrid devices with electronic transducers, and oscillometric devices are available; all of these require frequent calibration, well-trained operators and technically sound execution. Because the white-coat effect is common in this group, there is a good case for the use of HBPM, which could also be used to detect orthostatic changes at home. Also, HBPM predicts cardiovascular events better than clinical BP, and is also useful in monitoring treatment. Ambulatory blood pressure monitoring provides the most
precise assessment of BP over an extended period, but is more complex and expensive. Finally, the utility of noninvasive central arterial pressure through radial artery applanation tonometry, especially in patients with resistant hypertension and likely in the elderly because of advanced atherosclerotic disease and stiff arteries, may prove to be a useful tool to guide or modify drug therapy in the future and requires further study. Blood Press Monit c 2014 Wolters Kluwer Health | Lippincott 19:59–63 Williams & Wilkins.
Introduction
for 30% of all prescriptions written [4]. According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7), hypertension occurs in more than two-third of individuals after the age of 65 years [5]. With respect to subgroups, in the USA, the prevalence and severity of hypertension in elderly women is more marked than elderly men [6–9]. Compared with whites, blacks are more likely to have hypertension, have more severe and uncontrolled or difficult to control hypertension, develop hypertension at an earlier age, and suffer greater morbidity and mortality because of hypertension [5,10,11]. Further, studies have shown that in the ‘oldest old’ (i.e. age > 85 years), lower BPs were associated with shorter survival [12–15]. This finding, however, is somewhat difficult to interpret and is probably an example of reverse causality, with the lower BPs symptomatic of comorbidities, particularly heart failure. It would therefore be totally unjustified to withhold antihypertensive therapy in the oldest-old patients with an elevated BP, although the BP reduction should be less aggressive in the frail elderly compared with the fit [16].
Blood pressure (BP) measurement and optimal targets are poorly defined and complex in the elderly. The vagueness relates to the lack of a generally accepted definition of ‘elderly’ or ‘old’. It would appear that most developed nations have accepted the chronological age of at least 65 years as a definition of ‘elderly’, the most rapidly growing population in the USA and worldwide. The fastest-growing subgroup of the elderly are those older than 85 years of age, defined as the ‘oldest old’ (or ‘old old’), the group with the highest rate of chronic disease, acute illness, disability, and frailty [1–4]. A caveat to this is that chronological age is not necessarily synonymous with biological or physiological age. To date, there are no clear guidelines from national bodies with respect to BP measurements in the elderly, let alone goals of treatment. This review article will aim to highlight the complexities of BP measurement in the geriatric population. The topic of goals of treatment is controversial, particularly considering subgroups such as women, blacks, and age stratification within the elderly group, and will not be the focus of this paper. Epidemiology
The elderly population in the USA utilizes 50% of the federal health budget, 40% of hospital beds, and accounts c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1359-5237
Blood Pressure Monitoring 2014, 19:59–63 Keywords: ambulatory blood pressure monitoring, blood pressure, blood pressure measurement, blood pressure variability, elderly, geriatric, home blood pressure monitoring, orthostatic hypotension, pseudohypertension a
Mount Sinai Heart, Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, New York, New York, USA
b
Correspondence to Clive Rosendorff, MD, PhD, DScMed, Medicine 111, James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, New York, NY 10468, USA Tel: + 1 718 741 4292; fax: + 1 718 741 4233; e-mail: [email protected] Received 3 June 2013 Revised 20 September 2013 Accepted 6 December 2013
As with any other population, accurate measurement of the BP is essential to plan therapy. Technical considerations such as operator (i.e. nurse vs. physician), body posture, cuff size, type of device, white-coat effect, and arm size have DOI: 10.1097/MBP.0000000000000021
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been well described in numerous publications and summarized by Pickering et al. [17,18]. At present, it is widely accepted that for clinical use, office measurements, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM) play a role in patient management. It is recognized that clinical measurements may not be representative of an elderly patient’s true BP as the white-coat effect is particularly pronounced in this group [18,19]. The Prognostic Indicator of Cardiovascular and Cerebrovascular Events (PROOF) study observed that ambulatory BP is higher in both treated and untreated patients aged above 65 years [20]. In this study, the prevalence of ambulatory hypertension was as high as 31% in treated and 21% in patients who were never diagnosed or treated for hypertension. Thus, there is a good case for the use of ABPM and HBPM in this group, which could also be used to detect orthostatic changes and other hypertension syndromes in the elderly [18]. This is bolstered by the increasing evidence that HBPM predicts cardiovascular events better than the office measurements, and are also useful in monitoring treatment. However, issues such as cost effectiveness of HBPM and reimbursement for the use of the devices are yet to be clarified [21]. There may be some utility in the noninvasive measurement of the central (aortic) BP through radial artery applanation tonometry, especially in patients with resistant hypertension, and in the elderly, because of their advanced atherosclerotic disease and stiff arteries. Monitoring central BP may also be important because some classes of antihypertensive agents, while equipotent in reducing brachial artery BP, may have different effects on central BP, as shown in the Conduit Artery Function ´ ) substudy of the Anglo-Scandinavian Evaluation (CAFE Cardiac Outcomes Trial (ASCOT) [22]. Further, in this study, lower central BPs were found to have better cardiovascular outcomes compared with those with higher central BPs, although patients in both study groups had similar brachial BPs. Therefore, central BP measurement may prove to be a useful tool to guide or modify drug therapy and merits further study in the elderly.
Hypertension syndromes in the elderly Pseudohypertension
In his great work, ‘The Principles and Practice of Medicine’, Sir William Osler wrote in 1892, and referring to ‘arterio-sclerosis’: ‘It may be very difficult to obliterate the pulse, and the firmest pressure on the radial may not be sufficient to annihilate the pulse wave beyond the point of pressure’ [23]. Pseudohypertension is defined as a falsely elevated BP over and above the true BP. To compress calcified atherosclerotic arteries, higher amounts of cuff pressure are needed, which in turn is recorded as a higher BP [24]. Small studies estimate the prevalence to be about 1.7% in those older than 65 years of age [25]. A high index
of suspicion is needed to diagnose pseudohypertension and failure to recognize this may result in unnecessary therapy or escalation of therapy. A simple bedside maneuver referred to as the Osler’s maneuver has been described to identify pseudohypertension [26]. It involves palpating the distal pulseless artery after compressing the proximal artery either manually or by a cuff. If a pulse is palpable, it is considered positive, which indicates sclerosis and noncompressibility of the artery [26]. Studies by Spence et al. [27] have shown a difference of nearly 64 mmHg between estimated cuff and intra-arterial BP in some elderly patients. In Osler-positive patients, pseudohypertension was estimated to range from 10 to 54 mmHg [26]. Subsequent studies have disputed the clinical utility of the Osler maneuver because of its low predictive value [28,29]. White-coat hypertension
White-coat hypertension is a clinical conundrum faced by physicians and is identified by means of ABPM, with normal ABPM values being less than 140/90 (daytime), less than 125/75 (night-time), and less than 135/85 (24 h average) mmHg. At age above 80 years, white-coat hypertension was found to be prevalent in nearly 50% of the participants of the Hypertension in the Very Elderly Trial (HYVET) [30]. It is highly prevalent in older patients with isolated systolic hypertension [31–35]. In patients with isolated systolic hypertension, 28.6% of the untreated and 38.1% of the treated patients were found to have white-coat hypertension [35]. Isolated systolic hypertension
Isolated systolic hypertension is defined as systolic blood pressure (SBP) greater than 140 mmHg but with diastolic blood pressure (DBP) less than 90 mmHg [36,37]. Systolic hypertension increases progressively with age and it is estimated that in the age group above 60 years, prevalence is about 87% [37,38]. Studies have shown that there is variability of SBP in the clinic and by ambulatory recordings [39]. The SBP on average was 21 mmHg lower than the clinical recordings, whereas the DBP did not vary much [39]. Several studies have identified isolated systolic hypertension as a cardiovascular risk factor and controlling it improved cardiovascular outcomes, clearly shown by the Systolic Hypertension in the Elderly Program (SHEP) [40–43]. The difficulty remains between differentiating between isolated systolic hypertension and white-coat hypertension if the BP is elevated in the clinic but the ambulatory BP is normal. Orthostatic hypotension
Orthostatic hypotension is defined as a decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 min of being in the erect posture [44]. Its prevalence is estimated to be 20% in age above 65 years, 30% in age above 75 years, and about 50% in nursing home-dwelling elderly [45].
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BP measurement in the elderly Reddy et al. 61
Orthostatic BP should be measured ideally after 5 min of a quiet supine position and after 1 and 3 min of standing [45]. Once orthostatic hypotension is diagnosed, it requires a detailed history and physical examination to rule out common causes such as medications and autonomic neuropathy. Masked hypertension
Masked hypertension is characterized by normal BP in the office setting and an elevated BP elsewhere [46,47]. The prevalence is estimated to be as high as 8–20% in untreated adults and about 61% in treated adults [46]. In the population older than 65 years of age, the prevalence was estimated at 16% in the overall sample and 41% in participants who had normal office BP [48]. In this study, home BP threshold was set at 135 mmHg systolic and 85 mmHg diastolic. The prevalence tends to increase with age, reaching as high as 52% in age above 80 years [48]. It is important to diagnose masked hypertension because of the relatively higher incidence of cardiovascular events and target organ damage [46,49,50]. ABPM and HBPM are effective at diagnosing masked hypertension [46,47]. Male sex, obesity, anxiety, stress, smoking, and alcohol consumption have been found to increase the ambulatory BP [46]. Blood pressure variability in the elderly
BP is generally variable, with diurnal variability, betweenvisits variability, and device-to-device variability. The elderly have a higher incidence of variability in BP because of decompensated baroreceptor mechanisms [51,52]. This variability poses a huge challenge in the treatment of hypertension in the elderly [53]. Further, swings between hypertension and hypotension accentuate end-organ damage in the elderly [52,53]. Twenty-four hour variability in BP was higher in the elderly with hypertension than those without hypertension and this was found to be an independent risk factor for cardiovascular disease [52]. For every 5 mmHg increase in the night-time SBP variability, the risk of stroke increased by 80% [54]. ABPM is useful in detecting BP variability and can be used to tailor therapy in elderly patients [53]. Diurnal variation of blood pressure
BP has a characteristic circadian rhythm; there is a nocturnal decrease in BP, followed by an early-morning BP surge [55]. Normotensive adults have a 10–20% decrease in nocturnal BP, whereas the elderly have an attenuated decrease in nocturnal BP [55]. They are described as ‘nondippers’, and the probability of ‘nondipping’ increases with age from 2.8fold for the age group 30–60 years to 5.7-fold for the age group 60–80 years [56]. On the basis of the nocturnal decrease in BP, patients can be classified as dippers, extreme dippers, nondippers, and reverse dippers [57]. The reverse dippers were found to
have a high risk of cardiovascular events and mortality [57]. In these patients, the optimal treatment strategy is to prescribe medications that exert BP control over a 24-h period, especially night-time, to decrease the adverse cardiovascular risk. Difference between cuff and intra-arterial blood pressure
BP measurement in the elderly is more complicated than it appears, especially when measured by a cuff. In a study carried out by Finnegan et al. [58], intra-arterial SBP was lower and DBP was higher than sphygmomanometer cuff pressures. The mean SBP by direct measurement was higher by 5 mmHg, the mean diastolic pressure by direct measurement was lower by 8 mmHg, and the average mean cuff pressure was higher by 4 mmHg. This study suggests that there is overestimation of DBP by the cuff method in patients older than 65 years of age. It is clear, therefore, that SBP tends to be underestimated and DBP tends to be overestimated in the elderly. The measurement of intra-arterial BP is not practical for routine use; thus, cuff pressure remains the standard. Home blood pressure monitoring in the elderly
Elderly patients tend to have significant variations in BP and measurement of clinical BP might not provide an accurate estimate of their true BP. Hence, HBPM is an alternative strategy to evaluate elderly hypertensives, with evidence that this strategy can be successful [59], particularly as the elderly frequently have difficulties with mobility and their ability travel to appointments in the office or clinic. In the elderly, 96% of individuals older than 73 years of age were successful at monitoring their BP at home, whereas this rate was 97% at 1 year [60]. In patients with hypertension and chronic kidney disease, telemedicine HBPMs were a significant addition to office measurements [61], and also produced a trend toward improvements in BP control over usual care at 6 months [62]. In a study of 60 patients with dementia aged 75 years and older, HBPM by a relative using an automated device was a good alternative to 24-h ABPM [63]. Several different types of home BP monitors are available in the market; wrist and arm monitors are the most commonly used [21]. Elderly patients should be trained on the proper use of the equipment and recording of the BP should be maintained in a diary for physician evaluation. There should be several daytime (preferably at trough medication levels, usually in the early morning) and several evening readings per week. Validity and reliability of the HBPM device should be checked if there is discrepancy in the home and office recordings. The European Society of Hypertension has endorsed HBPM because of the convenience, low cost, and multiple recordings that can be obtained in comparison with one clinical recording performed weeks or months apart [60]. In our view, a practical approach would be to
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use a combination of both home and office BP recordings to tailor therapy.
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Ambulatory blood pressure monitoring in the elderly
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White-coat hypertension, masked hypertension, orthostatic hypotension, night-time hypertension, and BP variability can all be assessed by ABPM [31,64,65]. Elderly patients tend to have considerable variability in BP [64]. Therefore, it is often useful to assess the circadian BP rhythm in the elderly [65]. ABPM offers the convenience of being able to analyze the various BP patterns in the elderly [21,64,66]. Twenty-four hour assessment of BP also helps to tailor medications more appropriately [64]. In a study of 808 older (Z 60 years) patients whose untreated BP level on conventional measurement at baseline was 160 mmHg systolic and less than 90 mmHg diastolic, ABPM was a better predictor of cardiovascular risk than conventional BP measurement [67]. Most elderly patients can tolerate ABPM, which is similar to other age groups [66,68]. In view of the evidence, ABPM in the elderly would be very helpful in identifying hypertension syndromes and also evaluating treatment efficacy. The limitations are, of course, the cost, the presence or absence of significant cognitive impairment, and the ability of the patient to tolerate the monitor.
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Summary Here, ‘elderly’ is used to describe an age group older than 65 years of age. More than two-third of elderly individuals have hypertension, and this is associated with greater cardiovascular morbidity and mortality. As with any other population, accurate measurement of the BP is essential to plan and monitor the response to therapy. In the elderly, there is a greater prevalence of pseudohypertension because of calcified and incompressible arteries, white-coat hypertension, masked hypertension, isolated systolic hypertension, BP variability, and orthostatic hypotension and syncope because of overaggressive therapy. Consequently, 24-h ABPM is very useful in the evaluation and management of hypertension in the elderly, but is limited by availability and cost. An alternative is HBPM, and several recent studies have shown its utility in improving the predictive value of the BP values and in improving BP control.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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Blood pressure measurement in the geriatric population Arun K. Reddya,b, Mather R.D. Jogendraa,b and Clive Rosendorffa,b As the population above 60 years of age is the fastest growing and hypertension is highly prevalent in this group, accurate blood pressure (BP) measurement in the elderly is a very important and widely applicable subject. As with any other population, an accurate measurement of BP is essential to plan therapy and this remains an important consideration in the elderly as well. There are some unique problems of BP measurement in the elderly, including drug-induced orthostatic hypotension, white-coat hypertension, and advanced atherosclerotic disease with stiff arteries. For clinical use, home blood pressure monitoring (HBPM), office measurement, and ambulatory blood pressure monitoring all play a role in patient management. In the office setting, aneroid devices, hybrid devices with electronic transducers, and oscillometric devices are available; all of these require frequent calibration, well-trained operators and technically sound execution. Because the white-coat effect is common in this group, there is a good case for the use of HBPM, which could also be used to detect orthostatic changes at home. Also, HBPM predicts cardiovascular events better than clinical BP, and is also useful in monitoring treatment. Ambulatory blood pressure monitoring provides the most
precise assessment of BP over an extended period, but is more complex and expensive. Finally, the utility of noninvasive central arterial pressure through radial artery applanation tonometry, especially in patients with resistant hypertension and likely in the elderly because of advanced atherosclerotic disease and stiff arteries, may prove to be a useful tool to guide or modify drug therapy in the future and requires further study. Blood Press Monit c 2014 Wolters Kluwer Health | Lippincott 19:59–63 Williams & Wilkins.
Introduction
for 30% of all prescriptions written [4]. According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7), hypertension occurs in more than two-third of individuals after the age of 65 years [5]. With respect to subgroups, in the USA, the prevalence and severity of hypertension in elderly women is more marked than elderly men [6–9]. Compared with whites, blacks are more likely to have hypertension, have more severe and uncontrolled or difficult to control hypertension, develop hypertension at an earlier age, and suffer greater morbidity and mortality because of hypertension [5,10,11]. Further, studies have shown that in the ‘oldest old’ (i.e. age > 85 years), lower BPs were associated with shorter survival [12–15]. This finding, however, is somewhat difficult to interpret and is probably an example of reverse causality, with the lower BPs symptomatic of comorbidities, particularly heart failure. It would therefore be totally unjustified to withhold antihypertensive therapy in the oldest-old patients with an elevated BP, although the BP reduction should be less aggressive in the frail elderly compared with the fit [16].
Blood pressure (BP) measurement and optimal targets are poorly defined and complex in the elderly. The vagueness relates to the lack of a generally accepted definition of ‘elderly’ or ‘old’. It would appear that most developed nations have accepted the chronological age of at least 65 years as a definition of ‘elderly’, the most rapidly growing population in the USA and worldwide. The fastest-growing subgroup of the elderly are those older than 85 years of age, defined as the ‘oldest old’ (or ‘old old’), the group with the highest rate of chronic disease, acute illness, disability, and frailty [1–4]. A caveat to this is that chronological age is not necessarily synonymous with biological or physiological age. To date, there are no clear guidelines from national bodies with respect to BP measurements in the elderly, let alone goals of treatment. This review article will aim to highlight the complexities of BP measurement in the geriatric population. The topic of goals of treatment is controversial, particularly considering subgroups such as women, blacks, and age stratification within the elderly group, and will not be the focus of this paper. Epidemiology
The elderly population in the USA utilizes 50% of the federal health budget, 40% of hospital beds, and accounts c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1359-5237
Blood Pressure Monitoring 2014, 19:59–63 Keywords: ambulatory blood pressure monitoring, blood pressure, blood pressure measurement, blood pressure variability, elderly, geriatric, home blood pressure monitoring, orthostatic hypotension, pseudohypertension a
Mount Sinai Heart, Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, New York, New York, USA
b
Correspondence to Clive Rosendorff, MD, PhD, DScMed, Medicine 111, James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, New York, NY 10468, USA Tel: + 1 718 741 4292; fax: + 1 718 741 4233; e-mail: [email protected] Received 3 June 2013 Revised 20 September 2013 Accepted 6 December 2013
As with any other population, accurate measurement of the BP is essential to plan therapy. Technical considerations such as operator (i.e. nurse vs. physician), body posture, cuff size, type of device, white-coat effect, and arm size have DOI: 10.1097/MBP.0000000000000021
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been well described in numerous publications and summarized by Pickering et al. [17,18]. At present, it is widely accepted that for clinical use, office measurements, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM) play a role in patient management. It is recognized that clinical measurements may not be representative of an elderly patient’s true BP as the white-coat effect is particularly pronounced in this group [18,19]. The Prognostic Indicator of Cardiovascular and Cerebrovascular Events (PROOF) study observed that ambulatory BP is higher in both treated and untreated patients aged above 65 years [20]. In this study, the prevalence of ambulatory hypertension was as high as 31% in treated and 21% in patients who were never diagnosed or treated for hypertension. Thus, there is a good case for the use of ABPM and HBPM in this group, which could also be used to detect orthostatic changes and other hypertension syndromes in the elderly [18]. This is bolstered by the increasing evidence that HBPM predicts cardiovascular events better than the office measurements, and are also useful in monitoring treatment. However, issues such as cost effectiveness of HBPM and reimbursement for the use of the devices are yet to be clarified [21]. There may be some utility in the noninvasive measurement of the central (aortic) BP through radial artery applanation tonometry, especially in patients with resistant hypertension, and in the elderly, because of their advanced atherosclerotic disease and stiff arteries. Monitoring central BP may also be important because some classes of antihypertensive agents, while equipotent in reducing brachial artery BP, may have different effects on central BP, as shown in the Conduit Artery Function ´ ) substudy of the Anglo-Scandinavian Evaluation (CAFE Cardiac Outcomes Trial (ASCOT) [22]. Further, in this study, lower central BPs were found to have better cardiovascular outcomes compared with those with higher central BPs, although patients in both study groups had similar brachial BPs. Therefore, central BP measurement may prove to be a useful tool to guide or modify drug therapy and merits further study in the elderly.
Hypertension syndromes in the elderly Pseudohypertension
In his great work, ‘The Principles and Practice of Medicine’, Sir William Osler wrote in 1892, and referring to ‘arterio-sclerosis’: ‘It may be very difficult to obliterate the pulse, and the firmest pressure on the radial may not be sufficient to annihilate the pulse wave beyond the point of pressure’ [23]. Pseudohypertension is defined as a falsely elevated BP over and above the true BP. To compress calcified atherosclerotic arteries, higher amounts of cuff pressure are needed, which in turn is recorded as a higher BP [24]. Small studies estimate the prevalence to be about 1.7% in those older than 65 years of age [25]. A high index
of suspicion is needed to diagnose pseudohypertension and failure to recognize this may result in unnecessary therapy or escalation of therapy. A simple bedside maneuver referred to as the Osler’s maneuver has been described to identify pseudohypertension [26]. It involves palpating the distal pulseless artery after compressing the proximal artery either manually or by a cuff. If a pulse is palpable, it is considered positive, which indicates sclerosis and noncompressibility of the artery [26]. Studies by Spence et al. [27] have shown a difference of nearly 64 mmHg between estimated cuff and intra-arterial BP in some elderly patients. In Osler-positive patients, pseudohypertension was estimated to range from 10 to 54 mmHg [26]. Subsequent studies have disputed the clinical utility of the Osler maneuver because of its low predictive value [28,29]. White-coat hypertension
White-coat hypertension is a clinical conundrum faced by physicians and is identified by means of ABPM, with normal ABPM values being less than 140/90 (daytime), less than 125/75 (night-time), and less than 135/85 (24 h average) mmHg. At age above 80 years, white-coat hypertension was found to be prevalent in nearly 50% of the participants of the Hypertension in the Very Elderly Trial (HYVET) [30]. It is highly prevalent in older patients with isolated systolic hypertension [31–35]. In patients with isolated systolic hypertension, 28.6% of the untreated and 38.1% of the treated patients were found to have white-coat hypertension [35]. Isolated systolic hypertension
Isolated systolic hypertension is defined as systolic blood pressure (SBP) greater than 140 mmHg but with diastolic blood pressure (DBP) less than 90 mmHg [36,37]. Systolic hypertension increases progressively with age and it is estimated that in the age group above 60 years, prevalence is about 87% [37,38]. Studies have shown that there is variability of SBP in the clinic and by ambulatory recordings [39]. The SBP on average was 21 mmHg lower than the clinical recordings, whereas the DBP did not vary much [39]. Several studies have identified isolated systolic hypertension as a cardiovascular risk factor and controlling it improved cardiovascular outcomes, clearly shown by the Systolic Hypertension in the Elderly Program (SHEP) [40–43]. The difficulty remains between differentiating between isolated systolic hypertension and white-coat hypertension if the BP is elevated in the clinic but the ambulatory BP is normal. Orthostatic hypotension
Orthostatic hypotension is defined as a decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 min of being in the erect posture [44]. Its prevalence is estimated to be 20% in age above 65 years, 30% in age above 75 years, and about 50% in nursing home-dwelling elderly [45].
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BP measurement in the elderly Reddy et al. 61
Orthostatic BP should be measured ideally after 5 min of a quiet supine position and after 1 and 3 min of standing [45]. Once orthostatic hypotension is diagnosed, it requires a detailed history and physical examination to rule out common causes such as medications and autonomic neuropathy. Masked hypertension
Masked hypertension is characterized by normal BP in the office setting and an elevated BP elsewhere [46,47]. The prevalence is estimated to be as high as 8–20% in untreated adults and about 61% in treated adults [46]. In the population older than 65 years of age, the prevalence was estimated at 16% in the overall sample and 41% in participants who had normal office BP [48]. In this study, home BP threshold was set at 135 mmHg systolic and 85 mmHg diastolic. The prevalence tends to increase with age, reaching as high as 52% in age above 80 years [48]. It is important to diagnose masked hypertension because of the relatively higher incidence of cardiovascular events and target organ damage [46,49,50]. ABPM and HBPM are effective at diagnosing masked hypertension [46,47]. Male sex, obesity, anxiety, stress, smoking, and alcohol consumption have been found to increase the ambulatory BP [46]. Blood pressure variability in the elderly
BP is generally variable, with diurnal variability, betweenvisits variability, and device-to-device variability. The elderly have a higher incidence of variability in BP because of decompensated baroreceptor mechanisms [51,52]. This variability poses a huge challenge in the treatment of hypertension in the elderly [53]. Further, swings between hypertension and hypotension accentuate end-organ damage in the elderly [52,53]. Twenty-four hour variability in BP was higher in the elderly with hypertension than those without hypertension and this was found to be an independent risk factor for cardiovascular disease [52]. For every 5 mmHg increase in the night-time SBP variability, the risk of stroke increased by 80% [54]. ABPM is useful in detecting BP variability and can be used to tailor therapy in elderly patients [53]. Diurnal variation of blood pressure
BP has a characteristic circadian rhythm; there is a nocturnal decrease in BP, followed by an early-morning BP surge [55]. Normotensive adults have a 10–20% decrease in nocturnal BP, whereas the elderly have an attenuated decrease in nocturnal BP [55]. They are described as ‘nondippers’, and the probability of ‘nondipping’ increases with age from 2.8fold for the age group 30–60 years to 5.7-fold for the age group 60–80 years [56]. On the basis of the nocturnal decrease in BP, patients can be classified as dippers, extreme dippers, nondippers, and reverse dippers [57]. The reverse dippers were found to
have a high risk of cardiovascular events and mortality [57]. In these patients, the optimal treatment strategy is to prescribe medications that exert BP control over a 24-h period, especially night-time, to decrease the adverse cardiovascular risk. Difference between cuff and intra-arterial blood pressure
BP measurement in the elderly is more complicated than it appears, especially when measured by a cuff. In a study carried out by Finnegan et al. [58], intra-arterial SBP was lower and DBP was higher than sphygmomanometer cuff pressures. The mean SBP by direct measurement was higher by 5 mmHg, the mean diastolic pressure by direct measurement was lower by 8 mmHg, and the average mean cuff pressure was higher by 4 mmHg. This study suggests that there is overestimation of DBP by the cuff method in patients older than 65 years of age. It is clear, therefore, that SBP tends to be underestimated and DBP tends to be overestimated in the elderly. The measurement of intra-arterial BP is not practical for routine use; thus, cuff pressure remains the standard. Home blood pressure monitoring in the elderly
Elderly patients tend to have significant variations in BP and measurement of clinical BP might not provide an accurate estimate of their true BP. Hence, HBPM is an alternative strategy to evaluate elderly hypertensives, with evidence that this strategy can be successful [59], particularly as the elderly frequently have difficulties with mobility and their ability travel to appointments in the office or clinic. In the elderly, 96% of individuals older than 73 years of age were successful at monitoring their BP at home, whereas this rate was 97% at 1 year [60]. In patients with hypertension and chronic kidney disease, telemedicine HBPMs were a significant addition to office measurements [61], and also produced a trend toward improvements in BP control over usual care at 6 months [62]. In a study of 60 patients with dementia aged 75 years and older, HBPM by a relative using an automated device was a good alternative to 24-h ABPM [63]. Several different types of home BP monitors are available in the market; wrist and arm monitors are the most commonly used [21]. Elderly patients should be trained on the proper use of the equipment and recording of the BP should be maintained in a diary for physician evaluation. There should be several daytime (preferably at trough medication levels, usually in the early morning) and several evening readings per week. Validity and reliability of the HBPM device should be checked if there is discrepancy in the home and office recordings. The European Society of Hypertension has endorsed HBPM because of the convenience, low cost, and multiple recordings that can be obtained in comparison with one clinical recording performed weeks or months apart [60]. In our view, a practical approach would be to
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use a combination of both home and office BP recordings to tailor therapy.
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Ambulatory blood pressure monitoring in the elderly
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White-coat hypertension, masked hypertension, orthostatic hypotension, night-time hypertension, and BP variability can all be assessed by ABPM [31,64,65]. Elderly patients tend to have considerable variability in BP [64]. Therefore, it is often useful to assess the circadian BP rhythm in the elderly [65]. ABPM offers the convenience of being able to analyze the various BP patterns in the elderly [21,64,66]. Twenty-four hour assessment of BP also helps to tailor medications more appropriately [64]. In a study of 808 older (Z 60 years) patients whose untreated BP level on conventional measurement at baseline was 160 mmHg systolic and less than 90 mmHg diastolic, ABPM was a better predictor of cardiovascular risk than conventional BP measurement [67]. Most elderly patients can tolerate ABPM, which is similar to other age groups [66,68]. In view of the evidence, ABPM in the elderly would be very helpful in identifying hypertension syndromes and also evaluating treatment efficacy. The limitations are, of course, the cost, the presence or absence of significant cognitive impairment, and the ability of the patient to tolerate the monitor.
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Summary Here, ‘elderly’ is used to describe an age group older than 65 years of age. More than two-third of elderly individuals have hypertension, and this is associated with greater cardiovascular morbidity and mortality. As with any other population, accurate measurement of the BP is essential to plan and monitor the response to therapy. In the elderly, there is a greater prevalence of pseudohypertension because of calcified and incompressible arteries, white-coat hypertension, masked hypertension, isolated systolic hypertension, BP variability, and orthostatic hypotension and syncope because of overaggressive therapy. Consequently, 24-h ABPM is very useful in the evaluation and management of hypertension in the elderly, but is limited by availability and cost. An alternative is HBPM, and several recent studies have shown its utility in improving the predictive value of the BP values and in improving BP control.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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