Blood Pressure Control in the Elderly Needs Common Sense and Individualization

The recent SPRINT study pointed out the benefits of lowering blood pressure to < 120 mm Hg rather than 140 mm Hg in patients’ high risk for cardiovascular events because this reduced all-cause mortality by 25% and cardiovascular events by 35%. The SPRINT study is ongoing and will hopefully one day answer the question of does this data apply to the older elderly or our increasing population of 80 and 90 year olds. Previous studies looking at presumed dementia including pathological autopsy review of brains hinted at aggressive blood pressure lowering causing low perfusion or blood supply to the brain resulting in dementia type symptoms. In lay terms the anatomic findings did not support the diagnosis of dementia but the behavior which was dementia like may have been due to over aggressive lowering of blood pressure preventing elderly brains from receiving enough blood.

Nanette Wenger MD, a professor Emeritus of Cardiology at the Emory University School of Medicine and one of the most common sense teachers of clinical medicine cited the need for individuality in treating this patient group. She reviewed the many existing blood pressure guidelines and suggested keeping the systolic blood pressure of people over 80 to < 150/90 while shooting for < 140/90 in younger adults. Her clinical talk at the American Heart Association meeting recently contrasted the treatment of an 80 year old active vibrant individual managing all his or her affairs , in contrast to a wheelchair bound mildly cognitively impaired person living in a skilled nursing facility. She talked about starting slow with a low dose of medication and gradually titrating the dosage to control the pressure while checking to see if the blood pressure abruptly drops upon standing up or sitting up from a supine position. In most cases it requires at least 2-3 medications at low dosage to control blood pressure without producing adverse effects. It is still unclear if both younger adults and certainly older adults will tolerate and take higher dosages and more medications to achieve the suggested outcomes that the SPRINT study is encouraging. This fact makes it increasingly clear that patients will need a physician who has the time and takes the time to learn of their lifestyle and how taking the medication impacts it. In today’s medical world of conveyor belt template driven care encouraged by employers and insurers, finding that type of individual attention and access is a challenge in itself.

“There really is no template for the oldest old,” Dr Wenger advised. For this reason geriatricians and primary care physicians who are accessible and take the time to determine the entire clinical picture are necessary to tailor individual care.

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