Hypertension in older people: part 1

Once considered part of the normal aging process, the development of isolated systolic hypertension represents a late manifestation of increased arterial stiffness in older people. Furthermore, isolated systolic hypertension is the single most frequent subtype of hypertension in the US adult population. Indeed, central arterial stiffness rather than peripheral vascular resistance becomes the dominant hemodynamic factor in both normotensive and hypertensive individuals after the age of 50-60 years. Stiffening disease, an age-related degeneration of the elastic elements of the thoracic aorta, is associated with a widening of brachial pulse pressure. Brachial pulse pressure predicts future cardiovascular disease events. However, pressure wave amplification produces higher brachial than aortic pressures and, therefore, central rather than peripheral blood pressure indices are more reliable measures of cardiovascular risk. Stiffening disease of aging is accompanied by early wave reflection, which results in a significant augmentation of central systolic pressure in late systole and further adds to increased cardiac afterload--so-called ventricular-vascular uncoupling. Diabetes, impaired renal function, and untreated or poorly treated hypertension may lead to premature arterial stiffening; its consequences are stiffening and hypertrophy of the left ventricle and predisposition to coronary heart disease, heart failure, stroke, vascular dementia, and chronic kidney disease.     

Hypertension in women: part I

The basis for the treatment of hypertension in women has evolved in step with the inclusion of women in studies of treatment in hypertension. Recent outcome trials comparing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or calcium antagonists with diuretics and beta-blockers in older, high-risk patients have generally shown similar benefits for women and men. The current evidence therefore indicates that sex should not play a role in decisions about whether to treat hypertension or about the choice of agents.     

Hypertension,heart failure,and frailty in older people: A common but unclear situation

Hypertension and heart failure are common conditions in older people. Comorbidity, together with aging, is commonly associated with frailty, which is a cause of a worse prognosis, more hospitalizations, increased dependency, and mortality. Despite being increasingly common conditions, data on the prevalence and influence of frailty in hypertensive older patients with HF are lacking. This may be due to the multidimensional aspects of frailty and the differing tools used to evaluate it. Nevertheless, in clinical practice, it is common to see frail hypertensive patients with HF but the specific characteristics of this group of patients, including multimorbidity and frailty, and the lack of data from registries or randomized clinical trials make the diagnosis and management of these patients more difficult than in those of other ages. This review focuses on what is known and on where future investigations should focus in this common but unclear situation.     

Hypertension in people with Type 2 diabetes: knowledge-based diabetes-specific guidelines

The International Diabetes Federation (Europe) has updated these guidelines on hypertension management specifically in Type 2 diabetes in the light of recent results of the first prospective, randomized controlled studies to investigate clinical outcomes in people with diabetes and hypertension. The guidelines are knowledge based, i.e. based not only on evidence originating from clinical trials, but also from epidemiological and pathophysiological studies. A successful management strategy requires the following components:

• 1 Regular surveillance to detect developing hypertension and other cardiovascular (CV) risk factors.
• 2 Considering more frequent monitoring and review of CV risk factors if any single blood pressure (BP) measurement > 140/85 mmHg (or 130/75 if microalbuminuria); when appropriate, using ambulatory or home monitoring to establish the baseline BP.
• 3 Considering other CV risk factors, such as a raised albumin excretion rate, in setting the intervention threshold.
• 4 Individualizing the target BP in accordance with other CV risk factors.
• 5 Agreeing lifestyle and therapeutic interventions with the patient, with education and empowerment as required.
• 6 Implementing lifestyle modifications, including controlling calorie, salt and alcohol intake, increased physical activity, weight control and smoking cessation.
• 7 Therapeutic strategy: the primary goal of therapy is to reduce BP markedly. Combination therapy is often necessary, e.g. an angiotensin converting enzyme (ACE) inhibitor and a diuretic. Some classes are particularly useful for certain patients, notably longer-acting ACE inhibitors, angiotensin 2 receptor antagonists (A2RAs) and calcium antagonists in those at risk of diabetic nephropathy, loop diuretics and thiazides in those at risk of hyperkalaemia, β-blockers and calcium antagonists (except short-acting dihydropyridines) in patients with angina, β-blockers and ACE inhibitors after a myocardial infarction or in those with left ventricular dysfunction, and thiazide diuretics and long-acting dihydropyridine calcium antagonists for isolated systolic hypertension. A2RAs should be particularly considered when ACE inhibitors are not tolerated. α₁-Blockers should not be considered first line in the absence of outcome data. Cost of drugs will modify these strategies in developing countries.
• 8 Monitoring response to therapies and, if target levels are not achieved, either intensifying drug therapy if the CV risk justifies it, or reassessing the target.
• 9 Maintaining a quality assurance strategy.

This strategy is summarized in a simple, practical management algorithm.     

Hypertension in older adults

The high prevalence of hypertension in older persons (nearly one of two subjects aged 60 years and older) suggests that the recognition and treatment should be a priority for physicians. Although diastolic blood pressure is regarded as an important risk factor, it is now clear that isolated systolic hypertension and elevated pulse pressure also play an important role in the development of cerebrovascular disease, congestive heart failure, and coronary heart disease, which are the major causes of cardiovascular morbidity and mortality in the population aged older than 65 years. Controlled, randomized trials have shown that treatment of systolic as well as systolodiastolic hypertension decreases the incidence of cardiovascular and cerebrovascular complications in older adults. The question of whether treatment of hypertension should be maintained in very old persons, those older than 80 years, is still undecided.     

Dementia in older people: an update

Dementia is a common condition of the elderly characterised by multiple cognitive deficits resulting in a decline from previous level of function. In the older person, multiple pathologies contribute, including changes commonly seen in Alzheimer disease, dementia with Lewy bodies in addition to vascular changes. Comorbid factors, such as depression, delirium and polypharmacy can contribute to cognitive decline. Novel biomarkers and neuroimaging techniques may assist in the near future to improve accuracy of diagnosis. To date, pharmacological therapies have been largely unsuccessful and provide symptomatic relief only. The timely diagnosis of dementia can facilitate important discussions regarding personal and financial planning and introduce education and supports to the person with dementia and their carers. The person with dementia commonly experiences behavioural and psychological symptoms of dementia that may cause much distress, including to families and carers. Clinical guidelines indicate non‐pharmacological approaches as first line measures, including attention to pain, nutrition and the environment. Dementia is recognised as a National Health Priority in Australia, and efforts to target risk factors as preventative measures to delay onset of dementia require further urgent consideration.     

Clearinghouse: older people and HIV

A list of 18 articles from professional magazines and journals are referenced on the subject of older people and HIV. Topics include research on aging, health care service delivery, and the problems associated with unrecognized HIV in older people. Contact information is included for the National Association on HIV Over Fifty (NAHOF) and the New Jersey School of Osteopathic Medicine.     

Stair negotiation in older people: a review

Locomotion on stairs is among the most challenging and hazardous activities of daily living for older individuals. This is evidenced by the reports that stair falls account for more than 10% of fatal fall accidents. The demands that stairs place on the musculoskeletal and cardiovascular systems are compounded by the need for input from the somatosensory, visual, and vestibular systems at various stages in the task. Many of these collaborating systems deteriorate with aging, thus increasing the difficulty and risk of failure in a task that inherently involves exposure to significant danger. The task itself varies in its degree of challenge depending on many structural and environmental factors that are outside the control of the stair user. This review explores existing literature in the area of stair negotiation by older persons in an effort to define the key factors associated with difficulty and safety on stairs and to interpret these findings in the light of possible interventions that could increase stair safety. Further research is needed to ensure that current recommendations for stair design are suitable for older stair users. A Glossary of Terms is also provided.     

Air travel in older people

Commercial air travel is one of the safest means of transport. However, the environment within the aircraft cabin may have deleterious physiological effects on passengers, especially those with underlying medical problems and those who are old. With growing affluence, cheaper airfares and an ageing population, there will be more older people travelling by air over extended periods and longer distances, with a concomitant rise in the number of medical illnesses in the air. Older people may encounter various problems during a long journey. Certain actions may help to minimize these problems.     

Dizziness in older people.

Patients use the term dizziness to describe a sensation of altered orientation in space. Because visual, proprioceptive, somatosensory and vestibular signals provide the main information about the position of the head and body in space, damage to any of these systems can lead to a complaint of dizziness. Changes in the brain centers that integrate these orienting signals can also result in a sensation of dizziness. This review focuses on the pathophysiology, diagnosis, and management of the common causes of dizziness in older people.