Hypertension in the Geriatric Patient: Review and Update

Transcription

1 Hypertension in the Geriatric Patient: Review and Update Donna Miller, MD Senior Associate Consultant, Division of Hospital Internal Medicine Instructor in Medicine CAPA Annual Conference October 24, MFMER slide-1

2 Disclosures I have no relevant financial relationships to disclose 2015 MFMER slide-2

3 Objectives Identify unique considerations related to blood pressure in geriatric patients Restate the evidence base supporting guidelines for blood pressure targets in healthy older adults Recognize the importance of function in the approach to hypertension (HTN) management in geriatric patients 2015 MFMER slide-3

4 Overview General hypertension principles Evidence and treatment guidelines Orthostatic hypotension Frailty Cognition 2015 MFMER slide-4

5 The Heterogeneity of Aging 85 year old male with HTN Robust Few comorbidities Cognition intact Independent function 85 year old male with HTN Frail Multiple comorbidities Cognitive impairment Functional dependence These are two very different patients Growing evidence would suggest that we approach hypertension differently in these two patients MFMER slide-5

6 Case 1: I m just here for a check up. Mrs. Well is an 81 year old community-dwelling female with knee osteoarthritis and depression. Blood pressure on 3 separate occasions has been 164/84, 158/80, and 162/84. Is this normal aging or pathogenic? 2015 MFMER slide-6

7 Cardiovascular Effects of Aging Stiffer Large vessels less distensible Decreased vascular compliance Slower Baroreceptors less sensitive Increased blood pressure variability 2015 MFMER slide-7

8 Cardiovascular Effects of Aging 67% community-dwelling older adults have HTN AHA/ACC Guideline JACC 2011; Geriatrics Review Syllabus 8 th Edition 2015 MFMER slide-8

9 Blood Pressure: J-Shaped Curve Is this cause or correlation? Sim et al.j Am Coll Cardiol. 2014;64(6): Denardo et ail. Am J Med 2010; Dorresteijn et al. Hypertension 2012 Dorresteijn et al. Hypertension. 2012;59: MFMER slide-9

10 Denardo et al. Americal Journal of Medicine 2010; 123(8): MFMER slide-10

11 U-shaped curve appears in the oldest old. Observational study in Sweden Age 85 (n=139), age 90 (n=128), age 95 (n=81) Systolic blood pressure (SBP) < 120 mmhg correlated with higher mortality Even after controlling for health status! Mortality nadir was found at SBP 164 mmhg Molander J Am Geriatr Soc 56: , MFMER slide-11

12 Consider other factors in HTN diagnosis. Pseudohypertension White coat hypertension Masked hypertension Orthostatic hypotension Renal artery stenosis Obstructive sleep apnea NSAIDs Alcohol Tobacco Steroids ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly 2015 MFMER slide-12

13 Case 1: I m just here for a check up. Mrs. Well is an 81 year old community-dwelling female with knee osteoarthritis and depression. Blood pressure on 3 separate occasions has been 164/84, 158/80, and 162/84. Is this normal aging or pathogenic? Is there literature evidence to support benefit to starting an antihypertensive? 2015 MFMER slide-13

14 HYpertension in the Very Elderly Trial (HYVET) Randomized trial with 3845 patients age >80 Treatment started if SBP >160 mmhg Indapamide (diuretic) Perindopril (ACE inhibitor) added prn Target BP <150 mmhg Study terminated due to preliminary results Beckett et al NEJM 358(18): MFMER slide-14

15 HYpertension in the Very Elderly Trial (HYVET) Results: 21% decrease mortality 23% decrease cardiovascular mortality 64% decrease in CHF Non-significant decrease in stroke (p=0.06) Beckett et al NEJM 358(18): MFMER slide-15

16 HYpertension in the Very Elderly Trial (HYVET) Patients who were excluded: Severe CV disease Renal failure Dementia Clinically significant comorbidities Beckett et al NEJM 358(18): MFMER slide-16

17 Take Home Point(s) Treat (stage 2) hypertension in healthy community-dwelling older adults Evidence is lacking in sicker older adults 2015 MFMER slide-17

18 Guidelines and/or Consensus Statements Age >60 Age > ACC/AHA <140/ ok in some No lower than 130/ NICE <140/80 Treat when >160; Target <150/ ESH-ESC Perhaps lower if robust If good physical and mental health 2014 CHEP <140/90 < JNC8 Treat when SBP >150; Target <150/ MFMER slide-18

19 Guidelines and/or Consensus Statements Age >60 Age > ACC/AHA <140/ ok in some No lower than 130/ NICE <140/80 Treat when >160; Target <150/ ESH-ESC Perhaps lower if robust If good physical and mental health 2014 CHEP <140/90 < JNC8 Treat when SBP >150; Target <150/90 Summary <140/90 unless frail <150/90 but not less than 130/ MFMER slide-19

20 Systolic Blood Pressure Intervention Trial (SPRINT) What is ideal BP target in patients age >50 with hypertension? Big Study N=9361 Older patients Average age 68 28% over age 75 Sicker patients Functional assessment Cognition Gait speed 28% CKD 20% CV disease 10% Framingham risk Average baseline MoCA 22.9 Average baseline 0.8 m/s Ambrosius et al. Clinical Trials 2014, Vol. 11(5) MFMER slide-20

21 Systolic Blood Pressure Intervention Trial (SPRINT) Sneak peek at initial results from SPRINT Target SBP 140 (control) vs. Target SBP 120 Reduced rates of CV events by almost 33% Reduced mortality by almost 25% NIH press release 9/11/ MFMER slide-21

22 Treatment: Lifestyle Measures DASH diet Low sodium diet* Caution: nutrition, hyponatremia, orthostasis Weight loss in overweight/obese* Caution: muscle loss, cachexia Alcohol below maximum recommended levels *Whelton et al. JAMA. 1998;279(11): MFMER slide-22

23 Eat chocolate! Flavanols in cocoa increase nitric oxide Meta-analyses of 20 studies n = 856 Mean difference SBP: mm Hg, p=0.005 Mean difference DBP: mm Hg, p=0.006 Ried et al Cochrane Review Aug MFMER slide-23

24 Treatment: Medication Considerations Medication class Examples Potential Considerations in Older Adults Thiazide diuretic HCTZ, indapamide chlorthalidone Hypokalemia,hyponatremia, hyperglycemia,incontinence Calcium channel block (dihydropyridine) Amlodipine, nifedipine,felodipine Edema ACE inhibitor/arb Lisinopril, perindopril, losartan Hyperkalemia Beta blocker Carvedilol, bisoprolol, nebivolol, atenolol Bradycardia, fatigue Less sensitive receptors Not first line 2015 MFMER slide-24

25 Treatment: Medication Considerations Medication class Examples Potential Considerations in Older Adults Alpha blocker Doxazosin, terazosin BPH (tamsulosin?) Orthostatic hypotension Avoid Vasodilators Hydralazine Orthostatic hypotension Avoid Central-acting agent Clonidine, methyldopa Anticholinergic Delirium Orthostatic hypotension Avoid 2015 MFMER slide-25

26 Take Home Point(s) General treatment targets Age over 60: <140/90, unless frail Age over 80: <150/90, not less than 130/65 Consider lifestyle measures (with caution) Start Low, Go Slow with medications 2015 MFMER slide-26

27 Case 2: I ve fallen, and I can t get up. Mr. Wobble is a 76 year old male with HTN and dietcontrolled diabetes who fell after feeling dizzy. Medications include HCTZ 25mg and lisinopril 40mg. Vitals: T 37 BP 110/60 HR 80 RR 18 Supine BP 122/74 Standing BP 98/76 Exam: Generally well appearance, non-diagnostic exam Labs/Studies: WBC 8 HgB 13 Na 130 BUN 40 Cr 1.6 Glucose 120 UA bland, CXR normal, ECG suggests LVH 2015 MFMER slide-27

28 Orthostatic hypotension increases with age. Defined as decrease in SBP by 20 mmhg or DBP by 10 mmhg within 3 minutes of standing. Benvenuto and Krakoff. J Hypertension Feb MFMER slide-28

29 Increase blood pressure Increase heart rate Increase vascular resistance Decrease parasympathetic Increase sympathetic tone Baroreceptors sense change Blunted Stiff already Slower and Blunted response Less sensitive and Slower to respond BP and cardiac output fall cc blood pools Less reserve to handle changes in position or fluid status 2015 MFMER slide-29

30 Orthostatic hypotension was addressed in HYVET methods. Exclusion criteria: Standing SBP 140 mmhg Mean baseline standing was 168mmHg Only 8-9% had orthostatic hypotension Medications were not increased for those with seated SBP >150 if standing SBP was < MFMER slide-30

31 Orthostatic hypotension is associated with worse outcomes. Patients with orthostatic hypotension may or may not have symptoms Increased risk: Stroke Myocardial infarction Mortality Benvenuto and Krakoff. J Hypertension Feb MFMER slide-31

32 Orthostatic hypotension is associated with cognitive impairment. Cognitive Status Orthostatic Hypotension Normal cognitive function 4% Mild cognitive impairment (MCI) 12% Alzheimer dementia 15% Vascular dementia 22% S. Mehrabian et al. Journal of the Neurological Sciences 299 (2010) MFMER slide-32

33 Orthostatic changes are linked to progression from MCI to dementia. Study of community-dwelling adults with MCI In 3 years, 30% converted to dementia Positional blood pressure was very dynamic Baseline seated SBP 148 mmhg 70% had >40mmHg drop (within 15 seconds) SBP generally stabilized by 30 seconds If not, twice the risk of dementia at 3 years Hayakawa et al. J Am Geriatr Soc 63: , MFMER slide-33

34 Take home point(s) Blood pressure is a dynamic (not static) thing Prevalence of orthostatic hypotension increases with age for multiple reasons We need to think about orthostatic hypotension, as it is linked with multiple negative outcomes 2015 MFMER slide-34

35 Case 3: I m fine, though I have no energy. Miss Step is an 80 year old female with arthritis, cataracts, CHF (EF normal), dementia, and hypertension who lives in a nursing home. Meds: Acetaminophen, amlodipine, clonidine, donepezil, furosemide, potassium, tramadol Vitals: Sitting BP 138/72 Standing BP 126/64 Is she frail? Is her blood pressure at target? 2015 MFMER slide-35

36 Frailty: Definition S-lowness (gait speed) L-ow activity level E-xhaustion W-eight loss (10lbs past year) W-eakness (grip strength) Need 3 for diagnosis of frailty Fried et al. J Gerontol A Biol Sci Med Sci MFMER slide-36

37 Low blood pressure in the oldest old and frail is worse than high blood pressure. Multiple studies of adults age 85 Majority with functional dependence Results: High SBP was not a risk factor for mortality SBP <140/70 associated with higher mortality Rastas et al. J Am Geriatr Soc 54: , Bemmel et al. Hypertens : MFMER slide-37

38 Tightly treated hypertension is linked to mortality in frail adults. PARTAGE study Frail adults (mean age 87) in nursing homes Nearly 60% taking BP meds had SBP <140 Target BP rates only 30% in community! Results: Mortality increased if SBP was <130 on combination ( 2 drug) therapy (HR 1.78) Benetos et al. J Hypertens. 2010;28(1): Lloyd-Jones et al. JAMA. 2005;294(4): Benetos et al. JAMA Intern Med. 2015;175 (6): MFMER slide-38

39 Gait Speed: A Geriatric Vital Sign Gait Speed Mortality in Patients with SBP>140 Faster (>0.8m/s) Higher (HR 1.35) Slower No association No test completed Lower (HR 0.38) Odden et al. Arch Intern Med. 2012;172(15): MFMER slide-39

40 Timed Up and Go Test Useful for fall risk and hypertension too? Podsiadlo D, Richardson S. The timed up & go": A test of basic functional mobility for frail elderly persons. JAGS. 1991;39: MFMER slide-40

41 Take home point(s) Benefit of treating hypertension in older adults may depend on one s degree of frailty Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit In frail individuals, low blood pressure on treatment is associated with worse outcomes 2015 MFMER slide-41

42 Case 4: My memory isn t what it used to be. Mr. Forgetful is a 90 year old retired pharmacist with mild cognitive impairment, hypertension, depression, and family history of Alzheimer s. Routine BP is 146/80 with no positional change. Medications: Amlodipine, citalopram, fish oil, vitamin E, vitamin C, and gingko. He asks you, Wouldn t better blood pressure control be good for my brain? 2015 MFMER slide-42

43 Mid-life hypertension is associated with late-life cognitive impairment. Surviving cohort of Honolulu Heart Program (n=3735, mean age 78) underwent cognitive testing 30 years later Results: Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment Launer et al. The Honolulu-Asia Aging Study. JAMA 1995;274: MFMER slide-43

44 Randomized trials suggest treatment of hypertension is beneficial for cognition. Study Age Follow up Outcome Treatment Control PROGRESS 64 4 years Cognitive decline SYST-EUR years Dementia diagnosis 9.1% 11% 3.3 per per 1000 Number needed to treat: Treatment of 1000 patients for 5 years can prevent 20 cases of dementia Tzourio et al. PROGRESS Group. Arch Intern Med. 2003;163: Forette et al. SYS-EUR Group. Arch Intern Med. 2002;162: MFMER slide-44

45 Association between late-life hypertension and cognitive impairment is unclear. Three studies reported no significant effect Seven studies reported a positive effect Three studies reported a U-shaped curve Qiu et al. Lancet Neurol 2005; 4: MFMER slide-45

46 Late-Life Blood Pressure and Cognition Leiden 85 Plus study Followed patients from age Higher SBP was better Less ADL disability Higher MMSE scores Slower decline in both measures over time Most pronounced in those with high disability Sabayan et al. J Am Geriatr Soc 60: , MFMER slide-46

47 Late-Life Blood Pressure and Cognition Cognitively impaired older adults Majority (69%) on blood pressure medication Lower BP (SBP <128) was associated with faster progression of cognitive decline Mossello et al. JAMA Internal Medicine MFMER slide-47

48 Late-Life Blood Pressure and Cognition 1540 community-based patients age >75 Tertile Mean BP Hypertension BP med use Low 124/69 61% 57% Middle 144/80 71% 65% High 179/94 78% 70% Higher SBP associated with better cognition Most pronounced in those aged 85 and older with ADL and IADL impairments Giulia et al. J Am Geriatr Soc 63: , MFMER slide-48

49 Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial N=385 age >75 with mild cognitive impairment Baseline BP 148/82 60% took 2 antihypertensive drugs 45% had orthostatic hypotension Results (at 16 weeks) Increased SBP 7mmHg and DBP 2mmHg No difference in cognition, depression, functional status, or quality of life Moonen et al. JAMA Intern Med. 2015;175(10): MFMER slide-49

50 Mid-life Hypertension Ischemic insults; Microvascular disease; White matter disease Atherosclerosis; BP medications; Circulatory dysregulation Late-life Low blood pressure Cerebral hypoperfusion; Ischemic damage Cognitive impairment Dementia Mortality Modified/updated from Qiu et al. Lancet Neurol 2005; 4: MFMER slide-50

51 Take home point(s) Mid-life hypertension is linked to cognitive decline and dementia in later life Treatment in 60s-70s seems to be beneficial Higher blood pressure in the oldest old seems to be associated with better cognition Especially in the setting of frailty and/or MCI 2015 MFMER slide-51

52 Summary Age associated cardiovascular changes Slower and stiffer Start low, go slow. Evidence and guidelines Most suggest <140/90 over age 60 Most suggest <150/90 over age 80 Less guidance on lower limit; perhaps 130/ MFMER slide-52

53 Summary Orthostatic hypotension Common; clinically significant Frailty SLEWW; Gait speed is good indicator Insufficient evidence for BP target in frailty Cognition Treat BP in younger years; too little, too late 2015 MFMER slide-53

54 Back to our cases Case 1: Hypertension in robust individuals Mrs. Well is an 81 year old community-dwelling female with knee osteoarthritis and depression. Blood pressure on 3 separate occasions has been 164/84, 158/80, and 162/84. Is this normal aging or pathogenic? Is there literature evidence to support benefit to starting an antihypertensive? 2015 MFMER slide-54

55 Back to our cases Case 2: Orthostatic hypotension Mr. Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy. Meds: HCTZ 25 and lisinopril 40 Vitals: Supine BP 122/74 Standing BP 98/76 Labs/Studies: Na 130 BUN 40 Cr 1.6 Management? 2015 MFMER slide-55

56 Back to our cases Case 3: Frailty Miss Step is an 80 year old female with arthritis, cataracts, CHF (EF normal), dementia, and hypertension who lives in a nursing home. Meds: Acetaminophen, amlodipine, clonidine, donepezil, furosemide, potassium, tramadol Vitals: Sitting BP 138/72 Standing BP 126/64 Is she frail? Is her blood pressure at target? 2015 MFMER slide-56

57 Back to our cases Case 4: Cognitive impairment Mr. Forgetful is a 90 year old retired pharmacist with mild cognitive impairment, hypertension, depression, and family history of Alzheimer s. Routine BP is 146/80 with no positional change. Medications: Amlodipine, citalopram, fish oil, vitamin E, vitamin C, and gingko. He asks you, Wouldn t better blood pressure control be good for my brain? him 2015 MFMER slide-57

58 Conclusion Treat HTN. Use FUNCTION as your guide. Healthy, independent Treat per current guidelines (< /90) Frail, comorbidity, cognitive impairment Evidence is insufficient to suggest benefit Individualize treatment Primum non nocere (first do no harm) 2015 MFMER slide-58

59 Mayo Clinic Locations 2015 MFMER slide-59

60 Questions & Discussion 2015 MFMER slide-60