hypertension in the geriatric patient: review and update · •pseudohypertension •white coat...
TRANSCRIPT
copy2015 MFMER | slide-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 2015
copy2015 MFMER | slide-2
Disclosures
bull I have no relevant financial relationships to disclose
copy2015 MFMER | slide-3
Objectives
bull Identify unique considerations related to blood pressure in geriatric patients
bull Restate the evidence base supporting guidelines for blood pressure targets in healthy older adults
bull Recognize the importance of function in the approach to hypertension (HTN) management in geriatric patients
copy2015 MFMER | slide-4
Overview
bull General hypertension principles
bull Evidence and treatment guidelines
bull Orthostatic hypotension
bull Frailty
bull Cognition
copy2015 MFMER | slide-5
The Heterogeneity of Aging
85 year old male with HTN
bull Robust
bull Few comorbidities
bull Cognition intact
bull Independent function
85 year old male with HTN
bull Frail
bull Multiple comorbidities
bull Cognitive impairment
bull Functional dependence
These are two very different patientshellip
Growing evidence would suggest that we approach
hypertension differently in these two patients
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-2
Disclosures
bull I have no relevant financial relationships to disclose
copy2015 MFMER | slide-3
Objectives
bull Identify unique considerations related to blood pressure in geriatric patients
bull Restate the evidence base supporting guidelines for blood pressure targets in healthy older adults
bull Recognize the importance of function in the approach to hypertension (HTN) management in geriatric patients
copy2015 MFMER | slide-4
Overview
bull General hypertension principles
bull Evidence and treatment guidelines
bull Orthostatic hypotension
bull Frailty
bull Cognition
copy2015 MFMER | slide-5
The Heterogeneity of Aging
85 year old male with HTN
bull Robust
bull Few comorbidities
bull Cognition intact
bull Independent function
85 year old male with HTN
bull Frail
bull Multiple comorbidities
bull Cognitive impairment
bull Functional dependence
These are two very different patientshellip
Growing evidence would suggest that we approach
hypertension differently in these two patients
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-3
Objectives
bull Identify unique considerations related to blood pressure in geriatric patients
bull Restate the evidence base supporting guidelines for blood pressure targets in healthy older adults
bull Recognize the importance of function in the approach to hypertension (HTN) management in geriatric patients
copy2015 MFMER | slide-4
Overview
bull General hypertension principles
bull Evidence and treatment guidelines
bull Orthostatic hypotension
bull Frailty
bull Cognition
copy2015 MFMER | slide-5
The Heterogeneity of Aging
85 year old male with HTN
bull Robust
bull Few comorbidities
bull Cognition intact
bull Independent function
85 year old male with HTN
bull Frail
bull Multiple comorbidities
bull Cognitive impairment
bull Functional dependence
These are two very different patientshellip
Growing evidence would suggest that we approach
hypertension differently in these two patients
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-4
Overview
bull General hypertension principles
bull Evidence and treatment guidelines
bull Orthostatic hypotension
bull Frailty
bull Cognition
copy2015 MFMER | slide-5
The Heterogeneity of Aging
85 year old male with HTN
bull Robust
bull Few comorbidities
bull Cognition intact
bull Independent function
85 year old male with HTN
bull Frail
bull Multiple comorbidities
bull Cognitive impairment
bull Functional dependence
These are two very different patientshellip
Growing evidence would suggest that we approach
hypertension differently in these two patients
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-5
The Heterogeneity of Aging
85 year old male with HTN
bull Robust
bull Few comorbidities
bull Cognition intact
bull Independent function
85 year old male with HTN
bull Frail
bull Multiple comorbidities
bull Cognitive impairment
bull Functional dependence
These are two very different patientshellip
Growing evidence would suggest that we approach
hypertension differently in these two patients
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-6
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-7
Cardiovascular Effects of Aging
bull Stiffer
bull Large vessels less distensible
bull Decreased vascular compliance
bull Slower
bull Baroreceptors less sensitive
bull Increased blood pressure variability
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-8
Cardiovascular Effects of Aging
bull 67 community-dwelling older adults have HTN
AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-9
Blood Pressure J-Shaped Curve
Is this cause or correlation
Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012
Dorresteijn et al Hypertension 20125914-21
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-10
Denardo et al Americal Journal of Medicine 2010 123(8)719-726
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-11
U-shaped curve appears in the oldest old
bull Observational study in Sweden
bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)
bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality
bull Even after controlling for health status
bull Mortality nadir was found at SBP 164 mmHg
Molander J Am Geriatr Soc 561853ndash1859 2008
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-12
Consider other factors in HTN ldquodiagnosisrdquo
bull Pseudohypertension
bull White coat hypertension
bull Masked hypertension
bull Orthostatic hypotension
bull Renal artery stenosis
bull Obstructive sleep apnea
bull NSAIDs
bull Alcohol
bull Tobacco
bull Steroids
ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-13
Case 1 ldquoIrsquom just here for a check uprdquo
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-14
HYpertension in the Very Elderly Trial (HYVET)
bull Randomized trial with 3845 patients age gt80
bull Treatment started if SBP gt160 mmHg
bull Indapamide (diuretic)
bull Perindopril (ACE inhibitor) added prn
bull Target BP lt150 mmHg
bull Study terminated due to preliminary results
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-15
HYpertension in the Very Elderly Trial (HYVET)
bull Results
bull 21 decrease mortality
bull 23 decrease cardiovascular mortality
bull 64 decrease in CHF
bull Non-significant decrease in stroke (p=006)
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-16
HYpertension in the Very Elderly Trial (HYVET)
bull Patients who were excluded
bull Severe CV disease
bull Renal failure
bull Dementia
bull Clinically significant comorbidities
Beckett et al 2008 NEJM 358(18)1887-1898
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-17
Take Home Point(s)
bull Treat (stage 2) hypertension in healthy community-dwelling older adults
bull Evidence is lacking in sicker older adults
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-18
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-19
Guidelines andor Consensus Statements
Age gt60 Age gt80
2011 ACCAHA
lt14090 140-145 ok in some
No lower than 13065
2011 NICE
lt14080 Treat when gt160 Target lt15090
2013 ESH-ESC
140-150
Perhaps lower if robust
140-150
If good physical and mental health
2014 CHEP
lt14090 lt150
2014 JNC8
Treat when SBP gt150 Target lt15090
Summary lt14090 unless frail lt15090 but not less than 13065
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-20
Systolic Blood Pressure Intervention Trial (SPRINT)
bull What is ideal BP target in patients age gt50 with hypertension
Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546
Big Study N=9361
Older patients Average age 68
28 over age 75
Sicker patients 28 CKD
20 CV disease
10 Framingham risk
Functional assessment
Cognition
Gait speed
Average baseline MoCA 229
Average baseline 08 ms
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-21
Systolic Blood Pressure Intervention Trial (SPRINT)
bull Sneak peek at initial results from SPRINT
bull Target SBP 140 (control)
vs
bull Target SBP 120
bull Reduced rates of CV events by almost 33
bull Reduced mortality by almost 25
NIH press release 9112015
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-22
Treatment Lifestyle Measures
bull DASH diet
bull Low sodium diet
bull Caution nutrition hyponatremia orthostasis
bull Weight loss in overweightobese
bull Caution muscle loss cachexia
bull Alcohol below maximum recommended levels
Whelton et al JAMA 1998279(11) 839-846
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-23
Eat chocolate
bull Flavanols in cocoa increase nitric oxide
bull Meta-analyses of 20 studies n = 856
bull Mean difference SBP -277 mm Hg p=0005
bull Mean difference DBP - 220 mm Hg p=0006
Ried et al Cochrane Review Aug 2012
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-24
Treatment Medication Considerations
Medication class Examples Potential Considerations
in Older Adults
Thiazide diuretic
HCTZ indapamide
chlorthalidone
Hypokalemiahyponatremia
hyperglycemiaincontinence
Calcium channel block
(dihydropyridine)
Amlodipine
nifedipinefelodipine
Edema
ACE inhibitorARB
Lisinopril
perindopril losartan
Hyperkalemia
Beta blocker
Carvedilol
bisoprolol
nebivolol atenolol
Bradycardia fatigue
Less sensitive receptors
Not first line
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-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
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-26
Take Home Point(s)
bull General treatment targets
bull Age over 60 lt14090 unless frail
bull Age over 80 lt15090 not less than 13065
bull Consider lifestyle measures (with caution)
bull ldquoStart Low Go Slowrdquo with medications
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-27
Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg
bull Vitals T 37 BP 11060 HR 80 RR 18
bull Supine BP 12274 Standing BP 9876
bull Exam Generally well appearance non-diagnostic exam
bull LabsStudies
bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120
bull UA bland CXR normal ECG suggests LVH
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-28
Orthostatic hypotension increases with age
bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-29
500-1000 cc blood pools
Increase sympathetic tone
Decrease parasympathetic
BP and cardiac output fall
Baroreceptors sense change
Increase heart rate
Increase vascular resistance
Slower and
Blunted response
Less sensitive and
Slower to respond
Blunted
Stiff already
Increase blood pressure
Less reserve to handle changes
in position or fluid status
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-30
Orthostatic hypotension was addressed in HYVET methods
bull Exclusion criteria Standing SBP le140 mmHg
bull Mean baseline standing was 168mmHg
bull Only 8-9 had orthostatic hypotension
bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-31
Orthostatic hypotension is associated with worse outcomes
bull Patients with orthostatic hypotension may or may not have symptoms hellip
bull Increased risk
bull Stroke
bull Myocardial infarction
bull Mortality
Benvenuto and Krakoff J Hypertension Feb 2011
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-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) 45ndash48
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-33
Orthostatic changes are linked to progression from MCI to dementia
bull Study of community-dwelling adults with MCI
bull In 3 years 30 converted to dementia
bull Positional blood pressure was very dynamic
bull Baseline seated SBP 148 mmHg
bull 70 had gt40mmHg drop (within 15 seconds)
bull SBP generally stabilized by 30 seconds
bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-34
Take home point(s)
bull Blood pressure is a dynamic (not static) thing
bull Prevalence of orthostatic hypotension increases with age for multiple reasons
bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-35
Case 3 ldquoIrsquom fine though I have no energyrdquo
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-36
Frailty Definition
Fried et al J Gerontol A Biol Sci Med Sci 2001
Need ge3 for diagnosis of frailty
bull S-lowness (gait speed)
bull L-ow activity level
bull E-xhaustion
bull W-eight loss (10lbs past year)
bull W-eakness (grip strength)
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-37
Low blood pressure in the oldest old and frail is worse than high blood pressure
bull Multiple studies of adults age ge 85
bull Majority with functional dependence
bull Results
bull High SBP was not a risk factor for mortality
bull SBP lt14070 associated with higher mortality
Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-38
Tightly treated hypertension is linked to mortality in frail adults
bull PARTAGE study
bull Frail adults (mean age 87) in nursing homes
bull Nearly 60 taking BP meds had SBP lt140
bull ldquoTarget BPrdquo rates only 30 in community
bull Results
bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)
Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472
Benetos et al JAMA Intern Med 2015175 (6)989-995
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-39
Gait Speed A Geriatric ldquoVital Signrdquo
Gait Speed Mortality
in Patients with SBPgt140
Faster (gt08ms)
Higher (HR 135)
Slower
No association
No test completed
Lower (HR 038)
Odden et al Arch Intern Med 2012172(15)1162-1168
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-40
Timed Up and Go Test
bull Useful for fall riskhellip and hypertension too
Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-41
Take home point(s)
bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty
bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit
bull In frail individuals low blood pressure on treatment is associated with worse outcomes
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-42
Case 4 ldquoMy memory isnrsquot what it used to berdquo
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-43
Mid-life hypertension is associated with late-life cognitive impairment
bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later
bull Results
bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment
Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-44
Randomized trials suggest treatment of hypertension is beneficial for cognition
bull Number needed to treat
bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia
Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052
Study Age Follow up Outcome Treatment Control
PROGRESS 64 4 years Cognitive
decline
91 11
SYST-EUR 70 39 years Dementia
diagnosis
33 per
1000
74 per
1000
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-45
Association between late-life hypertension and cognitive impairment is unclear
bull Three studies reported no significant effect
bull Seven studies reported a positive effect
bull Three studies reported a U-shaped curve
Qiu et al Lancet Neurol 2005 4 487ndash99
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-46
Late-Life Blood Pressure and Cognition
bull Leiden 85 Plus study
bull Followed patients from age 85-90
bull Higher SBP was better
bull Less ADL disability
bull Higher MMSE scores
bull Slower decline in both measures over time
bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-47
Late-Life Blood Pressure and Cognition
bull Cognitively impaired older adults
bull Majority (69) on blood pressure medication
bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline
Mossello et al JAMA Internal Medicine 2015
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-48
Late-Life Blood Pressure and Cognition
bull 1540 community-based patients age gt75
bull Higher SBP associated with better cognition
bull Most pronounced in those aged 85 and older with ADL and IADL impairments
Giulia et al J Am Geriatr Soc 631741ndash1748 2015
Tertile Mean BP Hypertension BP med use
Low 12469 61 57
Middle 14480 71 65
High 17994 78 70
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-49
Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial
bull N=385 age gt75 with mild cognitive impairment
bull Baseline BP 14882
bull 60 took ge 2 antihypertensive drugs
bull 45 had orthostatic hypotension
bull Results (at 16 weeks)
bull Increased SBP 7mmHg and DBP 2mmHg
bull No difference in cognition depression functional status or quality of life
Moonen et al JAMA Intern Med 2015175(10)1622-1630
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-50
Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99
Mid-life
Hypertension
Late-life
Low blood pressure
Ischemic insults
Microvascular disease
White matter disease
Cerebral hypoperfusion
Ischemic damage
Atherosclerosis
BP
medications
Circulatory
dysregulation
Cognitive impairment
Dementia
Mortality
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-51
Take home point(s)
bull Mid-life hypertension is linked to cognitive decline and dementia in later life
bull Treatment in 60s-70s seems to be beneficial
bull Higher blood pressure in the oldest old seems to be associated with better cognition
bull Especially in the setting of frailty andor MCI
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-52
Summary
bull Age associated cardiovascular changes
bull Slower and stiffer
bull ldquoStart low go slowrdquo
bull Evidence and guidelines
bull Most suggest lt14090 over age 60
bull Most suggest lt15090 over age 80
bull Less guidance on lower limit perhaps 13065
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-53
Summary
bull Orthostatic hypotension
bull Common clinically significant
bull Frailty
bull SLEWW Gait speed is good indicator
bull Insufficient evidence for BP target in frailty
bull Cognition
bull Treat BP in younger years ldquotoo little too laterdquo
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-54
Back to our caseshellip Case 1 Hypertension in robust individuals
bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284
bull Is this normal aging or pathogenic
bull Is there literature evidence to support benefit to starting an antihypertensive
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-55
Back to our caseshellip Case 2 Orthostatic hypotension
bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy
bull Meds HCTZ 25 and lisinopril 40
bull Vitals Supine BP 12274 Standing BP 9876
bull LabsStudies Na 130 BUN 40 Cr 16
bull Management
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-56
Back to our caseshellip Case 3 Frailty
bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home
bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol
bull Vitals Sitting BP 13872 Standing BP 12664
bull Is she frail
bull Is her blood pressure ldquoat targetrdquo
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-57
Back to our caseshellip Case 4 Cognitive impairment
bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change
bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko
bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo
him
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-58
Conclusion
bull Treat HTN Use FUNCTION as your guide
bull Healthy independent
bull Treat per current guidelines (lt140-15090)
bull Frail comorbidity cognitive impairment
bull Evidence is insufficient to suggest benefit
bull Individualize treatment
bull ldquoPrimum non nocererdquo (first do no harm)
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-59
Mayo Clinic Locations
copy2015 MFMER | slide-60
Questions amp Discussion
copy2015 MFMER | slide-60
Questions amp Discussion