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Therapy for older adults who are hypertensive
Therapy for Older Adults Who Are Hypertensive ences between elderly persons with morbidity and'mortality in women. high blood pressure and younger Elevation of the systolic pressure people. To address the special re- alone is termed isolated systolic hyquirements of the aged, the Na- pertension. It is defined as a systoltional High Blood Pressure Educa- ic of more than 160 mm. Hg with a tion Program has developed recom- diastolic of less than 90 mm. Hg. mendations for 'all health profes- Among the elderly, isolated systolic sionals who care for this fastest- hypertension is the more common growing segment of the population. form of high blood pressure. IsoTheir compiled guidelines, which lated systolic hypertension of 180 LINDA DANIELS reflect the consensus of all health- mm. Hg or more increases the risk RAY W. GIFFORD related groups represented on the of stroke and of death from coroHigh blood pressure affects at least NHBPEP's coordinating commit- nary disease by two and one-half 35 million Americans, both young tee, present current treatment and times in persons aged 65 to 74 comand old. Some facts about hyper- counseling recommendations(2). pared to those in the same age There is no universally accepted group whose systolic pressures are tension apply to both age groups. An elevation in blood pressure, definition of hypertension among below 180 mm. Hg. whether it is systolic or diastolic, is the elderly. However, about 40 perHypertension may be a contriba risk factor in both young and old cent of Caucasians and more than uting factor in senile dementia for stroke, kidney failure, and heart 50 percent of blacks over age 65 when it is caused primarily by vasdisease( 1). have either isolated systolic hyper- cular disease. Unfortunately, howThe basic treatment regardless tension or both systolic and dia- ever, there is no evidence that early of age usually includes dietary stolic hypertension (160/95 mm. treatment of hypertension can premodification, drugs to lower blood Hg or higher).I' vent senile dementia. pressure, or both. The goal of therMore specifically, among perDetection and Evaluation apy is to reduce diastolic pressure sons between the ages of 65 and 74, to below 90 mm. Hg. The value of nearly 59 percent of black women, Systolic blood pressure fluctuates treating systolic-diastolic hyperten- 50 percent of black men, 42 percent widely in elderly persons who have sion at any age has been demon- of white women, and 35 percent of rigid, atherosclerotic aortas. Therestrated conclusively. white men have hypertension(3). fore, the NHBPEP recommends Beyond these similarities, howWhat are the specific risks? As that multiple blood pressure meaever, there are significant differ- in younger persons, systolic-dia- surements be made before diagnosstolic hypertension doubles the risk ing or treating hypertension. of death in men and increases this Blood pressures should be meaLinda Daniels, R.N., M.S.N., F.A.A.N., who died recently, was the hypertension risk in women by two and one-half sured in both sitting and standing times that for normotensive women. positions because some elderly indinurse practitioner and education supervisor of the Milwaukee Blood Pressure Program, Borderline systolic-diastolic hy- viduals have a marked drop in Wise. She represented the American (140/90 to 160/95 mm. blood pressure when they stand. pertension Nurses' Association on the National High Blood Pressure Education Program's Coor- . Hg) increases the risk of morbidity For older adults with initial eledinating Committee, and was a member of and mortality in men by one and one- vated readings, the blood pressure the subgroup that developed the recommenhalf times, and doubles the risk of should be taken three times on each dations presented in this article. of three separate days before decidRay W. Gifford, M.D., heads the Dept. of IA diastolic pressure of 95 mm. Hg (rather ing on treatment. As for anyone than 90) was the diastolic level used in the Hypertension and Nephrology, Cleveland Clinic, Ohio, is a member of the NHBPEP's studies by Hanes (see reference 3) from with an elevated reading, education which the data on the incidence and risks of about hypertension and its control Coordinating Committee, and was chairhypertension were derived. man of the recommendation subgroup. begins with the first such reading.
Age-related changes are the basis of new recommendations for helping persons over age 65 to lower their blood pressure.
Geriatric Nursing May/June 198037
For the elderly with systolic-diastolic elevation, the recommendations for action are the same as for younger people. These recommendations are detailed in the Joint National Committee's first report on "Detection, Evaluation, and Treatment of High Blood Pressure"(4). A second JNC report will be published later this year. In community screening programs, persons over age 65 with systolic prcssures of 160 or more on two separate visits should be referred for full evaluation even though the diastolic blood pressure is 90 mm. Hg or below. For most hypertensives of any age, an extensive work-up for secondary causes is not neccssary(4). But such a work-up is important for an elderly person who has a sudden rise in a previously stable, elevated diastolic pressure. The abrupt .change may indicate that a secondary factor, such as renovascular disease, has been added. If diastolic hypertension Occurs for the first time after age 55, or if it is not controlled by a good therapeutic regimen, secondary causes are sought. Dietary Management There is a complex causal relationship between diet and hypertension. Although the precise nature of this relationship is not clear, longitudinal studies of large popuiations have shown that adults who·do not gain weight as they age have a low incidence of hypertension. In primitive societies that have a low salt intake, hypertension is rare. The two most promising aspects of dietary management at any age are weight reduction and restriction of sodium intake. Compared to drug therapy, dietary management has less potential for side effects and is unlikely to be harmful. It is particularly appropriate for overweight patients with borderline hypertension, when drugs may not be clearly indicated, or when drug side effects are important factors. The hypertension of some elderly people may respond to weight reduction and moderate sodium restriction, that is, 2 Gm. sodium Or 5 Gm. sodium chloride daily. However, be-
38 Geriatric Nursing May/June 1980
For any person with a high reading, education about lowering it should begin at once.
cause many older patients have firmly fixed eating habits, smaller caloric needs, a duller sense of taste, and reouced exercise abilities, the nurse should be careful to suggest realistic goals for weight loss and salt restriction. She should provide help in reading food labels so that patients can discriminate between foods high in sodium and those that are not. The nurse must be sensitive to the consequences if the patient fails in this endeavor. Ifdietary modification does not lower the blood pressure within three months, or sooner if the hypertension is severe or accompanied by complications, drug therapy should be pursued. Drug Therapy Reduction of cardiovascular mortality by antihypertensive therapy has been clearly demonstrated in all persons who have diastolic pressures 90 mm. Hg or greater. The goal of treatment for the elderly is the same as for younger persons: to reduce diastolic pressure to below 90 mm. Hg. And the same stepped-care regimen is followed. Most older adults can be treated with minimun side effects if certain precautions are -kept in mind. Elderly people may respond more readily to antihypertensive agents than younger persons. This increased responsiveness may be a result oflow blood volume and reduced
baroreceptor activity, which are common in persons over 65. The barorecepter nerves are located in the muscle walls of the aortic arch and carotid arteries. Normally, baroreceptors function, much like a thermostat, to maintain a stcady blood pressure. When the pressure rises, the baroreceptors are stretched by arterial distention. Then they fire impulses to the medulla that inhibit the sympathetic center. This reduces sympathetic stimulation to the heart and blood vessels. The result is a slower beat, diminished output, vasodilation, and fall in blood pressure to the original leve1.This process is reversed when blood pressure falls below the normallevel(5). With aging, however, this "barostat" becomes less sensitive to changes in pressure, and thus may fail to counteract the effect of antihypertensive agents. Drugs, therefore, are selected with particular care, initial doses are smaller than those for younger people, and dosages are increased gradually over weeks rather than days, as for younger adults. No definitive recommendations can be made about the level of isolated systolic hypertension, more common in the elderly, at which treatment should be started or even whether it should be started. However, for either systolic-dia-
stolic or isolated systolic high blood pressure, oral diuretics are the first step in drug therapy. Frequently, oral diuretics are effective as the sole agent controlling isolated systolic hypertension. . Adrenergic drugs, such as methyldopa (Aldomet) orclonidine (Catapres), may be added if the diuretic alone does not control blood pressure adequately. If necessary, hydralazine (Apresoline) may be added as a third agent. Sometimes hydralazine is given as a step-two drug, since it usually does not cause reflex tachycardia in elderly patients, because of their sluggish baroreceptor activity. Beta adrenergic blocking drugs, such as propranolol (Inderal) may be less effective for lowering blood pressure in elderly persons who have isolated systolic hypertension than they are for younger people. Certain side effects from antihypertensive agents occur more frequently in the elderly: muscle weakness and nausea due to low blood levels of potassium and sodium, drowsiness, and mental confu~ sion. These effects usually can be alleviated by appropriate changes in diet or drug regimen, and rarely require stopping antihypertensive therapy altogether. Giving small initial doses and increasing them over long periods can often prevent or minimize side effects in the elderly. A few agents, such as guanethidine (Ismelin), that produce severe orthostatic hypotension, should be avoided unless the blood pressure remains high. Complicating Conditions The presence of other disorders and the accompanying need for multiple medications may present special problems for older patients. Typical complications include congestive heart failure, symptomatic atherosclerotic heart disease, and cerebrovascular disease. These complications make it urgent to reduce blood pressure levels. Another common condition, diabetes mellitus, may require dietary changes or dosage adjustment of hypoglycemic agents. Because renal function is often impaired in el-
derly hypertensives, care must be taken in selecting medications. Adherence to a medical regimen is difficult for many hypertensives; the elderly face additional barriers. Impaired hearing or eyesight may make it difficult to understand and carry out instructions. Diminished taste perception often leads to oversalting food, and lifelong dietary habits are hard to change. Diuretics may cause hypokalemia if the diet is poor. The ability to exercise is often reduced. Forgetfulness may result in improper use or neglect of medications. Safety caps on drug containers are difficult to open. Over-the-counter medicines, such as decongestants, can interfere with the action of prescribed drugs(6). Living alone, a reluctance to seek advice, and the absence of· reinforcement from family and friends may hinder adherence. Fixed incomes, limits on health insurance benefits, and lack of mobility often discourage the elderly from acquiring their medications or keeping appointments. .
I
Implications for Counseling Nurses who successfully counsel the elderly or who provide direct care are innovative in their use of skills, materials, and resources to help these patients achieve blood pressure control, despite the obstacles. A caring attitude and active intervention strengthen the patient's belief that the nurse is genu- . inely concerned about him or her. Instructions should be specific. For many of the elderly it is best to limit initial sessions to the tasks essential in the pill-taking routine. During the first few minutes of subsequent visits, the nurse can review hypertensive and other (including over-the-counter) drugs, question the patient and listen for clues to such problems as side effects, forgetting pills, poor eating habits, or financial or transportation difficulties in acquiring medications. Often, asking the physician to prescribe new medications in small quantities until the drug of choice is determined helps the patient who has a limited income. Involving the
patient's pharmacist is helpful in monitoring the acquisition and refilling of prescriptions. Written instructions and other memory aids should be given to patients and family members. 2 The aids are selected with attention to the patient's hearing and sight, educational background, mental status, and native language. Interpreters should be called upon as necessary and translations of written materials provided. Spending time with the patient's spouse, close relative, or friend to discuss the treatment regimen builds support for adherence. Patients who live alone should identify a neighbor or friend who can help them follow the regimen, refill prescriptions, provide transportation for office visits, or accompany them on public transportation. References J. Kannel, W. B., and others. Role of
2.
3.
4.
5.
6.
blood pressure in the development of congestive heart failure. The Framingham study. N.Engl.J.M~d. 287:781787. Oct. 19, 1972. '. U.S. National High Blood Pressure Education Program, Coordinating Committee. Statem~nt on H),fNrt~n sion in the Eld~r/)'. S~ptember. /979. Bethesda, Md.; The Program, 1979. (Background Statement) U.S. Center for Health Statistics. Blood Prf!ssur~ Levels of Pusons 6Q].I Y~ars. United States. '/97/-/974. (Vital and Health Statistics, Ser. II, No. 203) (DHEW Pub!. No. (HRA) 78-1648) Washington, D.C., U.S Government Printing Office, 1977. U. S. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Report. (DHEW Publ. No. (NIH) 79-1088) Washington, D. C., U.S. Government Printing Office, 19777 Freis, E. C./ntroduction to Natur~ and ,Management of Hypertension. Bowie, Md., Robert J. Brady Co., 1974, pp. 46-49. U. S. National High Blood Pressure Education Program. Patient behavior for blood pressure control; guidelines for professionals. JAMA 241:2536, June 8, 1979.
2Patient education pamphlets and nursing materials are available, free, from the National High Blood Pressure Education Pre>gram, 120/80 National Institutes of Health, Bethesda, Md. 20205. These materials cover treatment recommended for the elderly, outcome goals, patient behaviors that are critical to blood pressure control, and interdisciplinary patient counseling.
Geriatric Nursing May/June t980 39
Age-related changes are the basis of new recommendations for helping persons over age 65 to lower their blood pressure.
Geriatric Nursing May/June 198037
For the elderly with systolic-diastolic elevation, the recommendations for action are the same as for younger people. These recommendations are detailed in the Joint National Committee's first report on "Detection, Evaluation, and Treatment of High Blood Pressure"(4). A second JNC report will be published later this year. In community screening programs, persons over age 65 with systolic prcssures of 160 or more on two separate visits should be referred for full evaluation even though the diastolic blood pressure is 90 mm. Hg or below. For most hypertensives of any age, an extensive work-up for secondary causes is not neccssary(4). But such a work-up is important for an elderly person who has a sudden rise in a previously stable, elevated diastolic pressure. The abrupt .change may indicate that a secondary factor, such as renovascular disease, has been added. If diastolic hypertension Occurs for the first time after age 55, or if it is not controlled by a good therapeutic regimen, secondary causes are sought. Dietary Management There is a complex causal relationship between diet and hypertension. Although the precise nature of this relationship is not clear, longitudinal studies of large popuiations have shown that adults who·do not gain weight as they age have a low incidence of hypertension. In primitive societies that have a low salt intake, hypertension is rare. The two most promising aspects of dietary management at any age are weight reduction and restriction of sodium intake. Compared to drug therapy, dietary management has less potential for side effects and is unlikely to be harmful. It is particularly appropriate for overweight patients with borderline hypertension, when drugs may not be clearly indicated, or when drug side effects are important factors. The hypertension of some elderly people may respond to weight reduction and moderate sodium restriction, that is, 2 Gm. sodium Or 5 Gm. sodium chloride daily. However, be-
38 Geriatric Nursing May/June 1980
For any person with a high reading, education about lowering it should begin at once.
cause many older patients have firmly fixed eating habits, smaller caloric needs, a duller sense of taste, and reouced exercise abilities, the nurse should be careful to suggest realistic goals for weight loss and salt restriction. She should provide help in reading food labels so that patients can discriminate between foods high in sodium and those that are not. The nurse must be sensitive to the consequences if the patient fails in this endeavor. Ifdietary modification does not lower the blood pressure within three months, or sooner if the hypertension is severe or accompanied by complications, drug therapy should be pursued. Drug Therapy Reduction of cardiovascular mortality by antihypertensive therapy has been clearly demonstrated in all persons who have diastolic pressures 90 mm. Hg or greater. The goal of treatment for the elderly is the same as for younger persons: to reduce diastolic pressure to below 90 mm. Hg. And the same stepped-care regimen is followed. Most older adults can be treated with minimun side effects if certain precautions are -kept in mind. Elderly people may respond more readily to antihypertensive agents than younger persons. This increased responsiveness may be a result oflow blood volume and reduced
baroreceptor activity, which are common in persons over 65. The barorecepter nerves are located in the muscle walls of the aortic arch and carotid arteries. Normally, baroreceptors function, much like a thermostat, to maintain a stcady blood pressure. When the pressure rises, the baroreceptors are stretched by arterial distention. Then they fire impulses to the medulla that inhibit the sympathetic center. This reduces sympathetic stimulation to the heart and blood vessels. The result is a slower beat, diminished output, vasodilation, and fall in blood pressure to the original leve1.This process is reversed when blood pressure falls below the normallevel(5). With aging, however, this "barostat" becomes less sensitive to changes in pressure, and thus may fail to counteract the effect of antihypertensive agents. Drugs, therefore, are selected with particular care, initial doses are smaller than those for younger people, and dosages are increased gradually over weeks rather than days, as for younger adults. No definitive recommendations can be made about the level of isolated systolic hypertension, more common in the elderly, at which treatment should be started or even whether it should be started. However, for either systolic-dia-
stolic or isolated systolic high blood pressure, oral diuretics are the first step in drug therapy. Frequently, oral diuretics are effective as the sole agent controlling isolated systolic hypertension. . Adrenergic drugs, such as methyldopa (Aldomet) orclonidine (Catapres), may be added if the diuretic alone does not control blood pressure adequately. If necessary, hydralazine (Apresoline) may be added as a third agent. Sometimes hydralazine is given as a step-two drug, since it usually does not cause reflex tachycardia in elderly patients, because of their sluggish baroreceptor activity. Beta adrenergic blocking drugs, such as propranolol (Inderal) may be less effective for lowering blood pressure in elderly persons who have isolated systolic hypertension than they are for younger people. Certain side effects from antihypertensive agents occur more frequently in the elderly: muscle weakness and nausea due to low blood levels of potassium and sodium, drowsiness, and mental confu~ sion. These effects usually can be alleviated by appropriate changes in diet or drug regimen, and rarely require stopping antihypertensive therapy altogether. Giving small initial doses and increasing them over long periods can often prevent or minimize side effects in the elderly. A few agents, such as guanethidine (Ismelin), that produce severe orthostatic hypotension, should be avoided unless the blood pressure remains high. Complicating Conditions The presence of other disorders and the accompanying need for multiple medications may present special problems for older patients. Typical complications include congestive heart failure, symptomatic atherosclerotic heart disease, and cerebrovascular disease. These complications make it urgent to reduce blood pressure levels. Another common condition, diabetes mellitus, may require dietary changes or dosage adjustment of hypoglycemic agents. Because renal function is often impaired in el-
derly hypertensives, care must be taken in selecting medications. Adherence to a medical regimen is difficult for many hypertensives; the elderly face additional barriers. Impaired hearing or eyesight may make it difficult to understand and carry out instructions. Diminished taste perception often leads to oversalting food, and lifelong dietary habits are hard to change. Diuretics may cause hypokalemia if the diet is poor. The ability to exercise is often reduced. Forgetfulness may result in improper use or neglect of medications. Safety caps on drug containers are difficult to open. Over-the-counter medicines, such as decongestants, can interfere with the action of prescribed drugs(6). Living alone, a reluctance to seek advice, and the absence of· reinforcement from family and friends may hinder adherence. Fixed incomes, limits on health insurance benefits, and lack of mobility often discourage the elderly from acquiring their medications or keeping appointments. .
I
Implications for Counseling Nurses who successfully counsel the elderly or who provide direct care are innovative in their use of skills, materials, and resources to help these patients achieve blood pressure control, despite the obstacles. A caring attitude and active intervention strengthen the patient's belief that the nurse is genu- . inely concerned about him or her. Instructions should be specific. For many of the elderly it is best to limit initial sessions to the tasks essential in the pill-taking routine. During the first few minutes of subsequent visits, the nurse can review hypertensive and other (including over-the-counter) drugs, question the patient and listen for clues to such problems as side effects, forgetting pills, poor eating habits, or financial or transportation difficulties in acquiring medications. Often, asking the physician to prescribe new medications in small quantities until the drug of choice is determined helps the patient who has a limited income. Involving the
patient's pharmacist is helpful in monitoring the acquisition and refilling of prescriptions. Written instructions and other memory aids should be given to patients and family members. 2 The aids are selected with attention to the patient's hearing and sight, educational background, mental status, and native language. Interpreters should be called upon as necessary and translations of written materials provided. Spending time with the patient's spouse, close relative, or friend to discuss the treatment regimen builds support for adherence. Patients who live alone should identify a neighbor or friend who can help them follow the regimen, refill prescriptions, provide transportation for office visits, or accompany them on public transportation. References J. Kannel, W. B., and others. Role of
2.
3.
4.
5.
6.
blood pressure in the development of congestive heart failure. The Framingham study. N.Engl.J.M~d. 287:781787. Oct. 19, 1972. '. U.S. National High Blood Pressure Education Program, Coordinating Committee. Statem~nt on H),fNrt~n sion in the Eld~r/)'. S~ptember. /979. Bethesda, Md.; The Program, 1979. (Background Statement) U.S. Center for Health Statistics. Blood Prf!ssur~ Levels of Pusons 6Q].I Y~ars. United States. '/97/-/974. (Vital and Health Statistics, Ser. II, No. 203) (DHEW Pub!. No. (HRA) 78-1648) Washington, D.C., U.S Government Printing Office, 1977. U. S. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Report. (DHEW Publ. No. (NIH) 79-1088) Washington, D. C., U.S. Government Printing Office, 19777 Freis, E. C./ntroduction to Natur~ and ,Management of Hypertension. Bowie, Md., Robert J. Brady Co., 1974, pp. 46-49. U. S. National High Blood Pressure Education Program. Patient behavior for blood pressure control; guidelines for professionals. JAMA 241:2536, June 8, 1979.
2Patient education pamphlets and nursing materials are available, free, from the National High Blood Pressure Education Pre>gram, 120/80 National Institutes of Health, Bethesda, Md. 20205. These materials cover treatment recommended for the elderly, outcome goals, patient behaviors that are critical to blood pressure control, and interdisciplinary patient counseling.
Geriatric Nursing May/June t980 39