In the face of overwhelming findings in favor of treatment for this potentially dangerous condition, the relative cheapness, accessibility and lack of side-effects of treatment and widespread use by patients and medical care-takers alike – I find it extremely difficult to say NO to the question.
But I feel called upon to mention a few negative points
Firstly, a comprehensive review by experts some years ago gives the following Key Points and Conclusions, which are generally applicable even nowadays.
KEY POINTS
▸ Approximately 10% of the US total annual drug expenditure is spent on antihypertensive medications.
▸ It is estimated that only 30% (range, 23%-38%) of elderly patients with hypertension are adequately managed in the United States, leaving considerable room for improvement.
▸ JNC 7 recommends treating all patients with uncomplicated hypertension, including those aged 65 to 79 years, to a target blood pressure (BP) of <140/90 mm Hg.
▸ For patients aged ≥80 years, most experts recommend a systolic BP goal of 140–145 mm Hg, to minimize medication side effects.
▸ A recent ACC/AHA statement suggests that lifestyle modifications may be all that is needed to treat milder forms of hypertension in elderly patients; in those with resistant hypertension, drug treatment is recommended.
▸ First-line drug therapy with diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be started at the lowest dose, and titrated as tolerated.
▸ The unique characteristics responsible for the increased risk for hypertension in the elderly population must be taken into account and considered carefully when choosing a treatment protocol.
Conclusions
JNC 7.Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program, Bethesda, MD: National Heart, Lung, and Blood Institute (US); August 2004. Report No. 04–5230.recommends a treatment BP target of <140/90 mm Hg for all patients with hypertension, including the elderly population. Clinical trials that included patients aged >65 years have shown that patients who receive treatment for their elevated BP have fewer strokes, fewer heart attacks, and less congestive HF compared with those with untreated hypertension. In patients aged 40 to 89 years, each 20-mm Hg increase in systolic BP or 10-mm Hg increase in diastolic BP is associated with a 2-fold increase in mortality from ischemic heart disease and a more than 2-fold increase in mortality from stroke.
There is great benefit in the successful treatment of hypertension in the elderly population. Encouraging lifestyle changes is the first-line treatment. Medications should be started as appropriate. Diuretics, ACE inhibitors, ARBs, and CCBs have all been proved as first-line treatment agents, and should be started with the lowest dose and titrated as tolerated. Vigilance is needed to avoid treatment-related adverse events. For very elderly patients (aged >80 years), the risks and benefits of tight control need to be frequently reevaluated
Even though experts state as aforementioned, in my opinion, we must take a second look at what we mean when we say someone,has hypertension – especially the elderly and the old, old. Apart from, and ignoring common biological, instrumental and statistical variability, does it mean the person’s blood pressure measurement has been found higher than those in the same group it belongs to, as defined ? Or does it mean that the person is afflicted with a disease or pathophysiological condition called ‘Hypertension’? The intra-arterial blood pressure would probably have been directly measured, using indwelling catheters, since Harvey discovered the circulation of blood. Nowadays, of course, blood pressure is clinically measured indirectly (with the mercury or aneroid sphygmomanometer) giving rise to various afore-mentioned intrinsic errors. This should be realized by the professional health care-taker or non-professional who is taking health care. The scientific controversy between the prestigious Robert Platt and George Pickering of the United Kingdom as to whether Hypertension is the tail-end of a distribution curve or a cardiovascular disease/ pathophysiological abnormality – is now resolved and all accept Hypertension as a cardiovascular disease.
Having said all that, what are the few practical issues and problems in the management of the elderly – What are they, When encountered,How dealt with and Why is Hypertension treatment demanded, required, given and received?
Previously, some decades ago, it was accepted that the arteries in the elderly were arteriosclerotic, rigid with loss of elasticity so that the systolic blood pressure is raised and the diastolic low with a wide pulse pressure which was regarded as physiological and a raised systolic blood pressure is not treated. Nowadays however, it has been shown that a raised systolic pressure alone is deleterious to healthcausing cardiovascular complications and increased mortality.
We should note that the population base and sampling frame on which recommendations and cut-off points have been made by JNC 7 does not include Blood pressure parameters measured in elderly; especially the old, old ( equal to or more than aged 80 years–even in USA and of course copied in Myanmar). One size does not fit all.
The elderly patient is usually clinically interviewed and examined by the professional health care professional in Myanmar) or nursing home (in USA, UK) or at a hospital in-patient ward (in MMR)because of co-morbidity or infirmity and the information given and received by the medical care-giver is filtered, sometimes through several layers – family member or close friend or attendant; and therefore the information may not correctly reflect what the patient wants to say and what the patient is feeling. An itch that the patient cannot reach and a ruffle in the bed-clothes, or a bed-bug or a mosquito that the patient cannot wave away may cause agony the bed-pan in bed may be well-nigh impossible with a drip-set or cannula inserted. So, unnecessary injections should be avoided.The doctor must be compassionate as well as know how to be compassionate. Lastly and most important, what difference does it make, from the patient view-point to live a few months or years longer if the quality of life is going be appalling. Most patients want to die peacefully and quietly among family and close friends. There are provisions in the USA to enable the patient to say beforehand ‘Do not resuscitate’ (DNR).
Aung Than Batu
