Hypertension therapy in very elderly. You must avoid orthostatic hypotension. 5
High blood pressure therapy in very elderly. These are people over 70 or 80 years of age. Treatment has important nuances. It is crucial to avoid fainting and falling due to orthostatic hypotension. Top hypertension expert discusses high blood pressure therapy in “very old”. Dr. Anton Titov, MD. What are the nuances of treating hypertension in the very elderly age group? “Very elderly” age is defined as over 70 or 80 years of age. Those patients who are over 70 or 80 years old. The point is not the age but the patient’s disease. You see how active is the patient. What he is able to do. Dr. Ehud Grossman, MD. The main point that I find in the elderly is this. They are very sensitive to lowering blood pressure. Because the blood flow to the brain depends on the blood pressure. When you lower the blood pressure too much, you get less perfusion to the brain. It may cause some damage. Point #2 is that elderly patients are more susceptible to orthostatic hypotension. Dr. Anton Titov, MD. The blood pressure falls when they stand up. Sometimes you lower the blood pressure. You control it to 140 / 80 when the patient is sitting. Then when patient stands up, his blood pressure falls to 80 – 90 systolic. Patient may faint. Dr. Ehud Grossman, MD. So the elderly are more friable. You have to be more careful. First, we agree that the blood pressure target may be a little bit higher in the very elderly than in the young patients. We have to see the whole picture of the patient. It’s not only the age but always the function and what additional diseases patient has. We have to start with lower doses of blood pressure control medications. We do the adjustment of the dose. We go gradually to prevent too much fall in blood pressure. This is even more risky because when you lower the blood pressure, you prevent in the long run a brain stroke and congestive heart failure. But the price that the patient pays is his blood pressure falls immediately. If he faints and breaks his leg. Then the immediate risk is much higher than the benefit of long-term prevention of disease. Dr. Ehud Grossman, MD. So you have to balance and see what you have. What is the risk of acute side effects of hypertension medications. So in the elderly you adjust medication dose slowly until you reach the blood pressure treatment target. It may takes several weeks or even months. Unlike in the young subjects where you can go more aggressively in the adjustment of medications and doses of hypertension medications. Dr. Anton Titov, MD. Does that mean that it makes sense for elderly patients to measure arterial blood pressure when they’re in a standing position? This especially depends on their functional health status. Definitely! The answer is yes. You have to take the blood pressure when you are sitting and when you are standing. When the first time that you do it, there is no difference between sitting and standing blood pressure values, then you don’t have to do it again. Dr. Ehud Grossman, MD. But when you start an anti-hypertension medications, you have to do measure blood pressure in a standing and sitting position again. Because some of the side effects of the medications are orthostatic hypotension. Every time when you change the dose, you also have to do it. So you start with normal response. But then when you give a new type of medication, then blood pressure might fall too much when you stand. So every time when you change the dose or the medication, you have to check the blood pressure while sitting and while standing. Dr. Anton Titov, MD. What would be the correct goal of blood pressure lowering in the standing position? Blood pressure goal in standing position is the same as in the sitting position. This means not lower than 10 millimeter from the sitting position. Sometimes the systolic blood pressure decreased by 20 millimeters of mercury while moving from the sitting to the standing position. We call it orthostatic response and it may be a problem. So we measure the blood pressure. A difference of 5 to 10 mm of mercury is acceptable. Sometimes it is 20 millimeter of mercury in the systolic blood pressure or 10 millimeter of mercury in the diastolic blood pressure. Dr. Ehud Grossman, MD. This is orthostatic hypotension. Dr. Anton Titov, MD. We try to prevent it because orthostatic hypotension may cause damage. We adjust doses of medications or change medications. Correct!
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