II. Pathophysiology: Vascular changes seen in the elderly

  1. Increased vascular resistance
  2. Reduced plasma renin activity
  3. Increased Left Ventricular Hypertrophy

IV. Pitfalls in the elderly

  1. Pseudohypertension occurs due to calcified arteries
    1. Calcified arteries are more difficult to compress
  2. Isolated Systolic Hypertension is common in elderly
    1. Treat aggressively if systolic BP >139
  3. Consider Ambulatory Blood Pressure Monitoring
    1. May better identify hypotensive episodes
  4. Consider two antihypertensives if SBP >160 or DBP>100

V. Management: First-Line Antihypertensives

  1. Thiazide Diuretics are the preferred antihypertensive
  2. Thazide Diuretics decrease morbidity and mortality
    1. Cerebrovascular Accident
    2. Congestive Heart Failure
    3. Myocardial Infarction
  3. Observe closely for adverse effects in elderly
    1. Dehydration
    2. Orthostatic Hypotension
    3. Hypokalemia
      1. Check Serum Potassium frequently
      2. Consider combining with Potassium-Sparing Diuretic

VI. Management: Second-Line Antihypertensives

  1. Beta Blockers
    1. Reduce morbidity and mortality in the elderly
    2. Consider in vascular disease and CHF
    3. Use specific agents: Atenolol, Metoprolol
  2. ACE Inhibitors or Angiotensin Receptor Blocker
    1. Consider in CAD, CVA, CHF, Diabetes, CRF
    2. Observe closely for adverse effects
      1. Dehydration or decreased circulatory volume
      2. Heart Failure
      3. Renal Artery Stenosis
  3. Calcium Channel Blockers
    1. Consider in Coronary Disease and Diabetes Mellitus
    2. Consider in black and salt-sensitive patients
    3. Observe for Orthostatic Hypotension with Nifedipine
    4. Avoid short-acting agents

VII. Use with caution: Central alpha agonists (e.g. Clonidine)

  1. These agents do not reduce morbidity or mortality
  2. Adverse effects are more common in the elderly
    1. Sedation
    2. Dry Mouth
    3. Depressed mood
    4. Hypotension
    5. Rebound Hypertension if abruptly stopped

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