Features of the treatment of hypertension in old age
Hypertension (HD) belongs to a group of diseases requiring lifelong treatment. High blood pressure (BP) is recorded in 50-70% of elderly people.
More attention should be paid to PAP - pulse pressure (the difference between SBP and DBP). The increase in this indicator is more than 50 mm Hg. Art. indicates an increase in the rigidity of the arterial wall. Such vessels interfere with normal blood flow and provoke the development of left ventricular hypertrophy, coronary circulation insufficiency, ischemic brain damage and drug resistance.
A gradual increase in SBP with stabilization or decrease in DBP occurs as the duration of hypertension increases, changing its hemodynamic structure, and acquires the features of isolated systolic hypertension (ISH).
Factors affecting the course of hypertension in old age:
- dysfunction of baroreceptors, sympathetic regulation;
- renal dysfunction;
- the work of the renin-angiotensin-aldosterone system (RAAS);
- malfunctions in the axis of the hypothalamus - pituitary gland - adrenal cortex;
- pronounced structural changes in the aorta and its main branches;
- violation of metabolic processes.
GB in the elderly is characterized by a number of features:
- High incidence of "pseudohypertension" - discrepancy between the actual intra-arterial pressure measured by the Korotkov method. As a result of sclerosed processes in the vessels, the blood pressure indicators obtained with the tonometer do not coincide with the actual ones, which serves as the basis for the appointment of untimely treatment.
- High lability of blood pressure. It significantly impairs the quality of life, forcing the patient to constantly expect an increase or decrease in indicators, violates the regimen of taking antihypertensive drugs, and reduces confidence in the doctor and the treatment prescribed by him. Patients with high blood pressure lability tolerate a decrease in pressure, accompanied by cardiocerebral syndrome (dizziness, headaches, drowsiness, palpitations, unsteadiness of gait), much worse.
- Hypersensitivity to salt. Renin activity gradually decreases with age. This leads to a good result in the treatment of hypertension with diuretics.
- Changes in the autonomic regulation of cardiac activity. The sensitivity of the myocardium to adrenaline increases, which causes the development of rhythm disturbances, ischemic heart damage in response, even with slight excitement or physical stress.
With age, the number and sensitivity of β2-adrenergic receptors, which causes an imbalance between the lumen of the vessel in the form of narrowing or dilation towards the spasm. Over time, the autoregulation of the cerebral, renal and coronary circulation changes. This leads to an increase in vascular resistance and a decrease in sensitivity to antihypertensive pills.
Sclerotic processes in the cerebral arteries, narrowing of their diameter and thickening of the walls lead to a deterioration in the adaptation of cerebral hemodynamics to decreased blood pressure. In older patients, hypertensive dementia (atrophy of the subcortical white matter) develops and the risk of stroke increases. Additionally, the prognosis worsens atherosclerosis of the carotid arteries, osteochondrosis of the cervical spine.
Particular attention is paid to renal function in the treatment of arterial hypertension (AH) in elderly people. Even a slight violation of the filtration capacity leads to an even greater increase in blood pressure.
Kidney damage in hypertension progresses slowly and imperceptibly. Only in the later stages do clinical symptoms appear, when it becomes much more difficult to correct the disorders.
Enhanced activation of the RAAS leads to hypertrophy of the muscular layer of the arterial wall, proliferation of connective tissue. The result is renal tubular atrophy, which is manifested by high serum creatinine and urea levels and symptoms of chronic renal failure (CRF).
Therefore, for elderly patients, before starting therapy for hypertension, it is necessary to determine:
- protein in the urine;
- glomerular filtration rate (GFR);
- plasma concentration of creatinine and urea.
Pressure drugs for the elderly
In the treatment of elderly patients with hypertension, it is optimal to adhere to a low-dose strategy, since the incidence of orthostatic hypotension increases due to age-related regulatory imbalance.
An excessive decrease in blood pressure in patients of this group causes cerebral ischemization with the development of neurological deficits and mental disorders.
A mild decrease in blood pressure makes it possible to gradually resume the functional state of the vessels.
Basic principles of therapy for elderly patients with hypertension:
- Start with non-drug methods (weight loss, nutrition, exercise).
- Treatment should be selected taking into account concomitant diseases.
- The optimal blood pressure level is considered to be the lowest blood pressure that the patient can tolerate well.
- Medicines must be selected individually, starting with minimal doses, with constant monitoring of clinical parameters (cerebral blood flow, ECG, GFR).
- For adequate treatment, a combination of two or more drugs from different groups with several pathways of metabolism and excretion is required.
Traditionally, first-line drugs in these patients are diuretics and calcium antagonists (especially with ISH). ACE inhibitors and sartans also show high efficiency.
The choice of medication to lower blood pressure in the elderly depends on:
- Risk factors:
- Floor.
- Lipid spectrum of blood.
- Smoking.
- Diabetes.
- Family history.
- Target organ damage:
- Cerebrovascular diseases.
- Angina pectoris.
- Myocardial infarction.
- Congestive heart failure (CHF).
- Nephropathy.
- Retinopathy.
Choosing a medicine for hypertension for elderly patients:
| Drug class | Indications | It is undesirable to use |
|---|---|---|
| Loop diuretics | CPN, ZSN | Arrhythmia-associated hypokalemia |
| Thiazide diuretics | ZSN, ISG | Gout, GFR <30 ml / min. |
| Aldosterone (AA) antagonists | CHF, cardiac cirrhosis of the liver, postinfarction cardiosclerosis, atrial fibrillation | CRF, hyperkalemia |
| β-blockers (BB) | Angina pectoris, postinfarction cardiosclerosis, tachyarrhythmias, CHF | Asthma, AV block II-III degree |
| Calcium antagonists (AA) | ISH, angina pectoris, vascular disease of the lower extremities, atherosclerosis of the carotid and renal arteries | Tachyarrhythmias, CHF |
| Calcium channel blockers (CCBs) | Angina pectoris, supraventricular tachycardia, carotid atherosclerosis | AV block II-III degree, CHF |
| ACE inhibitors | CHF, left ventricular dysfunction, postinfarction cardiosclerosis, nephropathy in diabetes mellitus and hypertension | Hyperkalemia, bilateral renal artery stenosis |
| Angiotensin II receptor antagonists (sartans) (ARA) | The same as for ACE inhibitors, and cough caused by taking an ACE inhibitor | Same as for ACE inhibitors |
| α-blockers (AB) | Benign prostatic hyperplasia, hypercholesterolemia | Orthostatic hypotension, CHF |
List of tablets for the treatment of hypertension in elderly patients:
| Drug class | Name | Dose | Multiplicity of application |
|---|---|---|---|
| Loop diuretics | "Furosemide" | 20-40 mg | 1 r / d |
| "Trifas Cor" | 5 mg | 1 r / d | |
| "Diuver" | 5 mg | 1 r / d | |
| "Britomar" | 5 mg | 1 r / d | |
| Thiazide diuretics | "Hydrochlorothiazide" | 12.5-50 mg | 1 r / d |
| "Hypothiazide" | 12.5-50 mg | 1 r / d | |
| "Indapamide" | 2.5 mg | 1 r / d | |
| Combined | "Diuretidine" | 1 tab. | 1 r / d |
| "Moduretic" | 1 tab. | 1 r / d | |
| Aldosterone antagonists | "Veroshpiron" | 25-50 mg | 1-2 r / d |
| "Spironolactone" | 25-50 mg | 1-2 r / d | |
| Eplerenone | 25 mg | 1-2 r / d | |
| α-blockers | "Doxazosin" | 1 mg | 1 r / d |
| β-blockers | Anaprilin | 80 mg | 2 r / d |
| "Atenolol" | 50 mg | 1-2 r / d | |
| "Bisoprolol" | Titration from 2.5 mg to the optimal dose | 1 r / d | |
| "Concor" | 2.5-5 mg | 1 r / d | |
| "Metoprolol" | 50 mg | 2 r / d | |
| "Nebilet" | 2.5-5 mg | 1 r / d | |
| Calcium antagonists | "Amlodipine" | 5-10 mg | 1 r / d |
| "Corinfar" | 10 mg | 2 r / d | |
| "Lerkamen" | 10 mg | 1 r / d | |
| "Nifedipine" | 10 mg | 2 r / d | |
| "Norvask" | 5 mg | 1 r / d | |
| Calcium channel blockers | "Verapamil" | 40-80 mg | 3 r / d |
| Diltiazem | 60 mg | 2 r / d | |
| ACE inhibitors | Berlipril | 5-10 mg | 1 r / d |
| "Captopril" | 6.25-12.5 mg | 2 r / d | |
| "Lisinopril" | 5-10 mg | 1 r / d | |
| "Prestarium" | 4 mg | 1 r / d | |
| "Perindopril" | 4 mg | 1 r / d | |
| Noliprel | 2-4 mg | 1 r / d | |
| Ramipril | 1.25-2.5 mg | 1 r / d | |
| Enalapril " | 5-10 mg | 1 r / d | |
| Angiotensin II antagonists (sartans) | "Vasar" | 80-160 mg | 1 r / d |
| Valsakor, Diocor | 80-160 mg | 1 r / d | |
| "Lorista", "Kozaar", "Lozap" | 25-50 mg | 1 r / d |
If blood pressure cannot be controlled with a combination of three drugs of different classes, then we are talking about a resistant form of hypertension.
Poor blood pressure control is facilitated by:
- obesity;
- metabolic syndrome;
- diabetes;
- chronic renal dysfunction (plasma creatinine> 133 mmol / L);
- atherosclerosis;
- left ventricular hypertrophy;
- high numbers of initial blood pressure;
- sleep apnea.
What to look for when taking medication?
Arterial hypertension in an older person is not only an increase in blood pressure, but also the resistance of the walls of arterioles, narrowing of their lumen, damage to the endothelium with almost irreversible changes in its structure.
"Aggressive" lowering blood pressure to the target level leads to a number of side effects:
- dizziness;
- unsteadiness, uncertainty in gait;
- general weakness;
- heartbeat;
- feeling short of air.
These phenomena significantly reduce the patient's adherence to treatment.
A medicine for pressure for the elderly should combine several qualities: high efficiency at minimal doses, mild decrease in blood pressure, a small number of contraindications, ease of use and an affordable price. Foreign drugs of the new generation meet these criteria, but unfortunately, they are more expensive in comparison with domestic counterparts.
High pressure pills for elderly patients are selected taking into account the accompanying diseases.
| Comorbidity | Recommended | Limit use |
|---|---|---|
| ZSN | Diuretics, ACE inhibitors, sartans, BB (with slow dose adjustment) | AA, AK, "Hydralazin" |
| Ischemic heart disease | BB, AK, ACE inhibitors, sartans | Hydralazine, AA |
| Disruption of cerebral blood flow | Diuretics, ACE inhibitors, sartans, AK dihydropyridine series | "Reserpine", "Dopegit", "Clonidine" |
| Chronic renal failure | Loop diuretics, AK, "Dopegit" | Thiazide diuretics, AA. Caution with ACE inhibitors and sartans (control GFR) |
| COPD | Diuretics, AK, sartans | Be careful - BB. ACE inhibitors sometimes cause coughing. |
| Gout | ACE inhibitors, sartans, AK | Diuretics |
| Albuminuria, proteinuria | ACE inhibitors, sartans, AK, "Moxonidin", "Urapidil" | BB, thiazide diuretics, "Clonidine" |
| Diabetes | Sartans, ACE inhibitors, AK, Moxonidin, Urapidil | BB, thiazide diuretics, "Clonidine" |
| Peptic ulcer and duodenal ulcer | Diuretics, sartans, ACE inhibitors | "Reserpine", BB |
Elderly patients are forced to take a regimen of two, three or even four antihypertensive drugs for adequate control of blood pressure.
Therefore, several recommendations for the use of drugs should be followed:
- At the doctor's appointment, tell about all the pills you are taking.
Some drugs weaken the effect of antihypertensive drugs (nonsteroidal anti-inflammatory, vasoconstrictor nasal drops, corticosteroids, phytotherapeutic drugs).
- On a separate sheet, write the entire list of medicines that must be taken every day, and keep it in a conspicuous place.
- Leave a reminder to take pills on your mobile phone.
- Keep a blood pressure diary. Measure blood pressure two to three times a day at the same time. These records will help the doctor choose the optimal treatment regimen.
- Before using each, read the instructions. Pay special attention to side effects and symptoms of overdose.
- It is optimal to divide the medication into two doses (in the morning and before bedtime). This contributes to 24-hour BP control, especially during dangerous night hours.
- Take medication systematically. If you missed the time, do not double the dose.
- Do not independently replace drugs, their dosage and frequency of use.
- If side symptoms appear, immediately consult a doctor.
- Undergo regular medical examinations. Monitor heart, liver and kidney function.
Symptoms requiring medical attention:
- a sharp drop in blood pressure with nausea, dizziness, darkening in the eyes;
- bradycardia;
- pain in the pericardial region, shortness of breath;
- the appearance of arrhythmias, tachycardia;
- a sharp deterioration in vision;
- swelling of the legs;
- decrease in the amount of urine;
- dry obsessive cough;
- subcutaneous hemorrhage, nosebleeds;
- allergic rash;
- nausea, abdominal pain, discoloration of stools.
To achieve the best effect, hypertensive patients are recommended to use non-drug methods of treatment:
- eat rationally, reduce weight;
- limit the amount of salt;
- stay a lot in the fresh air, walk, do morning exercises;
- exclude alcohol, tobacco and caffeine;
- minimize stress levels.
Conclusions
The problem of blood pressure control in elderly patients requires an integrated approach involving a therapist, cardiologist and neurologist.
The main task of the doctor is to choose such a combination of drugs that will ensure effective control of blood pressure, prevent the development of complications, taking into account the age-related characteristics of hemodynamics and concomitant diseases.
