Tip Sheets

What to know about hypertension and older adults

By Liz Seegert

Hypertension is a common, but serious chronic condition among adults worldwide. In the U.S., The American Heart Association (AHA) estimates that nearly half of all adults in the United States – about 103 million people – have high blood pressure. Only about half (54 percent) of them have it under control, according to the CDC. About one of every five people with the condition are unaware that they have it.

Hypertension risk increases with age and after age 65, it affects more women than men. Nearly 70 percent of women, compared with 64 percent of men, have the condition by their early 70s. After age 75, prevalence increases to 78.5 percent of women and 66.7 percent of men. African Americans develop high blood pressure more often, and at an earlier age, than do whites and Hispanics. More African American women than men have high blood pressure. Adult Medicaid beneficiaries are at higher risk for hypertension compared with privately insured adults; almost one third of adult Medicaid beneficiaries had hypertension in 2012, according to the CDC.

High blood pressure increases risk of stroke, heart attack, heart failure and renal failure. It can also exacerbate other chronic conditions like diabetes. Overall, cardiovascular diseases are the leading cause of death worldwide, responsible for nearly 18 million fatalities in 2015 according to the AHA. In the United States, heart disease is the leading cause of death and stroke is number five. Yet despite widespread awareness and preventive efforts, hypertension control is lower among older patients, according to this article from Brian Egan, M.D., professor of medicine at the University of South Carolina School of Medicine-Greenville, which was written prior to revised guidelines issued in 2017 by the American Heart Association/American College of Cardiology.

The latest AHA/ACC guidelines:

• normal blood pressure as <120/

• elevated BP 120-129/

• hypertension stage 1 as 130-139 or 80-89 mm Hg

• hypertension stage 2 as ≥140 or ≥90 mm Hg.

These guidelines do not recommend different standards for older adults, saying that “treatment of hypertension with an SBP [systolic blood pressure] goal of less than 130 mm Hg is recommended for non-institutionalized, ambulatory, community-dwelling adults aged 65 years or older.”

Not all experts agree with the revised protocol when it comes to their older patients. The National Institutes on Aging says that older adults often have a high systolic (top number) but a normal diastolic (bottom number) reading. This is known as isolated systolic hypertension (ISH), caused by age-related stiffening of the major arteries. It is the most common form of high blood pressure in older people. Treatment for ISH is the same as other types of high blood pressure, however, it may require more than one type of blood pressure medication.

Costs

The CDC estimates that hypertension costs the U.S. $46 billion annually in health care services, medications, and missed days of work. The Health Care Cost Institute (HCCI) projects that over the 20-year period between 2010 and 2030, the annual estimated direct cost of hypertension will rise from $69.9 billion to $200.3 billion.

Their analysis also found that adults with hypertension spent 3.2 times more in total and 2.2 times more out-of-pocket than adults without hypertension in 2016. “This suggests the brand-name drugs people used became more expensive, either through the utilization of different drugs or price hikes for existing ones,” according to their report.

Cost of treatment varies depending on the drug combinations, required co-payments and insurance plan. Low income seniors on Medicaid are likely to encounter one or more cost-sharing practices that may affect their ability to continue treatment as prescribed., according to a CDC analysis. Two pulmonary hypertension drugs, Remodulin and Tyvaso, rank among the top five most expensive drugs under Medicare in the United States, according to this Motley Fool article. Per patient cost for Tyvaso under Medicare was $107,489 in 2015 and $144,070 per patient for Remodulin.

Treatment

Treatment for hypertension is complex, involving various therapeutic drug classes, dosages and trial and error. Most patients need at least two antihypertensive drugs to achieve their blood pressure goal and it may take several attempts to find the most effective combination.

Regardless of the new hypertension guidelines, treatment strategies differ in older populations than in younger patients. While lifestyle changes like diet, exercise, and stress management are always encouraged, this article points out that it’s more difficult to maintain for older patients. Older adults often have multiple chronic conditions and juggle multiple medications. Providers must balance hypertension management options with concurrent drug therapies, side effects, and risks.

According to aging expert Leslie Kernisian, M.D., there comes a point of “diminishing returns” after lowering blood pressure past a certain point. She aims to get high risk patients down to moderate risk level, and moderate risk patients lower. However, getting patients below systolic pressure of 120, as called for in the 2015 SPRINT trial, may be unworkable in the real world. Researchers halted that large trial a year early, but Kernisian pointed out in this blog post that the cohort was carefully selected, were on multiple anti-hypertensive medications and did not include participants who also had other common chronic conditions.

Diuretics, also known as water pills, are a first line treatment in older adults. They act on the kidneys to help the body eliminate sodium and water, reducing blood volume. Furosemide was one of the most commonly prescribed for Medicare Part D patients, according to this list from Humana Health.

• Beta blockers reduce the workload on the heart and open blood vessels, causing a slower and less forceful heartbeat. When prescribed alone, beta blockers don't work as well, especially in older people, but may be effective when combined with other blood pressure medications.

• Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications. One drug, Lisinopril, was the most commonly filled prescription under Medicare Part D in 2013, with 36.9 million claims, at a cost of $307 million, according to this NPR story.

• Angiotensin II receptor blockers (ARBs) help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ARB as one of their medications.

• Calcium channel blockers relax the muscles of the blood vessels and some slow the heart rate. Calcium channel blockers may work better for older people than do ACE inhibitors alone.

• Renin inhibitors slow down the prduction of renin, an enzyme produced by the kidneys that increases blood pressure.

• Secondary medications include

• • Alpha blockers, which reduce nerve impulses to blood vessels, thus reducing the effects of natural chemicals that narrow blood vessels.

  • Alpha-beta blockers both reduce nerve impulses to blood vessels and slow the heartbeat to lower the amount of blood that must be pumped through the vessels.

  • Central-acting agents prevent the brain from signaling the nervous system to increase heart rate and narrow blood vessels.  

  • Vasodilators work directly on the muscles in the walls of the arteries, preventing them from tightening and the arteries from narrowing.

  • Aldosterone antagonists block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

However as this Consumer Reports article points out, many most of these drugs have side effects that can cause other problems in older adults, like falls and fractures.

Story ideas

• How are physicians or institutions addressing incidence of hypertension among older adults in your community? Are there public awareness programs or events, such as free blood pressure screenings?

• What else are public health officials doing to help manage high blood pressure among the population, especially older adults, such as nutrition counseling, exercise programs, special efforts in nursing homes or assisted living facilities, etc.

• What proportion of older adults who were hospitalized for a stroke or heart attack also have high blood pressure?

• What are prescribing patterns of anti-hypertensives among health practitioners in your community? How does that affect cost for insurers and patients?

• What local or state initiatives exist for older patients who cannot afford their hypertension medications?

Sources

Nicole Napoli,  associate director, media relations, American College of Cardiology, 202-375-6523, nnapoli@acc.org

Karen P. Alexander, M.D., F.A.C.C., chair of American College of Cardiology’s Geriatric Section, and professor, Duke University School of Medicine, Durham, N.C., 919-668-8871

 [Note: she discloses significant research grants from Sanofi Aventis, Gilead, Regeneron].

NYU Langone Geriatric Cardiology Program, media relations: 212-404-3500

Vanderbilt University, Geriatric Cardiology Clinic,  Craig Boerner, senior information officer / national news director, craig.boerner@vanderbilt.edu, 615-322-4747

Daniel E Forman, M.D., chair, Section of Geriatric Cardiology, University of Pittsburgh Department of Medicine, formand@pitt.edu, 412-692-2360

Peter A. Boling, M.D., chair, Division of Geriatric Medicine, Virigina Commonwealth University, peter.boling@vcuhealth.org

Leslie Kernisian, M.D., M.P.H., clinical instructor, University of California, San Francisco, Division of Geriatrics, info@drkernisan.net, 415-574-0545

Reading and additional information

• Medicare Part D Prescriber Utilization and Payment Data – downloadable files to parse information by drug, location, condition and more.

• This 2016 MMWR from the CDC highlights the issues with non-adherence to anti-hypertensive medication among various populations.

• Heart Disease and Stroke Statistics 2018 Update from the American Heart Association.

• This Cochrane Review found that “at the present time there is insufficient evidence to know whether a higher BP target (less than150 to 160/95 to 105 mmHg) or a lower BP target (less than 140/90 mmHg) is better for older adults with high BP.”

• This story from WDSU, New Orleans, about whether pharmacist-led programs in barbershops could significantly lower high blood pressure in black men in the United States.

• This story on a possible link between lower blood pressure and improved cognition.

• This article highlights information from the Journal of Family Practice on treating hypertension in older patients.