REVIEW ARTICLE

Hypertension in the Elderly

Can We Improve Results of Therapy?
L. Michael Prisant, MD; Marvin Moser, MD

wareness of and therapy for hypertension in the United States have been increasing in
older patients. Despite this improvement, hypertension continues to be poorly controlled in this patient population. The control rate, defined as systolic blood pressure less
than 140 mm Hg and diastolic blood pressure less than 90 mm Hg, is surprisingly low for
older patients, despite abundant data documenting the reduction of cardiovascular events by treating
both systolic-diastolic and isolated systolic hypertension. Comorbid diseases and physiological alterations in the elderly, including reduced myocardial contractility, renal function, total body water, baroreceptor responsiveness, and cognitive function, must be considered, but in general these have not
limited the effectiveness of antihypertensive drug therapy.
Arch Intern Med. 2000;160:283-289
Recently, interest has been revived in the use
of combination therapy for the treatment of
hypertension. This approach has been supported by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure.1 Complex drug regimens
can result in noncompliance; adverse drug
reactions are increased if high doses of a
single drug are used, and excessive costs may
be incurred if medication is dispensed separately. New fixed-dose combination antihypertensive drugs can simplify dosing regimens, improve compliance, improve blood
pressure (BP) control, decrease dosedependent adverse effects, and reduce cost.
Combinations that include low doses of diuretics have proved effective without an increase in orthostatic hypotension. It is especially important that BP control be
achieved in older patients to avoid the debilitating complications of stroke, heart
failure, angina, and renal failure that may
impair their quality of life. The use of combination therapy may help to increase the
number of elderly patients whose hypertension is well controlled.
PREVALENCE
The prevalence of hypertension increases
with aging.2 For women, the prevalence exceeds that of men between the fifth and sixth
decade of life. According to the National

From the Section of Cardiology, Hypertension Unit, Medical College of Georgia,

Augusta (Dr Prisant); and the Department of Medicine, Yale University School
of Medicine, New Haven, Conn (Dr Moser).
ARCH INTERN MED/ VOL 160, FEB 14, 2000
283

Health and Nutrition Examination Survey

III, 1988-1991,3 the prevalence of hypertension for those aged 65 to 74 years was
72% for African Americans, 53% for whites,
and 55% for Mexican Americans. The actual distribution of elevated BP by level for
the US population 60 years and older was
49.6% for stage 1 hypertension (140-159/
90-99 mm Hg), 18.2% for stage 2 (160-179/
100-109 mm Hg), and 6.5% for stage 3
($180/110 mm Hg).
PHYSIOLOGICAL
CONSIDERATIONS
This high prevalence of hypertension in
older persons suggests that the recognition and treatment of hypertension should
be a priority for physicians. After a diagnosis is made, based on several readings over
time and a persistent BP of 140/90 mm Hg
or greater, there are certain factors to be considered prior to instituting any type of
therapy. Physiological effects of aging include a decrease in glomerular filtration, cardiac index, and maximal breathing capacity.4 Metabolism may decrease with changes
in hepatic blood flow and reduced hepatic
mass, and intestinal absorption is altered by
a higher gastric pH, a decreased absorptive
surface, a decline in gastrointestinal motility, and reduced splanchnic blood flow. Total body water and lean body mass are reduced, and body fat increases in older
individuals. Thus, the volume of distribution of water-soluble drugs may be smaller
in the elderly, resulting in higher plasma
concentrations. Lipid-soluble drugs have a

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greater distribution and a longer

elimination time. Theoretically, these
alterations in physiology may increase the likelihood of adverse drug
reactions in the elderly. Altered drug
concentrations, impaired organ functions and response, multiple disease
states, increased number of medications, and, perhaps, altered compliance favor the higher likelihood of adverse drug reactions in older persons.
Despite these changes, most elderly patients tolerate medication
without a significant increase in adverse events compared with younger
patients or control groups.5-8 It is important to take a careful drug history
(including over-the-counter drugs)
andtoknowtheeffectsagingmayhave
on the medications prescribed; many
elderly patients may be taking 2 or 3
drugs in addition to antihypertensive
agents. Prescribed and over-thecounter drugs should be reviewed
regularly.4 Fixed-dose combination
drugs for hypertension have the potentialforsimplifyingdrugtherapyand
reducing drug costs; this is especially
important in the elderly.9 There is also
the possibility of drug-induced illness
in elderly patients. For example, anorexiaandweightlossmightbecaused
by digitalis intoxication rather than an
underlying malignant neoplasm; severe constipation may be secondary
totheuseofacalciumchannelblocker
and therefore would not require a
workup for an intestinal lesion.
DIAGNOSIS
The diagnosis of hypertension in the
elderly presents certain challenges to
physicians.1 Older patients may have
rigid arteries as a result of atherosclerosis that increase the measured BP.

Itmayrequiremorepressureinthecuff
to obliterate the brachial artery; systolic BP may be recorded at a level
higherthanthetruereading.However,
a pulseless, palpable radial artery (Osler sign) that is present after inflation
of the BP cuff above the systolic BP is
relatively uncommon and is not as reliable an indicator of pseudohypertension as previously thought.10,11 In addition, there is increased variability in
the measurement of BP in older persons, especially in women.12 More
measurementsmayberequiredbefore
concluding that the patient has hypertension. Finally, posturalhypotension
may occur more commonly among elderly patients. Defining postural hypotension as a decrease in systolic BP
of 20 mm Hg or more, the Systolic Hypertension in the Elderly Program
(SHEP) observed a prevalence of
10.4% at 1 minute and 12.1% at 3 minutes13; however, postural hypotension
was present at both 1 and 2 minutes
in only 5.3% of the population. It is
reasonable to monitor standing BP in
elderly patients on a regular basis, especially after initiating specific medical therapy.
Essential hypertension is the
most common cause of hypertension
in the elderly. However, secondary
hypertension is more common in the
elderly than in younger patients. Renovascular hypertension is probably
the most common cause of secondary hypertension and should be suspected in new-onset hypertension in
patients 60 years or older or in those
whose blood pressure becomes difficult to control with multiple drug
therapy. Excessive ethanol use and
nonsteroidalanti-inflammatorydrugs
are often overlooked as secondary
causesofelevatedBPinthisagegroup.

RANDOMIZED CONTROL
TRIALS OF HYPERTENSION
TREATMENT IN THE ELDERLY
Randomized hypertension treatment trials in the elderly have documented a 34% reduction in strokes,
a 19% reduction in coronary heart
disease events, and a 23% reduction
in vascular deaths after 5 years of follow-up with a 12- to 14-mm Hg
change in systolic BP and a 5- to
6-mm Hg change in diastolic BP compared with placebo or control.14 In
1985, the European Working Party
on Hypertension in the Elderly Trial,
a randomized, multicenter, placebocontrolled, double-blind study
(N = 840), was the first trial to assess the effects of antihypertensive
drug therapy on persons 60 years or
older with a systolic BP of 160 to 239
mm Hg and a diastolic BP of 90 to 119
mm Hg.15,16 Active therapy with 1 or
2 tablets of hydrochlorothiazide/
triamterene (25/50 mg) every day,
with the addition of methyldopa
(250-2000 mg) in 35% of the subjects, reduced cardiac deaths by 38%
(P = .04). During the past 10 years,
additional trials have clearly added to
our knowledge of the treatment of hypertension of the elderly. It is interesting that it has not been previously emphasized that combinations
of drugs have been needed to achieve
the reductions in vascular events observed in all of these treatment trials
(Table 1).
Medical Research Council Trial
in the Elderly
The Medical Research Council Trial
in the Elderly (MRC-Elderly) was a
randomized, placebo-controlled,

Table 1. Trials Examining Treatment of Hypertension in the Elderly*

Stroke reduction, %
CAD change, %
CHF reduction, %
% of Patients receiving
combination drug therapy

EWPHE
(N = 840)

MRC-Elderly
(N = 4396)

SHEP
(N = 4736)

STOP-H
(N = 1627)

Syst-China
(N = 2394)

Syst-Eur
(N = 4695)

36
20
22
35

25
19
Not stated
52 (b-blocker);
38 (diuretic)

33
27
55
44

47
13
51
67

38
+6
58
11-26

42
26
27
26-36

*EWPHE indicates European Working Party on Hypertension in the Elderly; MRC-Elderly, Medical Research Council Trial in the Elderly;
SHEP, Systolic Hypertension in the Elderly Program; STOP-H, Swedish Trial in Old Patients With Hypertension; Syst-China, Systolic Hypertension in China Trial;
Syst-Eur, Systolic Hypertension in Europe Trial; CAD, coronary artery disease; and CHF, coronary heart failure.
P,.01.
CAD events were reduced for subjects who were treated with diuretics but not b-blockers.
Myocardial infarction only; however, the rate of sudden death was 6.8 vs 2.3 per 1000 patient-years for placebo vs active treatment (relative risk, 0.33).

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single-blind trial of 4396 patients.17

Patients received placebo, amiloride
hydrochloride(2.5-5mg)withhydrochlorothiazide (25-50 mg), or atenolol (50-100 mg). To be eligible for
this trial, male and female patients
aged 65 to 74 years were required to
have a systolic BP between 160 and
209 mm Hg and a diastolic BP of 114
mm Hg or lower. Treatment with diuretics and b-blockers significantly
(P = .04) reduced the rate of strokes
compared with placebo. Overall coronary events, when the results of both
treatments were combined, were not
significantly reduced by drug therapy
(P = .08). However, treatment with
diuretics was superior (P = .006) to
b-blocker therapy in reducing coronary events and reduced these events
significantly. The benefit of b-blockers in reducing overall cardiovascular events was not seen among smokers, but in nonsmokers the rate (per
1000 patient-years) of cardiovascular events was 19.6 for treatment with
b-blockers, 14.3 for treatment with
diuretics, and 23.3 for placebo. A
combination of drugs was often required to achieve target BP control;
52% of patients who were treated with
b-blockers and 38% of patients who
were treated with diuretics required
additional antihypertensive drugs to
achieve a systolic BP goal of 150 to
160 mm Hg.

greater percentage of elderly patients (P = .003) receiving active

drugs were free of cardiovascular
events compared with those receiving placebo over the 4 years of treatment. Although not a primary end
point, total mortality was significantly (P = .008) reduced as well.
Systolic Hypertension
The Framingham Study originally
identified systolic BP as a prime risk
factor for cardiovascular diseases.19
Clinical trials may have directed attention away from the systolic BP by
emphasizing a reduction in diastolic
BP and its relationship to a reduction
in cardiovascular events. A recent
analysis has documented that systolic
BP is a better predictor of cardiovascular events than diastolic BP.20 The
relative risk of systolic hypertension
(.159/,80 mm Hg) was 4.2 times
greater than that of an optimum BP
(,120/,80 mm Hg) compared with
a risk 3.2 times greater for diastolic
hypertension (,120/.99 mm Hg).20
This observation, although not new,
has again focused attention on the
treatment of systolic BP, especially in
elderlypatients.Threetrialshavebeen
completed that specifically address
the cohort of pure isolated systolic hypertension.6,21,22
Systolic Hypertension
in the Elderly Program

Swedish Trial in Old Patients

With Hypertension
The Swedish Trial in Old Patients
With Hypertension (STOP-Hypertension) was a multicenter, randomized, double-blind trial involving 927
patients aged 70 to 84 years with
either a systolic BP of 180 to 230
mm Hg and a diastolic BP of 90
mm Hg or higher or a diastolic BP
of 105 to 120 mm Hg.18 The primary end points included stroke,
myocardial infarction, and cardiovascular deaths. The drugs used
could include atenolol (50 mg once
daily), hydrochlorothiazide (25 mg
once daily) in combination with
amiloride (2.5 mg once daily), metoprolol (100 mg once daily),
pindolol (5 mg once daily), or
placebo. Two thirds of the active patients required a combination of antihypertensive therapy drugs to
achieve BP control. A significantly

The Systolic Hypertension in the Elderly Program (SHEP) trial was a multicenter, randomized, double-blind,
placebo-controlled trial of patients
60 years or older.7 Subjects received
either placebo or chlorthalidone
(12.5-25 mg once daily), with either
atenolol (25-50 mg once daily) or reserpine (0.05 mg once daily) added,
if needed. A reduction of 36% in fatal and nonfatal strokes was achieved
compared with patients receiving placebo. There was also a significantly
lower rate of nonfatal heart failure23
and myocardial infarction. To achieve
these results, 44% of the subjects received combination drug therapy to
attain the target BP goal. Interestingly, subjects receiving active therapy
were not more likely to experience
faintness on standing, feelings of imbalance, falls, or fractures compared
with patients receiving placebo.7

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285

Active drug therapy did result

in statistically significant (but clinically unimportant) changes in levels
of glucose (an increase of 0.3 mmol/L
[3.6 mg/dL], P,.01), total cholesterol
(an increase of 0.09 mmol/L [3.5
mg/dL], P,.01), creatinine (an increase of 2 mol/L [0.03 mg/dL],
P,.001), triglycerides (an increase
of 0.19 mmol/L [17 mg/dL],P,.001),
uricacid(anincreaseof0.004mmol/L
[0.06 mg/dL], P,.001), and potassium (a decrease of 0.3 mmol/L,
P,.001).24 There was no significant
increase of new cases of diabetes
mellituswithactivetherapycompared
with placebo (8.6% vs 7.5%, P = .25)
after 3 years of treatment. The patients
with diabetes who received active
treatment in the SHEP cohort experienced the same or a greater reduction in total cardiovascular events
than patients without diabetes25; their
absolute reduction in cardiovascular
events was 2 times greater than that
of patients without diabetes. The outcome among 1148 patients with hypertension and type 2 diabetes is also
consistent with the benefits observed
in the United Kingdom Prospective
Diabetes Study 39,26 which documented the equal effectiveness of tight
BP control and treatment with either
atenolol or captopril in reducing the
incidenceofdiabeticendpointsofmacrovascular(myocardialinfarction,sudden death, heart failure, or stroke) and
microvascular (retinopathy, albuminuria, or renal failure) complications.
Sixty percent of subjects required 2 or
moredrugstoattaintargetBP,andtight
BP control resulted in a significantly
greaterreductionindiabeticendpoints
(including death) than less tight
control.27
Finally, in the SHEP trial, patients with baseline hyperlipidemia
also experienced a reduction in coronary heart disease events in this diuretic- and b-blockerbased 5-year
trial that was equivalent to that of
subjects with normal lipid levels. Importantly, the incidence of dementia or depression was not increased
by therapy and BP lowering.6,7
The Systolic Hypertension
in Europe Trial
The Systolic Hypertension in Europe (Syst-Eur) Trial was a randomized, double-blind placebo trial in pa-

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Table 2. Risk Classification and Treatment

Risk Group
Blood Pressure Level
(Systolic/Diastolic), mm Hg

High normal (130-139/86-89)

Stage 1 (140-159/90-99)
Stages 2 and 3 ($160/$100)

Lifestyle therapy
Lifestyle therapy (up to 12 mo)
Drug therapy and lifestyle therapy

Lifestyle therapy
Lifestyle therapy (up to 6 mo)
Drug therapy and lifestyle therapy

Drug therapy* and lifestyle therapy

Drug therapy and lifestyle therapy
Drug therapy and lifestyle therapy

*For heart or kidney failure and diabetes mellitus.

For patients with multiple risk factors, clinicians should consider drugs as initial therapy with lifestyle therapy.

tients 60 years and older with isolated

systolic hypertension.21 Subjects received an intermediately long-acting
calcium channel blocker (nitrendipine, 10-40 mg once daily), with
enalapril maleate (5-20 mg once daily)
if needed; this was supplemented with
hydrochlorothiazide (12.5-20 mg
once daily), if needed, to achieve BP
control. The use of combination drug
therapy was common to achieve BP
control. There was a 42% reduction
in fatal and nonfatal strokes for active treatment (n = 2398) compared
with placebo (n = 2297). For fatal and
nonfatal myocardial infarctions, however, there was only a nonsignificant
30% reduction in events (P = .12).
The study was stopped prematurely
after 2 to 2.5 years, and it is possible
(although speculative) that the trend
toward a reduction in coronary heart
disease events could have become significant over time.

end points were blindly evaluated

twice.
The average sitting BP was
170.5/86.0 mm Hg at entry. The average patient age was 66.5 years. Active drug therapy reduced total mortality by 39% (P = .003), cardiovascular mortality by 39% (P = .03), and
stroke mortality by 58% (P = .02).
Fatal and nonfatal heart failure was
reduced by 58% (P = .13), and fatal
and nonfatal myocardial infarction
increased by 6% (P = .91); however, cardiac end points occurred at
a 52% to 53% lower rate than stroke
end points.

The Systolic Hypertension

in China Trial

To guide the urgency of treatment,

the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure
has emphasized stratification, according to major risk factors and target organ damage or clinical cardiovascular disease and BP levels.1 The
major risk factors that are considered include smoking, dyslipoproteinemia, diabetes mellitus, older
than 60 years or menopausal status, and a family history of premature cardiovascular disease. Target
organ damage or clinical cardiovascular disease includes heart diseases (left ventricular hypertrophy,
angina or myocardial infarction,
coronary revascularization, and
congestive heart failure), stroke or
transient ischemic attack, nephropathy, peripheral arterial disease, and
retinopathy. It is obvious that older
persons are more likely to have more

The Systolic Hypertension in China

(Syst-China) Trial was designed to
determine whether the incidence of
stroke and other cardiovascular disease could be reduced in Chinese patients 60 years or older with isolated systolic hypertension by using
an alternate assignment approach of
titrated drug therapy (n = 1253) or
matching placebo (n = 1141).22 To
achieve a systolic BP less than 150
mm Hg and a change in sitting systolic BP of 20 mm Hg or greater, active drug treatment included nitrendipine (titrated 10 mg at bedtime, 20
mg at bedtime, and 20 mg twice
daily) and, if needed, either captopril (12.5-25 mg twice daily) or hydrochlorothiazide (12.5-25 mg twice
daily), or both. The trial was prematurely terminated with the publication of the Syst-Eur Trial,21 and

THE SIXTH REPORT

OF THE JOINT NATIONAL
COMMITTEE ON
PREVENTION, DETECTION,
EVALUATION, AND
TREATMENT OF HIGH BLOOD
PRESSURE

ARCH INTERN MED/ VOL 160, FEB 14, 2000

286

risk factors or target organ damage

and are at greater risk than younger
individuals.
Knowledge of risk factors and
target organ damage provides the information to stratify patients with
hypertension into 1 of 3 risk groups.
Patients in risk group A are classified as having no risk factors or target organ damage other than an elevated BP. Patients in risk group B
have 1 other risk factor (but not diabetes mellitus) in addition to hypertension. Risk group C identifies individuals who are at high risk as a
result of having target organ damage, clinical cardiovascular disease,
or diabetes mellitus alone, or having 2 or more risk factors. Older persons are more likely to fall into risk
group C and require initial drug
therapy as well as lifestyle interventions, even if they only have stage
1 hypertension (140-159/90-99
mm Hg) and receive treatment for
high-normal BP (130-139/85-89
mm Hg) if heart failure, renal insufficiency, or diabetes mellitus is
present (Table 2).1
LIFESTYLE THERAPY
The Joint National Committee and
the Society of Geriatric Cardiology
emphasize that lifestyle modifications should be a part of the treatment of hypertension regardless of
the age of patients.1,28 However, it is
often said that elderly patients will
not follow lifestyle therapy. Losing
weight, limiting alcohol intake,
increasing physical activities, and
reducing sodium intake are modifications in lifestyle that are recommended. Recently the Trial of Nonpharmacologic Interventions in the
Elderly (TONE) documented that
lifestyle modification could be
achieved in elderly patients.29 This
was a randomized controlled trial of

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Freedom From Recurrence of Hypertension While Not Receiving

Treatment for Hypertension or for a Cardiovascular Event, %

the usual care group, 34% of the sodium restriction group and 37% of
the weight reduction group achieved
the primary end point at 30 months.
This type of intensive intervention
is not always possible in the usual
care setting, but these study results
suggest what can be accomplished.

50
44%

45
40

37%
34%

35
30
25

TREATMENT

20
16%
15
10
5
0

Sodium Reduction
and Weight Reduction
(n = 147)

Sodium Reduction
(n = 144)

Weight Reduction
(n = 147)

Usual Care
(n = 147)

Figure 1. In the Trial of Nonpharmacologic Interventions in the Elderly (TONE), all groups received
therapy that was significantly different from usual care, but the groups were not significantly different
from one another (derived from data of Whelton et al 29 ).

80
73%

72%

72%
69%

70

68%
62%

Response Rate, %

60

50

38%

40

30

20

10

Clonidine

Atenolol

Diltiazem
Hydrochloride

Prazosin

Hydrochlorothiazide Captopril

Placebo

Figure 2. The response rate of single-drug therapy for hypertension in white men 60 years and older
(n = 408), defined as diastolic blood pressure of less than 90 mm Hg at the end of the titration period and
less than 95 mm Hg at the end of 1 year of treatment. Among the groups, only placebo was significantly
different ( P,.001) (derived from data of Materson et al 33,34).

875 men and women aged 60 to 80

years who had BP lower than 145/85
mm Hg while taking a single antihypertensive drug. Patients were
randomized to treatment based on
their body habitus. Obese patients
(n = 585) received either usual care
or sodium restriction, a dietary intake of 80 mmol over 24 hours as
measured by 24-hour urine sodium collection, a weight loss program to achieve a loss of 4.5 kg, or
a combination of sodium restriction and weight loss therapy. Nonobese patients (n = 390) were randomized to either usual care or

sodium restriction. After 3 months

of nonpharmacological therapy, antihypertensive medication withdrawal was attempted. The sodium
restriction group reduced average sodium intake by about 40 mmol/d. In
the weight loss group, average body
weight decreased by 3.5 kg. After 30
months, 44% of patients in the combined sodium and weight reduction group achieved the primary end
point, that is, freedom from recurrence of hypertension while not receiving specific treatment for hypertension or for a cardiovascular event
(Figure 1). Compared with 16% in

ARCH INTERN MED/ VOL 160, FEB 14, 2000

287

For patients without complications, diuretics or b-blockers should

be considered for initial therapy.
Low doses of medication should be
given and slowly titrated. The cardiovascular benefits of b-blockers for
elderly patients with hypertension
are not as clear as they are for those
receiving diuretics.30 However, data
do support the benefits of therapy
with b-blockers in reducing both
stroke- and heart failurerelated
events in patients with hypertension31 and in preventing recurrent
myocardial infarctions in both
high- and low-risk patients with
previous coronary episodes.32 Many
elderly patients fall into this category. The Veterans Affairs Cooperative Study Group on Antihypertensive Agents has documented the
ability of b-blocker therapy to lower
BP in older patients; results are similar to those achieved with other antihypertensive agents (Figure 2).33,34
As noted, most of the trials that
documented benefit from BP lowering used a diuretic plus another
therapeutic agent in at least 35% of
patients. Low-dose combinations
have been shown to be well tolerated in elderly patients with hypertension35 and are associated with
a better control rate than monotherapy (Figure 3).36,37 When lowdose diuretic combinations are used,
the risk of adverse effects is 5%
compared with 6% among patients
receiving placebo.38,39
The Joint National Committee
suggests diuretics or b-blockers as
initial therapeutic agents and the use
of other antihypertensive agents for
specific indications. For systolic
heart failure, converting enzyme inhibitors and diuretics are appropriate initial choices. For myocardial infarction, b-blockers without intrinsic
sympathomimetic activity are recommended; if systolic dysfunction
is also present, then angiotensin-

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Systolic Blood Pressure

Diastolic Blood Pressure

Table 3. Drugs for Comorbid

Conditions in the Elderly

Change in Blood Pressure From Baseline, mm Hg

2
2.3

Comorbid Condition

4
4.1

Angina

Atrial tachycardia
and fibrillation

8
10

Diabetes mellitus
(types 1 and 2)
with proteinuria

10.5

10.6

12

11.3
13.1

14

13.4

Diabetes mellitus
(type 2)
Essential tremor
Heart failure

16

Placebo (n = 23)
18

Bisoprolol/Hydrochlorothiazide, 5/6.25 mg (n = 52)

20

Hydrochlorothiazide, 25 mg (n = 52)

Figure 3. Comparison of placebo and b-blocker and combination therapy in patients aged 60 years or
older. Therapy with bisoprolol (5 mg) and hydrochlorothiazide (6.25 mg) lowered diastolic blood
pressure more effectively than hydrochlorothiazide (25 mg) alone ( P = .025). All 3 active treatments
lowered the diastolic and systolic blood pressure more than placebo ( P,.01 for both) (derived from data
of Frishman et al 36 and Burris and Mroczek 37 ).

100
90

Awareness
Treatment
Control
79%

80

Prevalence, %

70
60

70%

67%
58%

68%
58%

56%

50

46%

40
30

29%
25%

20

19%

16%

10
0

Black Men

White Men

Black Women

White Women

Figure 4. Awareness, treatment, and control of hypertension in the elderly ($70 years) (derived from
data of Burt et al 2).

converting enzyme inhibitors should

also be used. If type 1 diabetes with
proteinuria is present, angiotensinconverting enzyme inhibitors are indicated. For isolated systolic hypertension (primarily in the elderly),
diuretics are preferred, although a
long-acting dihydropyridine may be
an alternative if diuretics are ineffective or poorly tolerated. Other
drugs that can have favorable effects on comorbid diseases are listed
in Table 3.
Based on the studies we reviewed, combination therapy may
often be necessary to provide addi-

tional efficacy in elderly patients.

Since the overall national response
rate is low (and somewhat lower in
1988-1991), it may be that more patients in this age group should be receiving this type of therapy.2 The
control rate for men 70 years and
older varies from 16% to 29%
(Figure 4). Fixed-dose combinations have an advantage for the elderly in that they may help to increase compliance, reduce the cost
of antihypertensive therapy, and
achieve a higher response rate. Studies examining combination therapy
report a greater reduction in sys-

ARCH INTERN MED/ VOL 160, FEB 14, 2000

288

b-Blockers,
calcium antagonists
b-Blockers,
verapamil,
diltiazem
Angiotensin-converting
enzyme (ACE)
inhibitors preferred,
calcium antagonists
Low-dose diuretics

Nonselective b-blockers
ACE inhibitors
preferred, carvedilol,
losartan
Prostatism
a1-Blockers
Renal insufficiency ACE inhibitors
preferred

Bisoprolol, 5 mg (n = 54)

17.8

Drug

tolic than diastolic BP; this should

be of benefit to the elderly, in whom
systolic BP is often elevated disproportionately (Figure 3). The most
common reason for failure of therapy
is suboptimal drug use, namely failure to use a diuretic. Complex drug
regimens can result in noncompliance if drug regimens are complicated, if high doses result in
adverse drug reactions, and if separately dispensed medications
result in excessive cost. New fixeddose combination antihypertensive drugs can simplify dosing
regimens, improve compliance, improve BP control, decrease dosedependent adverse effects, and reduce cost. Therefore, this approach
to therapy may be advantageous to
elderly subjects. Moreover, a Veterans Affairs Study indicated that
combinations of antihypertensive
drugs that included a diuretic were
more effective than a combination
that did not.40
CONCLUSIONS
In summary, the treatment of hypertension in older persons requires consideration of not only altered drug metabolism but also
special physiological considerations, including postural hypotension, a decrease in cardiac output,
plasma volume, renal function, and
possibly altered mental capacity. The
treatment trials of hypertension in
the elderly have been successful in

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reducing coronary heart disease

events, strokes, and congestive heart
failure. These benefits have often
been achieved by the use of combination drug therapies. Combinations containing low doses of diuretics are highly effective; volume
depletion or orthostatic hypotension is unusual. It is important that
BP control be achieved to avoid the
debilitating complications of stroke,
heart failure, angina, myocardial
infarction, and renal failure that
impair the quality of life of older
patients.
Accepted for publication March 4,
1999.
Presented in part at the American Society of Hypertension Meeting,
New York, NY, May 13, 1998, and at
the International Society on Hypertension in Blacks, Charleston, SC, July
14, 1998.
Corresponding author: L. Michael Prisant, MD, BBR-6515A, Section of Cardiology, Medical College of
Georgia, Augusta, GA 39012-3105.

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