Management of Hypertension in the Elderly and Frail Elderly

Diagnostic and Therapeutic Approach to Different Hypertensive Phenotypes According to the 2023 ESH Guidelines

The European Society of Hypertension (ESH) in the guidelines document issued in 2023 made specific recommendations regarding the diagnostic and therapeutic approach for the different hypertensive phenotypes detectable in current clinical practice. The present paper will offer a critical review of these recommendations.The clinical hypertensive phenotypes of most frequent detection in current clinical practice, namely white-coat hypertension, masked hypertension, nocturnal hypertension and isolated systolic hypertension of the elderly will be reviewed. Other less common phenotypes will be also addressed. Recommendations for each clinical phenotype are made, emphasizing the need for an accurate diagnosis and treatment for specific clinical conditions, i.e. when target organ damage and/or high cardiovascular risk is detected. Areas of uncertainty related to clinical phenotypes in which pathophysiological and prognostic information are still lacking will be discussed. Future studies will allow to refine the guidelines recommendations, particularly for the clinical conditions for which pathophysiological and prognostic information are at present scanty.

Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents

OBJECTIVES

Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 24,870 Department of Veterans Affairs (VA) nursing home residents aged ≥65 years with long-term stays (≥180 days) from 2006 to 2019.

METHODS

We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission.

RESULTS

More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years).

CONCLUSIONS AND IMPLICATIONS

Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.

Frailty and chronic diseases: A bi-directional relationship

Frailty is a multidimensional syndrome associated with a decline in reserve capacity across multiple organ systems involving physical, psychological, and social aspects. Weakness is the earliest indicator of the frailty process. Multi-morbidity is the state of presence of two or more chronic diseases. Frailty and chronic diseases are interlinked as frail individuals are more prone to develop chronic diseases and multi-morbid individuals may present with frailty. They share common risk factors, pathogenesis, progression, and outcomes. Significant risk factors include obesity, smoking, aging, sedentary, and stressful lifestyle. Pathophysiological mechanisms involve high levels of circulating inflammatory cytokines as seen in individuals with frailty and chronic diseases such as hypertension, cardiovascular diseases, type 2 diabetes mellitus, chronic kidney disease, and anemia. Hence, frailty and chronic diseases go hand in hand and it is of utmost importance to identify them and intervene during early stages. Screening frailty and treating multi-morbidity incorporate both pharmacological and majorly non- pharmacological measures, such as physical activities, nutrition, pro-active care, minimizing polypharmacy and addressing reversible medical conditions. The purpose of this mini-review is to highlight the interrelation of frailty and chronic diseases through the discussion of their predictors and outcomes and how timely interventions are essential to prevent the progression of one to the other.

Orthogeriatric Assessment of the Elderly Patient with Fragility Hip Fracture: Preliminary Results of a Prospective Study

Nowadays, more studies deal with "OrthoGeriatrics", for the co-management of elderly patients suffering fractures, from the admission to the discharge and beyond. For the first time at Cagliari University Hospital, we introduced an orthogeriatric service, in which trained geriatricians stay in orthopedic unit alongside trained orthopedics. The primary aim of the study was to analyze the rate of death and rehospitalization in elderly femur-fractured people of 65 or more years of age, identifying possible predictive factors. The secondary aim of the study was to analyze the recovery of daily living autonomies during the months following surgery. To reach the aim, we designed a prospective study, which is currently ongoing. We evaluated femur-fractured patients aged 65 years or more with a comprehensive geriatric assessment before surgery. The most common fractures were lateral hip ones, treated with osteosynthesis. Cognitive-affective, functional, and nutritional status, mood, and comorbidities were less impaired than in the outpatient service of the same hospital devoted to frail elderly. Pain control was excellent. A significantly low delirium incidence was found. More than a third of the sample were recognized as frail (according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI)), and over a third of the sample were identified as a moderate-high risk of hospitalization and death (according to Multidimensional Prognostic Index (MPI)). Overall mortality rate was 13.87%, and rehospitalization rate was 11.84%. Frail people were more likely to die than non-frail (HR: 5.64), and pre-frail ones (HR: 3.97); similarly, high-risk patients were more likely to die than low-risk (HR: 8.04), and moderate-risk ones (HR: 5.46). Conversely, neither SHARE-FI nor MPI predicted rehospitalization. Creatinine (OR: 2.66, p = 0.003) and folate (OR: 0.75, p = 0.03) levels were independently associated with death and rehospitalization, respectively. Finally, the patients did recover the lost autonomies later, 6 months after surgery. Our study demonstrated that SHARE-FI and MPI are reliable tools to predict mortality in an orthogeriatric setting, and that creatinine and folate levels should also be measured given their independent association with negative outcomes.

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis

Background

Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively.

Methods

This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses.

Results

Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients.

Conclusions

Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00548-7.

The effects of exercise training on hypertensive older adults: an umbrella meta-analysis

Exercise training has been shown to blunt many of the physiological declines and common diseases of the aging process. One such beneficial effect is the reduction of blood pressure (BP) in hypertensive older adults. However, there is no consensus about which benefits of aerobic (AT) or resistance training (RT) may be lost by the use of combined training (CT) or even what benefits could be acquired only by performing CT, considering the extensive health needs of older adults with hypertension. Thus, we performed an umbrella meta-analysis. The benefits conferred by CT are extensive and encompass cardiorespiratory fitness, muscular fitness, and blood lipid profile improvements. CT may be recommended to improve the extensive health needs of hypertensive older adults that go beyond blood pressure reduction.

Real-world Antihypertensive Treatment Patterns, Treatment Adherence, and Blood Pressure Control in the Elderly: An Italian Awareness-raising Campaign on Hypertension by Senior Italia FederAnziani, the Italian Society of Hypertension and the Italian Federation of General Practitioners

INTRODUCTION

Achieving hypertension control is beneficial regardless of age. Fixed-combination pills have the potential of increasing adherence to treatment, improving the benefit/risk ratio, and simplifying therapy, with resulting convenience especially in the elderly.

AIM

We examined real-world antihypertensive treatment adherence and hypertension control rates in a cohort of Italian elderly individuals, enrolled in a prospective, pragmatic awareness-raising campaign on blood pressure (BP).

METHODS

13196 treated hypertensive elderly (mean age 73.2±7.5 years, 55.5% women) were recruited through opportunistic sampling, answered a brief questionnaire on antihypertensive therapy, and were followed-up for 6 months, when BP was measured as per routine care. Controlled hypertension was defined as BP < 140/90 mmHg. Real-world treatment adherence and hypertension control rates were evaluated at 6 months according to different treatment patterns (fixed-dose versus free combinations), using Yates correction for continuity to assess likelihood estimates for differences between treatments.

RESULTS

10551 participants (80%) were on a single-pill therapy and 3445 were on a fixed combination therapy of two (24.8%) or three (1.3%) drugs. Individuals on a fixed combination therapy were more adherent to treatment than the counterparts (p < 0.001). Full adherence increased with the number of drugs/pill among single-pill users (47.5%, 68.5%, and 100% with 1, 2, or 3 drugs/pill; p < 0.001). Hypertension control rates were 70% and 65.2% (p = 0.001) according to fixed or free combinations of two drugs and 71% and 63.9% (p = 0.321) for fixed or free combinations of three drugs.

CONCLUSIONS

Real-world data suggest that simplified treatment strategies and use of fixed combinations improve adherence to antihypertensive therapy and BP control in the elderly.

Antihypertensive Treatment in Elderly Frail Patients: Evidence From a Large Italian Database

Aim of our study was to assess the relationship between adherence with antihypertensive drugs and the risk of death in frail versus nonfrail old individuals. Using the database of the Lombardy Region (Italy), we identified 1 283 602 residents aged ≥65 years (mean age 76) who had ≥3 prescriptions of antihypertensive drugs between 2011 and 2012. A nested case-control design was applied, with cases being the cohort members who died during the observation period (7 years). Logistic regression was used to model the association of interest, with adjustment for potential confounders. Adherence was measured by the proportion of the follow-up covered by prescriptions, and the analysis was separately performed in patients with a good, medium, poor, and very poor clinical status, as assessed by a score that has been shown to be a sensitive predictor of death in the Italian population. The 7-year death probability increased from 16% (good) to 64% (very poor) clinical status. Compared with patients with very low adherence with antihypertensive treatment (<25% of follow-up time covered by prescriptions), those with high adherence (>75% of time covered by prescriptions) exhibited a lower risk of all-cause mortality in each group, the difference decreasing progressively (-44%, -43%, -40%, and -33%) from the good to the very poor clinical status. Adherence with antihypertensive drug treatment was also associated with a lower risk of cardiovascular mortality. Adherence with antihypertensive appears to be protective in frail old patients, but the benefit is less marked than in patients with a good clinical status.

Change in Prescribing for Secondary Prevention of Stroke and Coronary Heart Disease in Finnish Nursing Homes and Assisted Living Facilities

BACKGROUND

One quarter of residents in long-term care facilities (LTCFs) have a diagnosis of CHD or stroke and over half use at least one preventative cardiovascular medication. There have been no studies that have investigated the longitudinal change in secondary preventative cardiovascular medication use in residents in LTCFs over time.

OBJECTIVE

The aim of this study was to investigate the change in cardiovascular medication use among residents with coronary heart disease (CHD) and prior stroke in nursing homes (NHs) and assisted living facilities (ALFs) in Finland over time, and whether this change differs according to dementia status.

METHODS

Three comparable cross-sectional audits of cardiovascular medication use among residents aged 65 years and over with CHD or prior stroke in NHs in 2003 and 2011 and ALFs in 2007 and 2011 were compared. Logistic regression analyses adjusted for gender, age, mobility, cancer and length of stay were performed to examine the effect of study year, dementia and their interaction on medication use.

RESULTS

Cardiovascular medication use among residents with CHD (NHs: 89% vs 70%; ALFs: 89% vs 84%) and antithrombotic medication use among residents with stroke (NHs: 72% vs 63%; ALFs: 78% vs 69%) declined between 2003 and 2011 in NHs and 2007 and 2011 in ALFs. Decline in the use of diuretics, nitrates and digoxin were found in both groups and settings. Cardiovascular medication use among residents with CHD and dementia declined in NHs (88% [95% CI 85-91] in 2003 vs 70% [95% CI 64-75] in 2011) whereas there was no change among people without dementia. There was no change in cardiovascular medication use among residents with CHD in ALFs with or without dementia over time. Antithrombotic use was lower in residents with dementia compared with residents without dementia in NHs (p < 0.001) and ALFs (p = 0.026); however, the interaction between dementia diagnosis and time was non-significant.

CONCLUSIONS

The decline in cardiovascular medication use in residents with CHD and dementia suggests Finnish physicians are adopting a more conservative approach to the management of cardiovascular disease in the NH population.

Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues

PURPOSE OF REVIEW

As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group.

RECENT FINDINGS

Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.

Clinical inertia in hypertension: a new holistic and practical concept within the cardiovascular continuum and clinical care process

Purpose: Recognition of clinical inertia is essential to improve the control of chronic diseases. Although it is very intuitive, a better interpretation of the concept of clinical inertia is lacking, likely due to its high complexity. Materials and Methods: After a review of the published articles, we propose a practical vision of inertia, contextualized within the clinical process of hypertension care. Results: This new vision enables the integration of previous terms and definitions of clinical inertia, as well as proposing specific strategies for its reduction. Conclusion: Although some concepts should be considered as 'justified inertia' or 'investigator inertia', the idea that inertia may be present throughout the continuum of care gives physicians a holistic view of the problem that is easily applicable to their clinical practice. Measures to overcome inertia are complicated because of the intrinsic complexity of the concept.

Medical and lifestyle management of peripheral arterial disease

OBJECTIVE

Peripheral arterial disease (PAD) is a global health issue associated with impaired functional capacity and elevated risk of major adverse cardiovascular events (MACEs). With changing risk factor profiles and an aging population, the burden of disease is expected to increase. This review considers evidence for the noninvasive management of PAD and makes clinical recommendations accordingly.

METHODS

A comprehensive literature review was performed to examine the evidence for smoking cessation, exercise therapy, antiplatelet therapy, anticoagulant therapy, antihypertensive therapy, lipid-lowering therapy, and glycemic control in diabetes for patients with PAD.

RESULTS

Nicotine replacement, bupropion, and varenicline are safe and more effective than placebo in achieving smoking abstinence. Wherever it is practical and available, supervised exercise therapy is ideal treatment for intermittent claudication. Alternatively, step-monitored exercise can increase walking performance and the participant's compliance with less staff supervision. Clopidogrel is preferable to aspirin alone for all patients. However, small studies support the use of dual antiplatelet therapy after revascularization to improve limb outcomes. More recently, the addition of low-dose rivaroxaban to aspirin alone was proven to be more effective in reducing MACEs without a significant increase in major bleeding. However, the exact role of direct oral anticoagulant therapy in the management of PAD is still being understood. Evidence is emerging for more intensive blood pressure and lipid-lowering therapy than traditional targets. Whereas research in PAD is limited, there is clinical scope for an individualized approach to these risk factors. The management of diabetes remains challenging as glycemic control has not been demonstrated to improve macrovascular outcomes. Any potential impact of glycemic control on microvascular disease needs to be weighed against the risks of hypoglycemia. Sodium-glucose cotransporter 2 inhibitors appear to reduce MACEs, although caution is advised, given the increased incidence of lower limb amputation in clinical trials of canagliflozin.

CONCLUSIONS

Medical and lifestyle management of PAD should aim to improve functional outcomes and to reduce MACEs. Smoking cessation counseling or pharmacotherapy is recommended, although new strategies are needed. Whereas supervised exercise therapy is ideal, there can be barriers to clinical implementation. Other initiatives are being used as an alternative to walking-based supervised exercise therapy. More studies are required to investigate the role of intensive glycemic, blood pressure, and dyslipidemia control in patients with PAD. Overall, a multifactorial approach is recommended to alter the natural history of this condition.

How May Coexisting Frailty Influence Adherence to Treatment in Elderly Hypertensive Patients?

Background

Hypertension is considered to be the most common condition in the general population. It is the most important risk factor for premature deaths in the world. Treatment compliance at every stage is a condition for successful antihypertensive therapy, and improving the effectiveness of treatment is a major goal in preventing cardiovascular incidents. Treatment noncompliance and lack of cooperation stem from numerous problems of older age, including frailty syndrome.

Objective

To evaluate the effect of frailty syndrome on treatment compliance in older patients with hypertension.

Methods

The study sample consisted of 160 patients (91 women, 69 men) with hypertension aged 65 to 78 (mean = 72.09, SD = 7.98 years), hospitalized at the University Clinical Hospital due to exacerbation of disease symptoms. Standardised research tools were used: the Tilburg Frailty Indicator questionnaire and the questionnaire for the assessment of treatment compliance in patients with hypertension, the Hill-Bone Compliance to High Blood Pressure Therapy Scale.

Results

Frailty syndrome was diagnosed in 65.62% of patients: 35.62% with mild, 29.38% with moderate, and 0.62% with severe frailty. The treatment compliance was 36.14%. The prevalence of the FS and its three components (physical, psychological, social) significantly affected (p <0.05) the global score of the Hill-Bone Compliance to High Blood Pressure Therapy Scale and all subscales: “reduced sodium intake”, “appointment keeping”, and “antihypertensive medication taking”.

Conclusions

The coexistence of frailty syndrome has a negative impact on the compliance of older patients with hypertension. Diagnosis of frailty and of the associated difficulties in adhering to treatment may allow for targeting the older patients with a poorer prognosis and at risk of complications from untreated or undertreated hypertension and for planning interventions to improve hypertension control.

Hypertension Management at Older Age: An Update

Hypertension is a risk factor for cardiovascular morbidity and mortality with increasing prevalence with age, whose treatment is associated with benefits over fatal and non-fatal cardiovascular events even later in life. However, there are persistent concerns on the short- and long-term weighted benefits of treating hypertension in the very old, particularly in those with specific clinical features. In fact, a broad range of clinical scenarios can be observed at older ages, spanning from the healthy to the frailest patient, and hypertension clinical trials have traditionally excluded the latter, thus preventing the unconditioned application to these patients of the same recommendations as in younger ages. Persistent issues regarding high blood pressure management in the very old adult are mainly related to treatment threshold and targets, which have been differently addressed by American and European guidelines. Herein, we will examine the challenges related to high blood pressure treatment in healthy and frail older and very old adults. We will discuss the evidence behind current recommendations. Finally, we will recapitulate the recommended treatment options for high blood pressure in these patients in the light of the most recent guidelines.

Executive Summary of the 2018 Joint Consensus Document on Cardiovascular Disease Prevention in Italy

Cardiovascular diseases (CVDs) are the leading cause of death, disability and hospitalization in Italy. Primary prevention strategies are able to prevent clinically evident CVDs, mostly by early identifying asymptomatic, otherwise healthy individuals at risk of developing CVDs. A more modern approach recommended for effective CVD prevention is based on "4P", that is: Predictive, Preventive, Personalized and Participative. This executive document reflects the key points of a consensus paper on CV prevention in Italy, realized though the contribution of different Italian Scientific Societies and the National Research Council, and coordinated by the Italian Society of Cardiovascular Prevention (SIPREC), published in 2018. The need for such document relies on the difficulty to apply "sic et simpliciter" European guidelines, to which this document is largely inspired, to national, regional and local realities, in this Mediterranean country, namely Italy. Indeed, our Country has specific features in terms of demography, socio-cultural habits, distribution and prevalence of risk factors, organization, policy and access to National Health Service compared to other European countries.

Blood pressure management in older people: balancing the risks

Guidelines of arterial hypertension treatment based on individualised expected outcomes are not available for frail older persons. In this paper, we review the evidence, concerning management of arterial blood pressure (BP) in frail older patients. We focused on the best affordable methods for BP measurement; the age-related optimum BP; specific BP goals in agreement with the patients' general heath, frailty status, orthostatic and postprandial hypotension; balancing the benefits against risks of antihypertensive treatment. Lenient BP goals are generally recommended for older persons with moderate or severe frailty, multimorbidity and limited life expectancy. To this aim, there may be a need for deintensification of antihypertensive treatment.

Neuroimaging Signatures of Cerebral Small Vessel Disease at Blood Pressure Cutoff Levels of 130/80 and 140/90 mmHg: A Population-Based Study in Community-Dwellers Aged ≥ 60 Years

INTRODUCTION

Recent guidelines suggest that a blood pressure cutoff of 130/80 mmHg should be used to define arterial hypertension. This contrasts with the previously accepted cutoff of 140/90 mmHg.

AIM

Using the Atahualpa Project cohort, we aimed to assess the cutoff that better correlates with signatures of cerebral small vessel disease (SVD), which are related to arterial hypertension.

METHODS

Of 437 Atahualpa residents aged ≥ 60 years, 363 (83%) underwent brain MRI and blood pressure determinations. Using logistic regression models, we evaluated the association between SVD and the two different cutoffs, after adjusting for demographics and cardiovascular risk factors. Using receiver operator characteristics curve analysis, we calculated sensitivity, specificity, and the area under the curve for the predictive value of the two cutoffs for detecting signatures of SVD.

RESULTS

A comparison between the old and new cutoffs showed no differences in the ability to predict subjects with white matter hyperintensities, deep cerebral microbleeds or basal ganglia perivascular spaces. However, the new cutoff improved the identification of individuals with lacunar infarctions, which went from no association using the old cutoff (p = 0.097) to a significant association using the new cutoff (p = 0.036). The new cutoff was more sensitive but less specific than the old cutoff for identifying signatures of cerebral SVD. Areas under the curve were non-significantly higher for the old than for the new cutoffs for all the lesions of interest.

CONCLUSIONS

The new blood pressure cutoff is consistently more sensitive but less specific than the old cutoff for detecting signatures of cerebral SVD. The most striking effect of the new cutoff is the improvement in the identification of lacunar infarctions.

[Antihypertensive therapy in the elderly]

Arterial hypertension is the most common modifiable risk factor for cerebrovascular and cardiovascular morbidity and mortality in old age. The prevention of cognitive brain disorders is also a therapeutic goal of long-term treatment of hypertension. Older patients also have a higher risk of developing cardiovascular diseases and therefore benefit from a relatively moderate reduction in blood pressure. With respect to the high prevalence of hypertension in old age and the increasing incidence with time, the therapy of hypertension is becoming increasingly more important to achieve an improved prognosis for patients along with a reduction of costs. The accurate blood pressure measurement for elderly patients includes repeated measurements while standing and sitting. Additionally, the measurements should also be conducted by the patient or by a family member. The most accurate method for assessing the daily blood pressure level, e.g. practice hypertension, non-dipping and intermittent hypertension, is the 24-h blood pressure measurement by ambulatory blood pressure monitoring (ABPM). General measures and lifestyle interventions are effective for reducing blood pressure of elderly patients with hypertension and a low salt diet is scientifically proven to be superior. The same drugs used for young people are also recommended for older patients and most give preference to diuretics, renin-angiotensin-aldosterone system (RAAS) inhibitors and calcium antagonists. The target blood pressure in elderly patients is repeatedly the focus of scientific discussions. The current recommendations are presented in the text and the characteristics which must be particularly considered in the therapy of elderly patients are presented in detail.

Hypertension and Frailty Syndrome in Old Age: Current Perspectives

Hypertension is both a health problem and a financial one globally. It affects nearly 30 % of the general population. Elderly people, aged ≥65 years, are a special group of hypertensive patients. In this group, the overall prevalence of the disease reaches 60 %, rising to 70 % in those aged ≥80 years. In the elderly population, isolated systolic hypertension is quite common. High systolic blood pressure is associated with an increased risk of cardiovascular disease, cerebrovascular disease, peripheral artery disease, cognitive impairment and kidney disease. Considering the physiological changes resulting from ageing alongside multiple comorbidities, treatment of hypertension in elderly patients poses a significant challenge to treatment teams. Progressive disability with regard to the activities of daily life, more frequent hospitalisations and low quality of life are often seen in elderly patients. There is discussion in the literature regarding frailty syndrome associated with old age. Frailty is understood to involve decreased resistance to stressors, depleted adaptive and physiological reserves of a number of organs, endocrine dysregulation and immune dysfunction. The primary dilemma concerning frailty is whether it should only be defined on the basis of physical factors, or whether psychological and social factors should also be included. Proper nutrition and motor rehabilitation should be prioritised in care for frail patients. The risk of orthostatic hypotension is a significant issue in elderly patients. It results from an autonomic nervous system dysfunction and involves maladjustment of the cardiovascular system to sudden changes in the position of the body. Other significant issues in elderly patients include polypharmacy, increased risk of falls and cognitive impairment. Chronic diseases, including hypertension, deteriorate baroreceptor function and result in irreversible changes in cerebral and coronary circulation. Concurrent frailty or other components of geriatric syndrome in elderly patients are associated with a worse perception of health, an increased number of comorbidities and social isolation of the patient. It may also interfere with treatment adherence. Identifying causes of non-adherence to pharmaceutical treatment is a key factor in planning therapeutic interventions aimed at increasing control, preventing complications, and improving long-term outcomes and any adverse effects of treatment. Diagnosis of frailty and awareness of the associated difficulties in adhering to treatment may allow targeting of those elderly patients who have a poorer prognosis or may be at risk of complications from untreated or undertreated hypertension, and for the planning of interventions to improve hypertension control.