Hypertension and Stroke in older people

OLDER PEOPLE WITH HYPERTENSION
AND STROKE
Issues and challenges of chronic illnesses
and disabilities, Family support
Dr. Prabhjot Saini MSN PhD
Professor & Head, Medical Surgical Nursing Dept.
Research Coordinator, DMCH College of Nursing
Ludhiana, Punjab

Older people with Hypertension and
Stroke
 Introduction
 What is hypertension?
 Epidemeology
 Pathophysiology of HTN in elderly
 Diagnosis of Hypertension: Any Difference for the
Elderly?
 Treatment Considerations for the HTN in elderly?
 Should very old people be treated for HTN
 Differential diagnosis of HTN
 Benefits of Treatment & Which drug to choose?
 Issues & challenges among elderly stroke patients

Aging is an inevitable part of life & brings
along physiologic decline & disease
state …….
Introduction

Introduction
 High prevalence of hypertension in older persons
(nearly one of two subjects aged >60 years)
 It is a significant and often asymptomatic chronic
disease.
 HTN is a major cause of morbidity and mortality
among aged.
 The recognition and treatment of HTN should be a
priority among elderly
 Controlled, RCTs have shown that treatment of
hypertension decreases the incidence of
complications in older adults.

HTN among Elderly: Is it different?
 Hypertension in the elderly patients represents a
management dilemma among specialists and
practioners.
 Furthermore a difficult question arises about how
aggressive elderly patients should be treated.
“Is hypertension
in the elderly an
emergency state
or not?”
Does BP control
lowers risk of
CVD & death in
elderly?’’,
“What are the
general principles of
HTN management in
elderly?’’

Does the definition change with
ageing?
Is presentation of HTN in elderly
different from adults?
What is Hypertension?

What is Hypertension in elderly?
 The definition of hypertension does not change with age
 Both SBP and DBP should be used for the
classification of hypertension (JNCVI and the
WHO/International Society of Hypertension guidelines)
 Hypertension in older adults is generally defined by SBP
≥ 140 mmHg or DBP ≥ 90 mmHg over two clinic
visits (systolodiastolic HTN)
 Isolated systolic hypertension (ISH): SBP of ≥140
with a DBP of <90 mm Hg.

White Coat HTN
 BP recording in clinic is
high while at home is not.
 White coat HTN appears to
have no greater risk than
people with normal BP
(American College of Cardiology, 2012)

Masked HTN
 HTN is not detected by the routine methods
“undetected ambulatory HTN”
 Unusually high ambulatory pressure or a
low clinic pressure on that particular
occasion.
 Shows more extensive target organ damage
than true normotensive subjects

Epidemiology of HTN among
Elderly

Epidemiology of HTN among elderly
 After the age of 69, the prevalence of hypertension
rises to 50%
 An ambulatory population aged 65 to 74, the overall
prevalence was 49.6% for stage 1 hypertension, 18.2%
for stage 2 and 6.5% for stage 3 hypertension.
(1988–1991,National Health and Nutrition Examination
Survey)
 Both SBP and DBP are higher in blacks than in whites ,
and in women than in men after the age of 30.
 Between the fifth and the sixth decade of life, the
prevalence of hypertension is higher in women (40%–
50%) than in men (30%–40%).

Isolated Systolic HTN among
elderly
 Isolated systolic hypertension (ISH): SBP of ≥140
with a DBP of <90 mm Hg.
 In the Framingham study, ISH accounted for 57% of
cases of hypertension in men and for 2/3rd in women
between the ages of 65 and 89.
 The Systolic Hypertension in the Elderly Program
(SHEP) study found that the prevalence of ISH
increased from about 8% among subjects in their
60s to 22% by the age of 80

Why Blood Pressure Matters?
 High blood pressure increases risk for
dangerous health conditions:
 First heart attack: About 7 of every 10 people
having their first heart attack have high blood
pressure.
 First stroke: About 8 of every 10 people having their
first stroke have high blood pressure.
 Chronic heart failure: About 7 of every 10 people
with chronic heart failure have high blood pressure.
 Kidney disease is also a major risk factor for high
blood pressure.


Normal BP regulation
 BP is determined by the rate of cardiac
output and the SVR to blood flow.
 BP is regulated via several physiological
mechanisms to ensure an adequate tissue
blood flow such as:
 ANS
 Capillary fluid shift
 Hormonal : Adrenalin/Nor Adrenalin, RAS,
Aldosterone
 Kidney

Patho physiology of HTN among
elderly

Patho physiology of HTN among
elderly
 Arterial stiffness
 Neurohormonal and autonomic dysregulation
 Aging Kidney

Pathophysiology of HTN among
elderly
Arterial stiffness
 Elastic arteries show 2 major physical changes with age:
dilate and stiffen.
 Stiff artery has decreased capacitance and limited recoil.
 Furthermore, during systole the arteriosclerotic arterial
vessel exhibits limited expansion and fails to buffer
effectively the pressures generated by the heart causing
an increase in systolic BP (SBP).
 On the other hand, the loss of recoil during diastole
results in reduction in diastolic BP (DBP)
 Thus, aging even in normotensive individuals is
characterized by an increase pulse pressure.

Pathophysiology of HTN among
elderly
Neurohormonal mechanisms
 RAAS declines due to age-associated nephrosclerosis on the
juxtaglomerular apparatus.
 Plasma aldosterone levels also decreases with age. Elderly
patients with hypertension are more prone to drug-induced
hyperkalemia.
Autonomic dysregulation
 Sympathetic nervous system activity increases with advancing
age.
 Decreased baroreflex sensitivity with age causes orthostatic
hypotension in the elderly.

The aging kidney
 There is progressive development of
glomerulosclerosis and interstitial fibrosis, causes
decline in GFR and homeostatic mechanisms.
 Age-associated decline in sodium/potassium and
calcium ATP pumps lead to excess intracellular
calcium and sodium, thereby increase of
vasoconstriction and vascular resistance.
 Increased salt sensitivity leads to sodium overload in
older and obese subjects

No recoil during
relaxation
Decrease diastolic
BP
Ageing
Stiffened aorta and blood vessels (loss
of visco-elastic properties of B/V
Inc. atherosclerotic arterial disease
Hypertrophy & sclerosis of muscular
arteries & arterioles
Loss of recoil of b/v
Promotes earlier return of reflected
waves from arterial circulation
Amplifies Systolic pressure wave
generated with each wave
Inc systolic BP
Pathophysiology of HTN
among elderly
Increased pulse
pressure

Diagnosis of Hypertension: Any
Difference for the Elderly?

 The age-associated increase in large artery stiffness is
the major determinant of hypertension in the older adult
 Increased pulse wave velocity and large artery stiffness
produce a widened pulse pressure, resulting in isolated
systolic hypertension (ISH).
 Thus, pulse pressure should be considered in the
risk assessment of the older adult, than elevated SBP
or DBP alone.

How to calculate BP in
elderly
 The diagnosis of hypertension requires repeated and careful
measurement of BP in office setting with correct posture and
positioning.
 The patient should be seated comfortably for 5 minutes with
his or her back well supported and the arm supported at the
level of the heart before the first BP is taken.
 The patient's feet should touch the floor and legs should
not be crossed.
 The patient should not have smoked or ingested any
caffeine within 30 min prior to the BP determinations.

 BP should be measured with an appropriate sized cuff, with
an automated oscillometric device to minimize observer
bias.
 Wait for 5 min before the first BP is taken
 BP and HR should be measured 3 times at 1 min intervals
and the 3 readings be averaged.
 Measure both seated and standing BPs to avoid
overtreatment and orthostatic hypotension.
 It is also important to measure BP in both arms on the initial
assessment (Because of the presence of subclavian stenosis)

Home based check on BP
 Alternatively, checking BP at home can be
done with a clinic-calibrated arm cuff
 Masked hypertension must always be
considered, and in addition to home and office
BP measurements, 24-hour ambulatory BP
monitoring may be helpful in selected
patients.

Treatment Considerations for the
elderly?

Management
 Primary Goal is to reduce cardiovascular,
cerebrovascular and renal morbidity and mortality
 Other keys to management are:
 Prevention
 Patient education
 Lifestyle modification
 Medication
 Home based care

Hospitalization should be
considered if :
 Very high BP
 Severe head ache
 Chest pain
 Neurologic symptoms
 Altered mental status
 Acutely worsening renal failure
 S & S of hypertensive emergency

Goals to achieve with medical
management:
 Specific target recommendations differ, generally reducing
the SBP below 150 mm Hg in relatively fit elderly patients
(JNC 8 and 2013 ESC/ESH guidelines)
 Both guideline groups agree that in the setting of diabetes or
chronic kidney disease (CKD) the target should be less than
140 mm Hg.
 For frail patients treatment targets may need to be
individualized.
 Reducing BP by an average of 20 mm Hg is a reasonable
alternative.

Medicine can control blood pressure, but it can’t
cure it.
Do lifestyle measure actually
work?

Lifestyle modification: does it
work??
 Lifestyle therapy for hypertension is a
mainstay in the treatment of all hypertensive
individuals.
 It requires risk factor modification starting early
in the life span, including exercise, avoiding
smoking, and dietary modifications.

Lifestyle modification
 Keep a healthy weight
 Exercise every day
 Eat a healthy diet
 Cut down on salt
 Drink less alcohol
 Don’t smoke
 Get a good night’s sleep

Lifestyle modification
 "Exercise is essential, weight control is essential.
Eating a low-salt diet is quite important."
 National guidelines recommend at least 30 minutes of
exercise each day.
 For seniors, exercise can involve simple changes to
everyday routine, like walking more often and
engaging in household chores.
 Healthy nutrition is important for all of the standard
reasons with low salt and DASH diet

Dietary changes
Healthy nutrition is important for all of the standard
reasons .
 A low salt diet is particularly important for lowering
blood pressure
 The DASH diet (Dietary Approaches to Stop
Hypertension) –a low-sodium, low-fat diet that
emphasizes fruits, vegetables, reduces blood
pressure by an average of 11 systolic points
and 6 diastolic points.
 Under the DASH diet, an individual is advised to eat
no more than one-quarter teaspoon of salt per
day.

When lifestyle measures fail to lower BP to
goal, pharmacotherapy should be initiated.
Which drug to choose?

Pharmacological
management
 It is effective in preventing total mortality, stroke
and coronary events among elderly
 The initial antihypertensive drug should be started
at the lowest dose and gradually increased
depending on the BP response to the maximum
tolerated dose.
 The older adult may suffer from resistant
hypertension despite treatment
 Reassessment of subclinical organ damage
during treatment is also crucial.

Pharmacological therapy
 Antihypertensive drug therapy reduces the
development of new coronary events, stroke, and
CHF in older persons.
 Therapy with antihypertensive drugs reduces the
incidence of all strokes by 36% in older persons,
and by 34% in persons older than 80 years.
 Despite treatment with antihypertensive therapy, only
54.1% of US adults achieve BP control

When starting
antihypertensives..
 When it is time to initiate medical therapy, consideration
should be given to the following variables:
 the frailty of the patient,
 their ability to follow instructions,
 the complexity of their current medication regimen,
 supporting care (i.e., spouses and family)
 Carefully review the patient's medication list and stop or
reduce NSAIDs and decongestants
 Reviewing the patient's electrolytes and renal function prior to
initiation of therapy is prudent.
 Antihypertensive doses should start low, and BP should be
lowered gradually.

Classification: Anti hypertensive
agents
 Thiazide diuretics (HCTZ)
 Beta Blockers
 Angiotensin-converting Enzyme (ACE) Inhibitors
 Calcium channel blockers
 Angiotensin receptor blockers (ARB’s)

ADVERSE EFFECTS OF
ANTIHYPERTENSIVE DRUG THERAPY
 All antihypertensive drugs may predispose elderly persons to
develop symptomatic orthostatic hypotension and this may result
in falls or syncope.
 Diuretics may cause volume depletion. ACE inhibitors, ARBs,
calcium channel blockers, nitrates, hydralazine, and prazosin may
cause a reduction in SVR and venous dilation.
 Beta blockers, verapamil and diltiazem depress the sinus node
and the atrioventricular (AV) node and are contraindicated in
patients with severe sinus bradycardia, sinoatrial disease, and
marked first-, second-, and third-degree AV block.
 Beta blockers should not be given to bronchial asthma or to those
with lung disease and severe bronchospasm.
 Short-acting dihydropyridine CCB, such as nifedipine, have the
potential to increase cardiovascular events and should be avoided.

Stop, Look & listen
 Monitor BP frequently after therapy is initiated
 Include home measurements in decision making.
 In follow-up, ask questions about low tissue perfusion,
orthostasis, and falls.
 Target an initial SBP below 150 mm Hg, and a DBP
below 90 mm Hg.
 For patients with diabetes, IHD without diabetes, fit
patients or CKD, the goal SBP is <140 mm Hg.

Improving control among
elderly
 Improve relationship with patient
 Provide treatment and follow up within context
of patient’s cultural beliefs
 Agree on BP goal
 Once daily medications ideal for elderly
patients
 Use combination therapy and low cost
medications
 Focus on widespread and cost effective care

Ideal Home Care for elderly
hypertension:
 Achieve Changes in Patient Diet
 Verify understanding and adherence to lifestyle
changes
 Medication Adherence: Research suggests that
home visits are the most effective way to
eliminate medication non-adherence and uncover
medication discrepancies

 Observation & Assessment: Nurses can
do periodic skilled observation and
assessment for three weeks or more.

 Exercise & Home Activity Consultation: Physical
therapists can guide patients in choosing activities
and/or exercises appropriate for their physical condition
 Promoting self management: A home BP monitor, a
BP log, and recommendations to record BP regularly
and share the results with their home care nurse.

 Augmented counselling sessions: A “HTN
support” nurse and health educator can
strengthen self-management skills, adhere to
recommended medication and behavioral
regimens, and communicate more effectively
with their doctors.
 There can be subsequent biweekly phone
counseling sessions.

If left untreated,????
 Hypertension is known as the silent killer.
 However, people with chronically high blood
pressure have a much higher rate of heart
attack, stroke, chronic kidney disease, heart
failure, cardiac arrhythmia, cognitive
impairment, and premature death.
 These risks are particularly prevalent with
significantly elevated pressures ≥160/100
mmHg.

Stroke and hypertension in
elderly
 Hypertension is the single most important risk
factor for stroke.
 It causes about 50 per cent of ischemic strokes and
also increases the risk of hemorrhagic stroke
 Stroke is prevalent in elderly individuals, with 66% of
hospitalized cases being people over the age of 65.
 Many stroke survivors are able to recover functional
independence over time, but 25% are left with a
minor disability and 40% experience moderate-to-
severe disabilities.

Stroke and elderly:
challenges
 Second leading cause of hospital admissions
 30 days re-admissions rate high
 Medicare costs
 Need for enhances nursing care
 Serious issue for elderly
 Transitional care needed

Facts about stroke
 Strokes can be prevented 80% of the time.
 Stroke is the fifth leading cause of death in the US,
 Kills more than 130,000 each year—that’s 1 of every 20
deaths.
 Someone in the US has a stroke every 40 seconds.
Every four minutes, someone dies of stroke.
 Stroke is an important cause of disability.
 Stroke reduces mobility in more than half of stroke
survivors age 65 and over.

Knowing the Warning Signs and Symptoms
of stroke
 Remember the acronym F.A.S.T
 F(ace) – Have the person attempt to smile. If one side
of the face does not move as well as the other, it is a
sign of stroke.
 A(rms) – Have the person attempt to raise both of
their arms. Notice if one of their arms doesn’t move as
high as the other.
 S(peech) – Give the person a sentence that they can
repeat. Check if there are any slurred words.
 T(ime) –Act quickly and ensure elderly receives
immediate treatment, it can help save the life of the
stroke victim.

Signs of Stroke Symptoms
Men vs Women
 Women have different stroke symptoms
 60% of women will die from stroke compared to 40%
of men.
 Stroke kills up to twice as many women per year as
breast cancer.
 Signs of stroke as experienced by women:
 Sudden hiccups.
 Sudden nausea.
 Sudden general weakness.
 Sudden chest pain.
 Sudden shortness of breath.
 Sudden palpitations.

Types of Stroke in Elderly Patients
 Stroke - blood flow to brain obstructed
- Lack of oxygen in brain
Classification
Ischemic Stroke
 Embolic
 Thrombolic
Hemorrhagic Stroke
 Intracerebral haemorrhage
 Subarachnoid haemorrhage

Transient ischemic attack (TIA)
 Also known as mini stroke — is a brief period of
symptoms similar to a stroke.
 A temporary decrease in blood supply to part of brain
causes TIAs, which often last less than five
minutes.
 Having a TIA puts elderly at greater risk of having a
full-blown stroke, causing permanent damage later.
 Up to half of people whose symptoms appear to go
away actually have had a stroke causing brain
damage.

Medical risk factors
 High blood pressure
 Cigarette smoking or exposure to secondhand smoke.
 High cholesterol.
 Diabetes.
 Obstructive sleep apnea
 Cardiovascular disease, including heart failure, heart defects, heart
infection or abnormal heart rhythm.
 Personal or family history of stroke, heart attack or transient
ischemic attack.
 Being age 55 or older.
 Race — African-Americans have a higher risk of stroke
 Gender — Men have a higher risk of stroke than women. Women
are usually older when they have strokes, and they're more likely to
die of strokes than are men.

Complications of stroke
 A stroke can sometimes cause temporary or
permanent disabilities, depending on how long the
brain lacks blood flow and which part was
affected. Complications may include:
 Paralysis or loss of muscle movement.
 Difficulty talking or swallowing.
 Memory loss or thinking difficulties.
 Emotional problems.
 Pain.
 Changes in behavior and self-care ability.

Prognosis of stroke among
elderly

Prognosis
 An Ischemic stroke has a much higher rate of
survival when compared to hemorrhagic stroke.
 Hemorrhagic stroke survivors have a much
higher rate of regaining normal functions.
 25% of stroke victims have some small measure of
disability with 40% left with moderate-to-
extensive disability.
 These complications can affect simple, everyday
functions such as eating, dressing, walking or
standing up and aphasia.

Surviving a stroke is a life-changing
experience….
Stroke and elderly: Road to
recovery

Stroke Victims on the Road to Recovery
 Healthy eating and exercise are a great way
to help strengthen the body.
 Alcohol and nicotine should be avoided
 Rehabilitation options can help stroke
patients recover
Recovering from a stroke is something that
takes a lifetime….

Rehabilitation of elderly with
stroke
 Rehabilitation options can help stroke patients
recover:
 For patients having trouble with movement and
motor skills, physical therapists can help
strengthen balance, coordination, and
movement functions.
 Speech therapists can work with patients to help
restore typical speech patterns.
 Occupational therapists can help patients
relearn basic life skills that they may have lost.

Planning for Stroke Recovery at
Home
 Post-stroke care for the elderly includes many
important aspects.
 A caregiver can make sure that they take
medications and follow up
 Visit neurologist at least once every six weeks
following a stroke
 Maintain therapy schedule: Therapy should be
started immediately

Elderly stroke recovery starts with the right
care
Essential things to keep elderly safe and
moving forward during recovery from a stroke:
 Assistance with meals
 Maintaining hydration
 Dressing
 Personal hygiene
 Toileting
 Exercise
 Communication

Knowing the needs of a stroke
survivor
 Stroke can affect elderly in ways. They
may need a lot more help
 Depending on the severity elderly may have
difficulty talking, walking and moving their
limbs, eating and swallowing, paying
attention and thinking, and even seeing
and hearing.
 It’s important to understand there needs.
 It’s also important to teach the caregivers
how much they can influence stroke care.

Stroke Recovery
 Recovery is an ongoing process, It requires
 Hourly assistance to around-the-clock care
 Companionship, calming anxiety, stress and
depression
 Coordination and scheduling with therapists and
specialists
 Medication reminders for treatment and prevention
 Fall and injury prevention
 Change in condition alerts
 Transportation and scheduling of doctors’
appointments
 Assistance with bathing, dressing and personal care

Steps towards Prevention
 Take steps toward prevention:
 Cutting down on cholesterol and sugar, managing
blood pressure and weight, eating well, being
active, and quitting smoking are all ways to
reduce the risk.
 Taking immediate action
 Recognizing the signs of a stroke is the best
way to treat a stroke immediately and limit the
damage.
 Depending on the severity of the stroke,
individual may require home based care

Summary
 Incidence of Hypertension and stroke increases with
advancing age
 Both require active prevention strategies and recognizing
warning signs.
 Diagnosis and treatment is more challenging in elderly
compare to the young.
 Lifestyle and diet modification is the key to prevention
 Maintain SBP target should below 140mmHg.
 An ideal home based care can help to achieve target BP
goals among elderly
 Stroke survivors need an active home based care and
assistance

Hypertension and Stroke in older people

Hypertension and Stroke in older people

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