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COMMENTARY |
Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee.
My wife's grandmother Rose is 87, has hypertension, osteoporosis, and Parkinson's disease, and is sharp as a tack. She is on medications for all 3 conditions, as is currently the standard of care, and is apparently well controlled. It has come into question whether hypertension in the very old should be treated, or whether it would be healthier for Rose to allow her blood pressure to take its natural course without medical intervention. Would I, both as her grandson-in-law and as a physician, feel comfortable if her pressure were allowed to run at 200/100?
In his article titled, "Embracing Complexity: A Consideration of Hypertension in the Very Old" (1), Dr. James S. Goodwin challenges the established notion supported in 2 recent publications, "Age-Related Bias in the Management of Hypertension"(2) and its accompanying editorial "What is the Appropriate Treatment of Hypertension in Elders" (3). These 2 works contend that elevated blood pressure must be treated in all adults, regardless of age, in an effort to limit the associated comorbidities and mortality associated with uncontrolled hypertension. Both articles cite the preponderance of evidence that shows a reduction in stroke, congestive heart failure, and cardiovascular events with treatment of hypertension. Indeed, it is currently considered the standard of care to treat hypertension at all ages. Dr. Goodwin's position is that there is sufficient evidence in current studies [notably the recent works of Mattila (4), Hakala (5), and Bushvizen (6), among others] to suggest an inverse relationship between control of systolic blood pressure and survival in the age demographic above 85 years. It is also notable that such a relationship declines in consistency with younger subjects (i.e., age 75 years or younger), and that more standard models of hypertension directly relating to mortality and morbidity come into play (15).
There can be little argument, given the extensive amount of research, that treatment of hypertension in adults decreases mortality. However, when taken to the extremes of age, it is not unreasonable that axioms pioneered on healthier and younger patients may no longer be valid. As can be noted in physics and thermodynamics, the properties of matter increasingly vary from established models the closer one comes to absolute zero, so it could be that in medicine, the models of hypertension and physiologic response may vary the older the subject becomes. Given the tremendous changes that occur in physiology with aging, many of which impact the basic components of blood pressure, it is not unreasonable to question whether or not the definition of hypertension in an older individual may differ from that in a younger person, or even whether elevated blood pressure in the extremes of age is physiologic rather than pathologic. As with any process there comes a point or limit when physiology turns into pathology. The challenge confronting medicine and geriatrics is to define that point for this particular cohort.
There are multiple well-documented changes in the cardiac, vascular, renal, and neuroendocrine systems that impact hypertension. Whether such changes as increasing arterial stiffness in elderly persons (7), changes in cardiac output through increased systolic loads, increased impedance to systolic ejection, lower cardiac perfusion pressures, or decreased betasympathetic response (8) play a role in the inverse association of mortality and blood pressure is uncertain. Likewise, it is necessary to look not only at overall mortality but also at morbidity and end-organ damage to determine whether classically defined hypertension (9) is pathologic or physiologic. The end-point of death in this cohort has enough confounding variables that it may not be a valid marker when taken in isolation, nor can one discount the cumulative impact of 75 or more years of life and variable health status in making a judgment. Markers such as cognitive decline (10), creatinine and urine protein excretion (11), stroke (12), and cardiac function (7,8) may be better suited to offer more quantifiable endpoints.
History and research have shown that not all groups are physiologically equal. As was the case when children were determined to be physiologically more than just little adults, and when women were found to be more than just anatomically different from men, it will come to pass that we will find elderly people as more than just wrinkled adults, and those over 85 will need to be evaluated separately from those over 75, who in turn will need to be evaluated separately from those over 65 or 55. Similarly, elderly women and men will need to be evaluated separately. The fact that elderly women seem to not share the survival benefit of hypertension found in men underscores their physiologic differences (1).
I ultimately agree with Dr. Goodwin's assertion that further research devoted to this cohort is necessary. Given the goal of improving quality of life and not just duration, a balance must be found between morbidity and mortality. The issues raised cannot be considered in isolation: extrapolation is perilous. For my part, and given what we now know, I would not let Grandma Rose run high.
Acknowledgments
Special thanks go to Hosam Kamel, MD, David Schiedermayer, MD, and Kathryn M. Denson, MD.
Address all correspondence and reprint requests to Steven Denson, MD, Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin, Milwaukee, WI. 53226. Phone: (414) 456-6877; fax (414) 456-6212; e-mail: sdenson{at}mail.mcw.edu
REFERENCES
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