CPD: Managing hypertension in older people

Frailty nurse specialist Linda Nazarko advises on what nurses in general practice need to be aware of when reviewing and optimising management of older patients with hypertension. Complete the full module on Nursing in Practice 365 today.

Hypertension has been described as ‘the silent killer’, being responsible for around 75,000 deaths every year in the UK yet rarely associated with any symptoms and often undetected. It is thought to cause more than half of all strokes and heart attacks and also increases the risk of kidney disease, heart failure and vascular dementia.¹

The risk of hypertension increases with age due to the stiffening of the artery walls. As a consequence, hypertension is much more common in older people; while 35% of people aged 45-64 have hypertension the figure rises to 60% of people aged 65 and over.²

However, hypertension has to be managed carefully in older and frail people. It is important for nurses working in primary care to be up to date with guidelines on hypertension management and be aware of the specific considerations in older people, including the appropriate treatment and monitoring approaches in older age groups.

Older people are also particularly vulnerable to adverse effects from antihypertensive and other medications, so nurses need to be able to identify these and tailor treatment accordingly.

Learning objectives

By the end of this module, you will have a greater understanding of:

How hypertension affects older people.
How treatment targets should be modified in older people.
Recommended antihypertensive medications and their side effects.
Monitoring, reviewing and optimising treatment in older people.
How to explore nonadherence and other reasons for uncontrolled BP in older people.

How hypertension is diagnosed

Hypertension is generally defined as persistently raised arterial blood pressure (BP) and according to NICE is diagnosed by a sustained rise in BP above 140/90mmHg and either a subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average of 135/85 mmHg or higher.³

A raised clinic BP reading should always be followed up with ABPM – or HBPM, if ABPM is unsuitable or the person is unable to tolerate it – to confirm a diagnosis of hypertension.

A diagnosis of hypertension is staged as follows:

Stage 1 hypertension

Clinic BP ranging from 140/90mmHg to 159/99mmHg and subsequent ABPM daytime average or HBPM average BP ranging from 135/85mmHg to 149/94mmHg.

Stage 2 hypertension

Clinic BP of 160/100mmHg or higher but less than 180/120mmHg and subsequent ABPM daytime average or HBPM average BP of 150/95mmHg or higher.

Stage 3 or severe hypertension

Clinic systolic BP of 180mmHg or higher or clinic diastolic BP of 120mmHg or higher.

(Note that if Stage 3 hypertension is identified, the person will require urgent assessment by the GP or a specialist.)³

When should hypertension be treated in older people?

NICE recommends lifestyle changes in anyone with stage 1 hypertension.³

People with stage 1 hypertension and certain comorbidities or increased cardiovascular disease (CVD) risk should also be offered antihypertensive treatment. However, for people aged 80 or over, this is usually only recommended if their clinic BP is above 150/90mmHg. (See box 2 below.)

Blood pressure targets for people over the age of 80 are generally higher than for younger people. This is mainly because older people are at increased risk of postural hypotension, which is exacerbated by tighter BP control to a lower target, thereby increasing their risk of falls and thus fractures. Fractures can have life changing and even catastrophic consequences in older people.

To complete the full module worth 1.5 CPD points visit Nursing in Practice 365

Related Article: CPD: Managing hypertension in older people

Linda Nazarko is a frailty specialist nurse based in London

References