Hitting a wall when trying to control hypertension in my geriatric patients is common. Many of these individuals are taking five classes of medications, so contraindications can be a problem. Maximizing doses statistically does not help that much, as this increases the risk of worrisome side effects. How good is “good enough”? My facility guidelines require BP <140/90 mm Hg in patients younger than age 75 years. — Jolene Wolf, RN, MSN, FNP, Jonesboro, Ark.

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Randomized trials have provided evidence of the benefit of treating hypertension in elderly patients, including those older than age 80 years. Treating systolic BP (SBP) and diastolic BP (DBP) to targets that are <140/90 is associated with a decrease in cardiovascular disease complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg. In general, three classes of drugs are considered first-line therapy for the treatment of hypertension in elderly patients: low-dose thiazide diuretics (e.g., 12.5-25mg/day of chlorthalidone [Hydone Tablet, Hygroton, Thalitone]), long-acting calcium channel blockers (e.g., dihydropyridine) and ACE inhibitors or angiotension II receptor blockers.

Lifestyle changes should be at the cornerstone of BP control. For overweight patients, a 10-kg weight loss can lead to an average drop in SBP of 6 mm Hg and DBP decrease of around 5 mm Hg. Restricting dietary sodium intake to 2.4 g/day can reduce SBP by 2 mm Hg to 8 mm Hg. Increasing physical activity can led to a 4- to 9-mm Hg decrease in SBP. Limiting alcohol intake to no more than two drinks a day for men and no more than one drink daily for women can reduce BP 2 to 4 mm Hg. Finally, encourage a diet high in fiber and low in fat to further reduce BP. The Dietary Approaches to Stop Hypertension (DASH) diet is a good place to start.

Concomitant use of medications can also affect BP control, including the use of stimulants, oral contraceptives, cyclosporine (Gengraf, Neoral, Sandimmune, Sangcya), erythropoietin (Epogen, Procrit), and corticosteroids. Such OTC medications as decongestants, weight-loss agents, nonsteroidal anti-inflammatory drugs, and herbal supplements (i.e., ephedra and ma huang) can contribute to elevated BP. Use of cocaine, amphetamines, and other illicit drugs can also contribute to poor BP control.

Consider such secondary causes of hypertension as obstructive sleep apnea, primary aldosteronism, renal artery stenosis, hyperparathyroidism, Cushing disease, pheochromocytoma, chronic kidney disease, and coarctation of the aorta.

The American Heart Association advises that it may benefit patients to split up antihypertensive medications and not take them at the same time. Have patients take at least one of their BP pills at night, which may lead to better 24-hour BP control. Remember the patient is the center of care. It is always important to be certain that the patient is actually taking what you have prescribed. Side effects to medications and lack of understanding can also contribute to adherence issues and inadequately controlled BP. – Deborah L. Cross, MPH, CRNP, ANP-BC (170-3)