H E YPERTENSION IN THE LDERLY C H LINICAL YPERTENSION V D AND ASCULAR ISEASES WILLIAM B. WHITE, MD SERIES EDITOR Hypertension in the Elderly, edited by L. Michael Prisant, MD, 2005 Lower Extremity Arterial Disease, edited by Dennis G. Caralis, MD, PhD, MPH, and George L. Bakris, MD, 2005 Secondary Hypertension:Clinical Presentation, Diagnosis, and Treatment, edited by George A. Mansoor, MD, 2004 Pediatric Hypertension, edited by Ronald J. Portman, MD, Jonathan M. Sorof, MD, and Julie R. Ingelfinger, MD, 2004 H YPERTENSION E IN THE LDERLY Edited by L. M P , ICHAEL RISANT MD Medical College of Georgia, Augusta, GA © 2005 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699; Fax: 973-256-8341; E-mail: [email protected]; or visit our Website: www.humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All articles, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regu- lations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recom- mended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. Production Editor: Robin B. Weisberg Cover design by Patricia F. Cleary This publication is printed on acid-free paper. ∞ ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials. Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc., provided that the base fee of US $30.00 per copy is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for users of the Transactional Reporting Service is: [1-58829- 197-9/05 $30.00]. Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 eISBN: 1-59259-911-7 Library of Congress Cataloging-in-Publication Data Hypertension in the elderly / edited by Michael L. Prisant. p. ; cm. -- (Clinical hypertension and vascular diseases) Includes bibliographical references and index. ISBN 1-58829-197-9 (alk. paper) 1. Hypertension in old age. [DNLM: 1. Hypertension--drug therapy--Aged. 2. Hypertension--etiology--Aged. 3. Antihypertensive Agents--therapeutic use--Aged. 4. Clinical Trials--Aged. WG 340 H99517 2005] I. Prisant, Michael L. II. Series. RC685.H8H7872 2005 618.97'6132--dc22 2004019019 D EDICATION With love to my wife, Rose Corinth Trincher, MD v A CKNOWLEDGMENT Without my mentor, Dr. Albert A. Carr, there would be no book, research, publications, teaching skills, or cognitive patient care. I was fortunate to have him as my friend and teacher. vi I M N EMORIAM In memory of Dr. Ray W. Gifford, 1923–2004 Dr. Gifford was the former chairman of the Department of Hyperten- sion and Renal Disease at The Cleveland Clinic and a renowned clini- cian, pioneering researcher, leader of medical professional societies, and internationally recognized expert on the nature and treatment of hypertension, nephrology, and cardiovascular disease. As a researcher, Dr. Gifford investigated the causes and treatments of hypertension. As chairman and a member of the Joint National Committee on Detection, Evaluation and Treatment of Hypertension, he coordinated and pro- duced standards for medical professionals across America in the diagno- sis and treatment of hypertension and related disorders. While Dr. Gifford was chairman of Hypertension and Renal Disease, he linked the Clinic’s strong research programs in the humoral, hemo- dynamic, and neurologic aspects of hypertension, with clinical programs that focused on treatment options and their benefits, as well as patient and physician education. The author of more than 460 scientific papers, and the textbook Pheochromocytoma (with William M. Manger, MD), Dr. Gifford performed long-term studies of patients with hypertension, evaluated medications and surgical treatments for hypertension, con- tributed to knowledge of arteriosclerosis and aneurysms, Raynaud’s dis- vii viii In Memoriam ease, renal artery disease, renal transplantation, the effect of hyperten- sion on the extremities, and the effects of dietary sodium, among many other subjects. Dr. Gifford enjoyed great rapport with his patients and was beloved by a large and loyal practice. Although he attempted to retire from the Clinic in 1993, strong demand from his patients brought him back to active practice until 1999. His influence on the discipline of hyperten- sion will be felt for many years. He will missed by his family and colleagues. S E ’ I ERIES DITOR S NTRODUCTION The importance of treating hypertension in the elderly has been greatly appreciated by physicians and scientists since the results of the Medical Research Council studies of the 1970s and the isolated systolic hyperten- sion trials SHEP and Syst-Eur that followed in the 1980s and 1990s. Despite this appreciation of the severity of the complications of this common disorder during advancing age, treatment rates to control blood pressure in elderly patients with hypertension have been quite low. Dr. Prisant’s volume on Hypertension in the Elderly is therefore a most clinically relevant contribution in the area of management of hyperten- sion in older people. This book brings together the basic pathophysi- ological, epidemiological, diagnostic, and therapeutic advances in the evaluation of high blood pressure in this population. The editor, Dr. Prisant, has astutely organized this volume into sec- tions that cover age-related changes in the cardiovascular system includ- ing the development of reductions in arterial compliance, overviews of the epidemiology of hypertension in the older patient, clinical evaluation that covers a variety of topics such as blood pressure measurement and hypertensive complications characteristic of the older patient, and nonpharmacological and pharmacological approaches to the treatment of hypertension in the elderly. Substantial coverage has been appropriately given to the impact of pharmacological treatments based on clinical trials in the elderly in Chapters 15 through 20. There are also a few chapters devoted to special patient populations that highlight problems of particular concern in older patients, including cerebrovascular disease, diabetes mellitus, heart fail- ure, and chronic arthritis. These sections contribute to the novelty of this book because they are grounded in clinical investigations that have led to enhanced understanding of the management of hypertension during advancing age. The complications of hypertension in older patients are complex, clinically challenging, and have led to much improved thera- pies targeted towards disease regression or prevention, as outlined in Chapters 12–14, and 22. The chapters in Hypertension in the Elderly have been written by a number of well-known, expert authors who have provided comprehen- sive, scientifically sound, and clinically appropriate information. As series editor of Clinical Hypertension and Vascular Diseases, I am pleased by the publication of this timely, well-organized book and know ix