Practice Update: Diabetes

MY APPROACH 22

My Approach to the Elderly Patient with Resistant Hypertension By George L Bakris MD, HonD, FASH, FASN, FAHA

Dr Bakris is Director, University of Chicago Medicine ASH Comprehensive Hypertension Center in Chicago.

W hen trying to understand the etiology of resistant hyper- tension in older adults (ie, >70 years of age), one needs to ask the following questions: 1 Is the person truly on a low-sodium diet (ie, <2300 mg/day)? The patient should be educated as to the specifics of the diet. If there is some question, a 24-hour urine should be checked for sodium and total creatinine. 2 Is the person getting at least 6 hours of uninterrupted sleep at night (ie, not interrupted by nocturia)? Note that this is dif- ferent from sleep apnea. Poor sleep quality can produce a pseudo-pheochromocytoma–type picture, which is mistaken for pheochromocytoma, with the workup being negative in all cases. 3 Is the person consuming excessive caffeine (eg, >2 cups of caffeinated coffee per day) or taking drugs that would raise blood pressure (BP) like NSAIDs or decongestants on a reg- ular basis? 4 Does the person have stage 3b or higher chronic kidney disease (eGFR <45 mL/min/1.73m 2 )? This is a common unap- preciated cause of resistant hypertension and is corrected by managing volume with low-sodium diets and diuretics. 5 Is there a history of persistent or difficult-to-correct hypokalemia, as that could be evidence of primary hyper- aldosteronism? This should always be checked. We have seen four referred patients this year ranging in age from 70 to 79 years who ultimately had this as a cause for resistant hypertension. In addition to the aforementioned considerations, the patient needs to be assessed for poor memory or early dementia, as this is a common cause of poor adherence to medication. Addi- tionally, cost of medications and complexity of the regimen need attention, as the patient is frequently embarrassed to admit that the meds are unaffordable or that the medication regimen is too complicated to follow. It is best to simplify the patient’s regimen so that most medications are taken once daily, or at most twice daily, to increase compliance. If the patient is on multiple medi- cations, purchase of a pillbox has proven to improve adherence. Once a proper history has been taken, then the approach becomes

more focused. Do not just start adding medicines to the patient’s regimen, especially “cheap” drugs that need to be taken frequently and are associated with major adverse consequences if a dose is missed (clonidine and hydralazine are good examples). Also, to reinforce lifestyle, we tell the patient that the basis of therapy is lifestyle; so, if, for example, the patient does not follow a low-so- dium diet, blockers of the renin–angiotensin system will not work because the high sodium suppresses the effects. Specific situations Poor sleep is a common cause of resistant and labile hyperten- sion in older adults, especially those over 75 years. They can be identified as almost all of them will have very high resting pulse rates, usually above 86 and frequently around 100 beats per min- ute. They should all be evaluated for sleep apnea but, additionally, should be tried at low initial doses of various agents designed to help them sleep (eg, trazodone or zolpidem). Note that you get an average of 1–mmHg drop in BP for every hour you wear the mask. Benzodiazepines should be avoided in this setting as they alter sleep cycles and do not provide for proper amounts of deep sleep, a part of sleep that is already reduced in older people. Use of these agents along with a low-sodium diet and education about sleep hygiene is critical. Sleep hygiene education at each visit should be reinforced (ie, do not watch television or read in bed). The bed is for the two S’es (sleep and sex). Guidelines clearly state that calcium antagonists and diuretics are the cornerstone of therapy in older people with resistant hyper- tension. Renin–angiotensin system blockers are ineffective unless used with either calcium antagonists or diuretics. Note that beta blockers are useful adjuncts to calcium antagonists or diuretics, especially in people with sleep issues due to a high sympathetic drive. At least 50% of the antihypertensive agents should be dosed at dinner, as people with resistant hypertension are no dippers on 24-hour ambulatory BP monitoring. Use of twice-daily or four-times daily drugs should be avoided at all cost. If clonidine is needed, the long-acting, once-weekly patch is preferred. Guanfacine, a long-act- ing agent that works by the same mechanism as clonidine, is very useful at bedtime as it is sedating and can help with sleep.

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