beta-blockers, hydralazine, and other newer clrugs for the elderly hypertensive needs inquiry. Clearly there are elderly hypertensives, as there are younger hypertensives, who are resistant to conventional pharmacotherapy. Lastly, the relationship of a variety of physician characteristics and attitudes to providerexpressed norms of diagnosis, investigation, therapy, and management raises some interesting questions. The suggestion that specialty training and years since training completed correlate with different diagnostic and management norms is an important area to pursue. A larger study would allow, as well, an examination of the relationship of the expressed norms to actual diagnostic, investigative, therapeutic, and management processes. In summary, 76% of hypertensive elderly patients enrolled or registered at one of four settings had controlled diastolic blood pressures after a minimum of 6 mo. follow-up; 24% remained with uncontrolled diastolic blood pressures equal to or greater than 100 mm Hg. Changes in diastolic pressure were generally toward lower pressures at last visit to the settings. Twenty-two patients (16%) had either a higher diastolic pressure at their last visit, or a diastolic pressure greater than 100 mm Hg, which did not change between visits. The patients who were least educated and least satisfied with care received tended to experience the less favorable diastolic blood pressure changes (higher at last
visit, or remaining high at both visits). No antihypertensive drugs were being taken by 36% of all patients at last visit. No antihypertensive drugs or combination products were being taken by 29% of all patients with uncontrolled diastolic blood pressures at last visit.
References Borhani, N. O., & Brokman, T. S. Alameda County blood pressure study. California State Dept. of Public Health —Univ. California at Davis, 1968. Inter-Society Commission for Heart Disease Resources. Guidelines for the detection, diagnosis and management of hypertensive populations. Circulation, 1971, 44, A263-A272. Langfeld, S. B. Hypertension: Deficient care of the medically served. Annals of Internal Medicine, 1973, 78, 19-23. Schoenberger, J . A., Stamler, J., Shekelle, R. B., & Shekelle, S. Current status of hypertension control in an industrial population. Journal of the American Medical Association, 1972, 222, 559-562. USDHEW. Blood pressure of adults by age and sex; United States, 1960-1962. Vital & Health Statistics, Series I I , No. 4, June, 1964. VA Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressure averaging 90 through I 14 mm H g . Journal of the American
M e d i c a l Association, 1970, 213, I 145-1 152.
VA Cooperative Study Group on Antihypertensive Agents. III. Influence of age, diastolic pressure and prior cardiovascular disease: Further analysis of side effects. Circulation, 1972, 45, 991-1003. Wilbur, J . A., & Barrow, J . G . Hypertension, a community problem. American Journal of Medicine, 1972, 52, 653-663.
Discussion:
Treatment of Hypertension in the Elderly
Robert F. Maronde, MD, 2 Donald C. Brodie, PhD,3 and Roger A. Benson, PhD4
Care of the elderly often includes the control and management of hypertension, which frequently is one of several co-existing chronic conditions. It is noteworthy that blood pressure in the healthy elderly may range over wide limits, as has been pointed out recently (Anderson, 1974). In Rutherford, Scotland, systolic readings as high as 215 mm Hg for men and 230 mm Hg for women, and 108 and I 10, respectively, for diastolic pressure, were often accepted as normal for those 80 years and older. Clinical judgment, therefore, must be an important factor in determining which elderly patients are suitable candidates for antihypertensive drug therapy. 1. Supported in part by Contract HRA 106-74-137 from the Bureau of Health Services Research. Health Resources Administration, PHS, USDHEW. This paper is an expanded revision of Dr. Maronde's remarks following Dr. Hoey's presentation. 2. Professor of Medicine, Clinical Pharmacology Section, Dept. of Medicine, Univ. of Southern California Schools of Medicine and Pharmacology, Los Angeles 90033. 3. Adjunct Professor of Medicine and Pharmacy, Clinical Pharmacology Section, Dept. of Medicine, Univ. of Southern California Schools of Medicine and Pharmacy. 4. Research Associate, Clinical Pharmacology Section, Dept. of Medicine, Univ. of Southern California Schools of Medicine and Pharmacology.
August 1975
325
In designing antihypertensive drug regimens for the elderly, prescription of thiazide diuretics is often the treatment of choice, with control of blood pressure through reduction of diastolic pressure as a therapeutic objective. In a recent study of health care in the elderly, it was shown (Hoey, 1974) that the number of uncontrolled cases of hypertension in four different settings in Maryland was reduced in those who received diuretic therapy. Rauwolfia alkaloids plus diuretic was more effective than diuretic plus methyldopa in reducing the number of uncontrolled1 cases. A combination of diuretic with rauwolfia was more effective than rauwolfia alone. When diuretics alone fail to control blood pressure, several combinations^ of diuretics with other agents (rauwolfia, methyldopa, and propranalcl) may provide suitable alternative regimens. Smith, Bachman, Galante, Hanowell, Johnson, Koch, Korfmacher, Thurm, & Bromer (1966), in a cooperative clinical trial involving 189 subjects (median age 50 years) with "moderately severe essential hypertension," compared the effectiveness of methyldopa alone and in combination with chlorothiazide, with rauwolfia alone and in combination. The results of this study have considerable significance in planning combination therapy in the treatment of hypertension in the elderly. "Satisfactory results" were obtained in nearly 80% of cases with chlorothiazide (500 mg) and rauwolfia whole root (100 mg) twice daily. Methyldopa alone or combined was not as effective. Side effects did not present a "serious problem." The authors recommended that the thiazide-methyldopa combination be reserved for cases that do not respond to the rauwolfia combination, and that this combination precede the use of more potent agents. The experiences at the LAC/USC Medical Center with thiazide and reserpine parallel those of Smith in that 53% of patients were controlled with this ^.combination (Maronde & Haywood, 1962). The use of rauwolfia alkaloids in the treatment of hypertension in the elderly requires consideration of several factors, particularly depression, cost, and the associated' incidence of breast cancer. The ""^relatively low doses required to lessen blood pressure appear to lessen the likelihood of depression. The cost ratio at the LAC/USC Medical Center between chlorothiazide-reserpine and chlorothiazidemethyldopa is about I : 20 for a 2 mo. supply. Hence, the rauwolfia combination benefits the elderly patient economically. While the recently associated incidence of breast cancer with the use of rauwolfia in postmenopausal hypertensive women in controversial at this time, the evidence to support the association is by no means conclusive. A study by DeWaard, Baandersvan Halewijn & Huizinga (1964) may have been overlooked, but the results must be introduced into the present discussion. In a study of mammary carcinoma in 204 women, the authors showed a noticeable increase in the incidence of cancer in several age brackets between the ages of 50 to 80 in hypertensive and in obese and hypertensive women. The implications of these data are obvious. The Assistant Secretary for Health and Scientific Affairs (Edwards, 1974) has stated " . . . there 'should be no general change or disruption of therapy in patients with high blood pressure' " (the recommendation of a committee of representatives of leading medical institutes and sections of HEW) "until definitive conclusions are possible." In addition to achieving control of blood pressure, there are several other health benefits that can accrue to elderly hypertensives who receive drug therapy. In a recent report (Hypertension-Stroke Cooperative Study Group, 1974), it is stated that "The hypothesis that antihypertensive therapy for hypertensive stroke survivors would alter the stroke recurrence rate was not statistically supported by the data." However, in examining the data on an age basis, it is noted that in the 70-year and above bracket the recurrence rate was 10.5% in the drug-treated group and 36.0% in the placebo group, with a " p " value of .08 ("p" value for the average of all ages was .42). Congestive heart failure occurred in six cases which received placebo medication, while non& occurred in the drugtreated group. Thus, it would seem that drug therapy may have a potential benefit to the elderly hypertensive insofar as the recurrence of stroke and the occurrence of congestive heart failure are concerned. In a study of the relationship between blood' pressure and intelligence in aged individuals over a 10-year period (Wilkie & Eisdorfer, 1971), the results showed an association between elevated blood pressure and intelligence loss and suggest that hypertension is related to intellectual changes among ._ the aged. In conclusion, the use of thiazide diuretics and rauwolfia alkaloids in combination, based on clinical evidence and medical judgments, is an effective and economic regimen in the treatment of hypertension in the elderly. References Anderson, W. F. Preventive aspects of geriatric medicine. Journal of the American Geriatrics Society, 1974, 22, 385-392. DeWaard, F., Baanders-van Halewijn, E. A., & Huizinga, J. The bimodal age distribution of patients with mammary carcinoma. Cancer, 1964, 17, 141-151. Edwards, C. C. Hospital Tribune, 1974, 8, I, Oct. 28. Hoey, J. R. (Personal communication) 1974. Hypertension-Stroke Cooperative Study Group. Effect of antihypertensive treatment on stroke recurrence. Journal of the American Medical Association, 1974, 229, 409-418. Maronde, R. F., & Haywood, L. J. Drug therapy of hypertension. California Medicine, 1962, 97, 206-208. Smith, W. M., Bachman, B., Galante, J. G., Hanowell, E. G., Johnson, W. P., Koch, C. E., Jr., Korf macher, S. D., Thurm, R. H., & Bromer, L. Cooperative clinical trial of alpha-methyldopa; III. Double-blind control comparison of alpha-methyldopa and chlorothiazide, and chlorothiazide and rauwolfia. Annals of Internal Medicine, 1966, 65, 657-671.
Wilkie, F., & Eisdorfer, C. Intelligence and blood pressure in the aged. Science, 1971, 172, 959-962. 5. The term combination does not mean combined drugs in a single dosage form. It does mean separate dosage forms of two or more drugs administered concurrently.
326
The Gerontologist