Blood pressure, especially systolic pressure, increases with age in Western countries and in most cultures in which salt intake is high. In women, the increase is more marked after age 50. Although treated conservatively in the past, most clinicians now believe that hypertension should be treated vigorously in the elderly.The basic principles of therapy are not different in the geriatric age group from those described, but the usual cau-tions regarding altered pharmacokinetics and blunted compensa-tory mechanisms apply. Because of its safety, nondrug therapy (weight reduction in the obese and salt restriction) should be encouraged. Thiazides are a reasonable first step in drug therapy. The hypokalemia, hyperglycemia, and hyperuricemia caused by these agents are more relevant in the elderly because of the higher incidence in these patients of arrhythmias, type 2 diabetes, and gout. Thus, use of low antihypertensive doses—rather than maxi-mum diuretic doses—is important. Calcium channel blockers are effective and safe if titrated to the appropriate response. They are especially useful in patients who also have atherosclerotic angina . Beta blockers are potentially hazardous in patients with obstructive airway disease and are considered less use-ful than calcium channel blockers in older patients unless heart failure is present. Angiotensin-converting enzyme inhibitors are also considered less useful in the elderly unless heart failure or dia-betes is present. The most powerful drugs, such as minoxidil, are rarely needed. Every patient receiving antihypertensive drugs should be checked regularly for orthostatic hypotension because of the danger of cerebral ischemia and falls.
Heart failure is a common and particularly lethal disease in the elderly. Fear of this condition may be one reason why physicians overuse cardiac glycosides in this age group. The toxic effects of digoxin are particularly dangerous in the geriatric population, since the elderly are more susceptible to arrhythmias. The clearance of digoxin is usually decreased in the older age group, and although the volume of distribution is often decreased as well, the half-life of this drug may be increased by 50% or more. Because the drug is cleared mostly by the kidneys, renal function must be considered in designing a dosage regimen. There is no evidence that there is any increase in pharmacodynamic sensitivity to the therapeutic effects of the cardiac glycosides; in fact, animal studies suggest a possible decrease in therapeutic sensitivity. On the other hand, there is probably an increase in sensitivity to the toxic arrhyth-mogenic actions. Hypokalemia, hypomagnesemia, hypoxemia (from pulmonary disease), and coronary atherosclerosis all contrib-ute to the high incidence of digitalis-induced arrhythmias in geri-atric patients. The less common toxicities of digitalis such as delirium, visual changes, and endocrine abnormalities also occur more often in older than in younger patients.
The treatment of arrhythmias in the elderly is particularly chal-lenging because of the lack of good hemodynamic reserve, the frequency of electrolyte disturbances, and the high prevalence of severe coronary disease. The clearances of quinidine and procain-amide decrease and their half-lives increase with age. Disopyramide should probably be avoided in the geriatric population because its major toxicities—antimuscarinic action, leading to voiding prob-lems in men; and negative inotropic cardiac effects, leading to heart failure—are particularly undesirable in these patients. The clearance of lidocaine appears to be little changed, but the half-life is increased in the elderly. Although this observation implies an increase in the volume of distribution, it has been recommended that the loading dose of this drug be reduced in geriatric patients because of their greater sensitivity to its toxic effects.
Recent evidence indicates that many patients with atrial fibrillation—a very common arrhythmia in the elderly—do as well with simple control of ventricular rate as with conversion to normal sinus rhythm. Measures (such as anticoagulant drugs) should be taken to reduce the risk of thromboembolism in chronic atrial fibrillation.