Dr. Mehdi Reza Emadzadeh

Department of cardiology

Mashhad University of Medical Science

From a physiologic standpoint human aging is characterized by progressive constriction of

the homeostatic reserve of every organ system

HOMEOSTENOSIS

Principles of geriatric medicine

• Individuals become more dissimilar as they age.

• An abrupt decline in any system or function is always due to disease and not to “normal aging”.

• Normal aging can be attenuated by modification of risk factors.

• Healthy old age is not an oxymoron

Other Concepts

• Disease presentation is of ten atypical in the elderly.

• Because of decreased physiologic reserve, older patients often develop symptoms at an earlier stage of their disease.

• Since many homeostatic mechanisms may be compromised concurrently,there are usually multiple abnormalities amenable to treatment.

• Many findings that are abnormal in younger patients are relatively common in older people.

• Because symptoms in older people are often due to multiple causes,the diagnostic “law of parsimony” often does not apply.

• Because the older patient is more likely to suffer the adverse consequences of disease, treatment __ and even prevention__ may be equally or even more effective.

EPIDEMIOLOGY

• The population 65 years and older has grown from 20 million in 1970 to

35 million in 2000 and there will be 69 million by 2030

• At present 1 in every ten people is 60 years or older. By 2050 this is projected to become 1 in every 5.

• The number of 100 years and older is projected to increase from 145000 in 1999 to 2.2 million by2050

• In this older population cardiovascular disease plays a significant role and is the most common cause of morbidity and mortality.

• The overall cost of treating cardiac disease in people older than the age of 65 years was estimated at $58 billion in 1995.

SYSTEMIC HYPERTENSION IN THE ELDERLY prevalence and incidence

• - BP>140/90 occurs in half to two thirds of people older than 65y and in 75% of people older than 80y.

• - Systolic hypertension becomes more prevalent with aging.

• - “Isolated” systolic hypertension, without elevation of diastolic blood pressure, is present in about 8 percent of sexagenarians and more than 25 percent of the population older than 80 years of age.

TREATMENT

• - The need for treatment of hypertension in the elderly.

• - There is cardiovascular benefit for treatment of systolic or diastolic blood pressure in the elderly.

• - Combination of drug regimens including a diuretic are usually required to approach blood pressure targets.

• - Different combination of pharmacological agents

may have advantages based on the patients,

concomitant diseases, genetics, or risk factors.

• - Dihydropyridine calcium channel blockers greater stroke benefit.

• - ACE inhibitors cardiac benefit, primarily in

men.

• NSAIDS, as well as cox-2 selective NSAIDS.

• Thiazide diuretics.

• - Lower initial drug dosages and slower medication titration, as well as the need for monitor for postural hypotension.

• - Postural hypotension of greater than 20 mmHg or 20 percent of systolic pressure is a risk factor for falls and fractures that carries significant morbidity and mortality.

• - Diuretic therapy.

• - Postprandial decline in both systolic and diastolic blood pressure.

CURRENT CONTROVERSIES

• - Target blood pressure for systolic blood pressure in the very old.

• - Differences in central versus peripheral blood pressure.

• - Lifestyle modifications.

• Impact of blood pressure treatment on development of dementia.