INTRODUCTION

Aging is an inevitable part of life that brings

along some inconvenient events, such as physiological

decline and disease. Abrass, (1990) hypertension is a

risk factor in cardiovascular disease morbidity and

mortality, particular in the elderly. It is a

significant and often asymptomatic chronic disease,

which requires optimal control and persistent adherence

to prescribed medication to reduce the risk of

cardiovascular, cerebrovascular and renal disease,

(Hamphton, 2003). Hypertension in the elderly patient

represents a management dilemma to cardiovascular (CV)

specialists and other practioners.

Further more, with the wide adoption of multiple

drugs strategies targeting subgroups of hypertensive

patients with specific risk conditions to how blood

pressure (BP) beyond traditional goals, difficult

questions arises about how aggressive elderly patients

should be treated “is hypertension in the elderly an

emergency state or not?” Does the blood Pressure

control lower the risk associated with cardiovascular

disease and death in the geriatric population?” “What

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are the general principles of hypertension management

in this population?” the purpose of the following

article is to answer those questions through a review

of pathophysiology of aging, clinical assessment and

diagnosis of hypertension and finally recommendations

for its management.

Definition

Hypertension is defined by the seventh report of

the joint National committee on prevention, detection,

Evaluation and treatment of high blood pressure (JNC-

7., 2003) as a systolic blood pressure greater than

140mmHg and a diastolic pressure greater than 90mmHg

based on the average of two or more accurate blood

pressure measurement taken during two or more contact

with health care provider, (Suzanne et al 2010).

OBJECTIVES

This seminar work is discussed under the following

objectives

1. Explain the pathophysiology of Hypertension

2. Outline the causes and prevention of Hypertension

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3. Discuss the complication associated with

hypertension

EPIDEMIOLOGY

As our population ages, the important of

cardiovascular disease (CVD) as the leading cause of

death in adult became increasing clear. (Health U.S,

2007). One major reason for this trend is the pattern

of hypertension changes and increasing hypertension

prevalence with age (about 1billion people worldwide),

(Kearnely et al, 2005) according to JNC -7 hypertension

occurs in more than two thirds of individuals after age

of 65 years (Chobanian et al data, 2003). From the

Framingham heart study, in men and women after free of

hypertension at 55years of age indicate that, the

remain lifetime risks for development of hypertension

through 80years are 93% and 91% respectively, (Levy et al,

1996). In other words, more than 90% of individuals who

are free of hypertension at 55years of age will develop

it during their remaining life span.

From the standpoint of epidemiology and

pathophysiology, some subgroups with particular

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characteristics such as elderly women and blacks that

require additional focus. Hypertension prevalence is

less in women than in men until 45years of age, is

similar in both sexes from 45 to 64 and is much higher

in women than in men over 65years of age, (Health U.S,

2007). The severity of hypertension increase markedly

with advancing age in women as well, after the age of

60years, the majority of women (age 60-79 years: 48.8%,

age≥80years:63%) has stage ii hypertension

≥160/100mmHg) or receives hypertensive therapy

(Wasserthel et al, 2000).

Furthermore, blood Pressure control is difficult to

achieve in elderly women, (Pimenta, 2012). Endothelial

dysfunction, increased arterial stiffness, obesity,

genetic factors, elevated total cholesterol and low

high-density lipoprotein cholesterol levels have been

implicated in menopause- related blood pressure

elevation rather than ovarian failure per se, (Cifkova,

2008).

Hypertension among blacks is earlier in onset,

more severe and uncontrolled and contributes to the

highest coronary artery disease (CAD) mortality rates

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in the USA in addition to the highest morbidity and

mortality attributed to stroke, left ventricular

hypertrophy (LVH), heart failure (HF) and chronic

kidney disease (CKD), (Chobanian et al, 2003). Compared

with whites, black are more likely to have

hypertension, more likely to be aware of it and more

likely to pharmacologically treated, but less likely to

achieve blood pressure control, (Hertz et al, 2003).

Hypertension is an important factor in the

disproportionate decrease life expectancy for black.

African-American men of 70.00 years versus of 75.90

years for white men and African-American women of 76.80

years versus of 80.80 years for women, (Heron et al,

(2009).

BLOOD PRESSURE REGULATION

Blood pressure is regulated through several

physiological mechanisms to ensure an adequate tissue

blood pressure. Blood pressure is determined by the

rate of flow of blood produced by the heart (cardiac

output) and the resistance of the vessels to blood

flow.

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The resistance produced mainly in the arterioles

and is known as the systematic vesicular resistance.

There are several physiological mechanisms that allow

blood pressure to maintain into normal range such as:

- The autonomic nervous system-is most rapidly

responding regulator of blood pressure and receive

continues information from the baroreceptors situated

in the carotid sinus and the aortic arch. This

information is relay to the vasomotor Centre. A

decrease in blood pressure causes activation of the

sympathetic nervous system resulting in increased

contractility of the heart (β-receptors) and

vasoconstriction of both arterial and venous side of

the circulation α-receptions, (Abrass, 1990)

- The capillary fluid shift mechanical-this also

refers to the exchange of fluid that occurs across the

capillary membranes between the blood and the

interstitial fluid. The fluid movement is controlled by

the capillary blood pressure, the interstitial fluid

pressure as well as colloid osmotic pressure of the

plasma. Low blood pressure results in the fluid moving

from the intestinal space into circulation helping to

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restore blood volume and blood pressure, (Levy et al,

1996).

- Hormonal mechanism exist both for lowing and

raising blood pressure, they act in various ways

including vasoconstriction and vasodilatation. The

principal hormones raising blood pressure are

a. adrenaline and nor adrenaline: they increase cardiac

output and cause vasoconstriction;

b. Rennin angiotensin aldosterone production is increase in

the kidney when stimulated by hypotension.

Angiotensin 1 is converted in the lung to Angiotensin

II, which is a potent vasoconstrictor, (Chobanian,

2003).

- The kidneys help to regulate the blood pressure by

increasing the blood volume and by the rennin-

angiotensin system (RAS) described above. They are the

most important organs for the long-term control of the

blood pressure, (Chobaniun, 2003).

PATHOPHYSIOLOGY OF HYPERTENSION.

Blood pressure is the product of cardiac output and

peripheral resistance (BP=CO×PR). Cardiac output is the

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product of heart rate and stroke volume. (CO=HR×SV). In

normal circulation, pressure is transferred from the

heart muscle to the blood each time the heart contracts

and then pressure is extended by the blood as it flows

through the blood vessels.

Hypertension can result from an increase in cardiac

output, an increase in peripheral resistance

(constriction of the blood vessels), or both. In

elderly, it can be as a result of elastic arteries

showing major physical changes with age. As they dilate

and stiffen, aorta and the proximal elastic arterials

dilate by approximately 10% with each beat of heart in

youth, while the muscular arteries dilate by only 3%

with each beat. Such difference in degree of stretch

can explain difference in aging between proximal and

distal arteries on the basis of fatigue, (O’ rourke et

al, 2007). The result is a stiff artery that has

decreased capacitance and limited recoil and is thus

unable to accommodate the changes that occur during the

cardiac cycle.

Further more, during systole the

arteriosclerotic arterial vessel exhibit limited

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expansion and fails to buffer effectively the pressure

generated by the heart causing an increase in systolic

blood pressure (SBP). On the other hand, the loss of

recoil during diastole results in reduction in

diastolic pressure (OBP) (Millar et al, 2000).

Neurohormonal and autonomic dysregulation:

Neurohormonal mechanisms such as the renin–angiotensin

aldosterone system decline with age. Plasma renin

activity at age of 60years is 40% to 60% of the levels

found in younger individuals, (Epstein, 1996). This has

been attributed to the effect of age-associated

nephrosclerosis on the juxtaglomerular apparatus.

Plasma aldosterone levels also decrease with age.

Consequently, elderly patients with hypertension are

more prone to drug-induced hyperkalaemia, (Flag, 1986).

In contrast, net basal sympathetic nervous system

activity increase with advancing age. Peripheral plasma

norepinephrine concentration in the elderly is double

the level found in the younger subject, (Seals et al,

2000). The age-associated rise in plasma norepinephrine

is thought to be a compensatory mechanism for reduction

in 𝜷-adrenergic responsiveness with aging.

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Decreased baroreflex sensitivity with the age

causes orthostatic hypotension in the elderly, (Davis

et al, 1987) and (Kario et al, 1998)

CLASSIFICATION OF HYPERTENSION

Classifications of blood pressure for adult according

to JNC-7. Is in the table1 below

CLASSIFICATION SBP(mmHg) DBP(mmHg)Normal ≤120 And ≤80Pre-hypertension 120-139 Or 80-89Stage I

hypertension

140-159 Or 90-99

Stage 2

hypertension

≥160 Or ≥100

SBP: systolic blood pressure

DBP: diastolic blood pressure

OR

Guidelines from the European society of

hypertension/European society of cardiology (ESH/ESC

2007 and 2009 update) stratify hypertension somewhat

differently. Table II.

CLASSIFICATION SBP(mmHg) DBP(mmHg)10

Optimal ≤ 120 and ≤80

Normal 120-129 80-84

High normal 130-139 85-89

Hypertension

Grade 1 (mild) 140-159 90-99

Grade 2 (moderate) 160-179 100-109

Grade 3 (severe) ≥180 ≥90

Isolated systolic

hypertension

≥140 ≤90

TYPES OF HYPERTENSION

Primary hypertension: the type of hypertension that

has no known cause (idiopathic).

secondary hypertension: this is due to known cause

or underlying disease such as –

a. Renal failure

b. Hyperaldosteronism

c. Cushing syndrome

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d. Coarctation of the aorta

e. Renovascular stenosis

f. Endocrine disorder (thyroid, parathyroid

abnormalities)

g. Obstructive sleep apnea

h. Drugs (nonsteroidal antiflammatory drugs, alcohol,

estrogen etc).

i. Chronic kidney disease

j. Pheochromocytoma.

CAUSES OF HYPERTENSION

Increased sympathetic nervous system activity related

to dysfunction of the autonomic nervous system.

Increase renal reabsorption of sodium, chloride, and

water related to a genetic variation in the pathways

by which the kidneys handle sodium.

Increased activity of the renin -angiotensin-

aldosterone system, resulting in expansion of

extracellular fluid volume and increase system

vascular resistance.

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Decreased vasodilatation of the arterioles related to

dysfunction of the vascular endothelium.

Resistance to insulin action, which may be a common

factor linking hypertension, types two diabetes

mellitus, hypertriglyceridemia, obesity, and glucose

intolerance, (Suzanne et al, 2010).

The predisposing factors

1.High sodium intake: - Sodium causes smooth vascular

muscle to constrict smaller blood vessels creating

more resistance to blood flow thereby elevating your

blood pressure. Also sodium causes the body to retain

water, with additional water, more pressure exerted

against the blood vessels causing your blood pressure

to rise. The daily-recommended salt intake is 5g.

Americans consumes 2-4 time that amount.

2.Genetic: If hypertension runs in the family, it is

advisable to see your doctor to monitor your blood

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pressure. Because the individual is at high risk of

hypertension.

3.Physiological influences: Imbalance of circulating

vasoconstrictors (e.g. angiotensin) and vasodilators

(e.g. prostaglandins), have been implicated to cause

hypertension. Also, increased sympathetic nervous

system activity resulting in increased

vasoconstriction. (Mary C, 2006).

4.Psychosocial influences: Suppressed anger and

hypertension have correlation according to Karren and

associates (2002). Some psychoanalysts believe this

may be associated with childhood rearing that forbid

expression of anger feelings, (Mary C, 2006).

5.Medications: Herbal supplements and some allergy

medications can also elevate blood pressure for e.g.

Aleve, Motrin, Advil, nasal decongestants and sprays,

also birth control pills. These can be interfering

with your blood pressure medication.

6.Alcohol: Excessive drinking is another factor that

causes hypertension; studies have shown that when

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heavy drinkers reduce their alcohol consumption their

blood pressure drops to a minimal level.

7.Smoking: - Tobacco nicotine causes narrowing of the

blood vessels, whereby putting more strain on the

heart making your pressure go up, also smoking

cause’s plague build up which causes an increase in

blood pressure.

8.Aging factor: this is one factor we have to control

over as your get older your blood pressure tends to

increased.

9.Race: Studies have shown that Black Americans are at

the high risk for hypertension then white Americans.

Those with the lowest risk are white females, the

highest risk black females.

CLINICAL MANIFESTATIONS

Physical examination may reveal no abnormalities

other than elevated blood pressure. Occasionally,

Retinal changes such as hemorrhage, exudates (fluid

accumulation), arteriolar narrowing, and cotton wool

spots (small infarctions) occurs.

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In severe hypertension, papillodema (a swelling of

the optic disk) may be seen.

People with hypertension may be asymptomatic and

remain so for many years. However, other signs are

headache, vertigo, flushed face, spontaneous nose

blood and blurred vision.

Chronic and progressive hypertension may reveal signs

and symptoms associated with specific organ system

damage. For example

Dyspnea, chest pain, or cardiac hypertrophy may

indicate cardiovascular damage.

Confusion and parasthesia may suggest

cerebrovascular damage and

Elevated serum creatinine or blood urea nitrogen

may signal kidney damage (May C, 2006).

MANAGEMENT/ TREATMENT OF HYPERTENSION IN THE ELDERLY

PEOPLE.

There are two types of management of hypertension

namely:

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Non-pharmacological management and

Pharmacological management

NON-PHARMACOLOGICAL MANAGEMENT

Non-pharmacological management of hypertension is

too often over looked in the elderly, because many

patients prefer just being given a prescription and

continuing their current lifestyle, this course of

action is not ideal, the best way to treat is through

change of lifestyle. The popular option opinion is that

thirty minutes of exercise three times a week is

enough. If a patient needs to lower his blood pressure,

that is probably with enough exercise. Aim for at least

thirty minutes, six days a weak. Walking is a great

exercise.

Diet modification: - studies have shown that a diet

high in sodium contributes to high blood pressure.

Limiting the sodium can help. This reduces systolic

blood pressure to 2-8 mmHg.

Weight reduction: - Reduction in weight reduces the

systolic blood pressure by 5-2mmHg per 10kg less.

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Moderate alcohol consumption: - Moderate consumption

of alcohol reduce hypertension by 2-4mmHg of systolic

blood pressure.

Dietary Approaches to stop hypertension (DASH) diet

which reduces the systolic blood pressure by 8-

14mmHg should be the cornerstone of hypertension

treatment in combination or not with active

treatment.

Individual with hypertension is advised to avoid

smoking because of how it causes the narrowing of the

blood vessels.

Relaxation techniques, such as meditation, Yoga,

hypnosis and biofeedback reduce blood pressure in

some individual. These are especially useful for

individuals with higher initial pressures and as

adjunctive therapy to pharmacological treatment.

Supporting psychotherapy, during which the individual

is encourage expressing honest feelings, particularly

anger, and may also be helpful.

PHARMACOLOGICAL MANAGEMENT OF HYPERTENSION IN THE

ELDERLY PATIENTS.

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When life style measures or modifications fail to

lower blood pressure, pharmacotherapy should be

initiated. The safety and efficacy of multiple

medication classes has been studied in elderly patients

over the last 30 years. Randomized controlled trials

have consistently demonstrated that anti hypertension

therapy in the elderly effective in preventing total

mortality, stroke and coronary events, (Chobanian et al,

2003). Another important consideration is that for most

trials, the goal and achieved blood pressure are higher

than that recommended by JNC-7, which is still showing

a significant benefit of treatment.

GENERAL PRINCIPALS OF PHARMACOLOGICAL MANAGEMENT

There is often a debate about which

antihypertensive drug class should be used first in

elderly patients with hypertension. Because of several

classes of antihypertensive drugs available are

effective in preventing cardiovascular disease. The

principals are:

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the treatment decisions most be guided by the pressure

of compelling indications such as diabetes mellitus,

stroke or heart failure and by the tolerability of

individual drugs or drug combination.

The initial antihypertensive drug should start at the

lowest does and gradually increased depending on the

blood pressure response to the maximum tolerated dose,

(Chobanian et al, 2008).

It then antihypertensive response to the initial drugs

is inadequate after reaching full dose, a second drug

from another class should be added.

If the anti hypertensive response is inadequate after

reaching the full dose of two classes of drug, a third

from another class should be added, (Chobanian et al,

2003).

PHARMACOLOGICAL AGENTS

The JNC-7 trial recommends a thiazide diuretic as

initial drug therapy or in combination with other

class, (Chobanian et al, 2003); Angiotensin-converting

enzyme inhibitors (ACEIs) can also considered for

first-line or combination, especially if diabetes,

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heart failure, post myocardial infarction or chronic

disease is present.

In hypertensive parents with diabetes mellitus,

angiotensin receptor blockers (ARB) is considered first

line treatment as an alternative to ACELs in patients

with hypertension and heart failure who cannot tolerate

ACELs. Other line of tolerate are direct rennin

inhibitors, Aldosterone receptors antagonists and

centrally acting agents.

The details about the drugs which including the

mode of action, the classes, the dosage, the

indication, the contradiction, the side effect, the

Route of administration and nursing responsibilities

are summarized below.

THIAZIDE DIURETICS

These are slow or long acting diuretics, which are

usually effective for 12-24hours. Hence, they are

taking once daily, since potassium is lost in urine,

potassium supplements e.g. slow-k is usually

prescribed. Examples of Thiazide diuretics include

chlorothiazide, chlorthalidone, hydrochlorothiazide,

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indapamide, methyclothiazide and metolazone

(zaroxolyn). One example is discussed below.

Chlorothiazide

Trade name: saluric, Diuril.

Group: - It is slow but long-acting Diuretics.

Mode of action: - It prevents sodium ion and chloride

reabsorption at the distal convoluted tubule of the

kidney thereby increasing the urinary output of the

electrolytes including potassium and water.

Indications: congestive cardiac failure, hypertension,

cirrhosis of livers, Nephrotic syndrome.

Dosage: 500mg-1g once or twice daily.

Route of Administration: Orally.

Side effects: Hpokalaemia, hypotension, Hypovolaemia,

Dehydration, dry month, muscle cramps,

thrombocytopenia, hyponatraemia.

Contra-indications: Shock, burns, cholera,

gastroenteritis, severe vomiting and severe diarrhea,

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dehydration, hypertension, hepatic failure, rend

failure, pregnancy, lactation.

Nursing Responsibility: Monitor the intake client for

the patient. Give the prescribed potassium supplement

to prevent hpokalaemia. Weigh the patient daily. Advise

on how or restrict salt (sodium) intake in the diet to

enable this drug (Chlorothiazide to be effective).

Benefits or advantages of thiazide compare to other

line of drug are:

They decrease stroke and cardiovascular mortality in

elderly patients with hypertension.

Because of their wide availability and low cost

Their effect on calcium reabsorption constitutes the

basis for their usefulness in preventing the formation

of calcium containing renal stones.

They have protective effects on rates of bone mineral

loss and prevention of hip fracture.

DISADVANTAGE

Their disadvantages includes metabolic side effects

like

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electrolyte abnormalities

dyslipidemia

Insulin resistant and new onset of diabetes

mellitus.

Angiotensin Converting Enzyme Inhibitors (ACEIs)

ACEIs are those anti hypertensive drug that inhibit

the conversion of angiotensin 1to angiotensin II in

multiple tissues and thus lower total peripheral

vascular resistance reducing blood pressure without

reflex stimulation of heart rate and cardiac output.

Examples of (ACEIs) are Captopril (Capoten), enalporil

(vasotec), enalaprilat (Vasotec IV), fosinopril

(monopril), lisinopril (Prinivil, zestril), ramipril

(altace) and trandolapril (marik). One example is

discussed below:

CAPTOPRIL

Trade name: epsitron, capoten

Group: It is an Anti- hypertensive and vasodilator

drug.

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Mode of action: (1). It inhibits the conversion of

angiotensin 1 to a vasoconstrictor called angiotensin

II in the kidney by inhibiting Angiotensin converting

enzyme called Rennin, thereby reducing the

vasoconstriction and peripheral resistance and

consequently. (2). It also reduces cardiac after-load

and increase cardiac output. (3). It promotes sodium

and water loss by reducing Aldosterone production,

which is responsible for sodium reabsorption from renal

tubules. This therefore increases urinary output of

sodium and water causing low blood volume in

circulation with a reduction in blood pressure.

Indication: Hypertension, congestive cardiac failure,

renal artery stenosis.

Dosage: the initially 12.5mg twice daily, then

increased to maintenance dose of 25mg twice daily which

should not exceed 50mg twice daily as required.

Route of administration: Orally.

Side effect: Agranulocytosis, Thrombocytopenia,

pemphigus, proteinuria, orthostatic hypotension, skin

rash, loss of taste (Ageusia), Neutropania, Angioedema,

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fever, Acute renal failure, Nephrotic syndrome,

leucopenia.

Contra-indications: Aortic sternosis, pregnancy,

Lactation, hypersensitivity.

Nursing responsibilities: - since potassium is not lost

in urine during excretion of sodium and water when

Captopril is used, care must be taken not to give the

patient potassium supplement so as not to cause

hyperkalaemia. Monitor white blood cell count to avert

blood disorders observe onset of dry cough when taking

epsitron and act immediately.

ADVANTAGE OF ACEIs

Reduction in mortality of patients with myocardial

infarction.

Reduction in mortality of patients with left

ventricular dysfunction.

Reducing diabetic renal disease in elderly patient.

It also reduces the risk of sarcopenia in elderly.

Angiotensin II Receptor Blockers (ARBs)

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Blockage of angiotensin II receptors directly

causes vasodilatation, reduces secretion of vasopressin

and reduces production and secretion of aldosterone.

The combined effect reduces blood pressure. The

examples are Candesartan, eprosartan, irbesartan,

losartan, telmisartan and valsartan.

Candesartan (Atacand)

Group: It is anti- Hypertensive drug

Mode of action: It blocks the angiotensin II receptors

causing vasodilatation, reduces secretion of

vasopressin and reduces production and secretion of

aldosterone.

Indication: Hypertension, renal failure, congestive

cardiac failure.

Dosage: 16-32mg twice daily.

Routs of administration: Oral

Side effects: Hypotension, cough, Angioedema, acute

renal failure, hyperkalaemia, skin rashes

Contra-induction: hypovolumic, pregnancy, aortic

stenosis.

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Nursing Responsibilities: (1) Observe the onset of dry

cough when take and act immediately. (2). Monitor for

hyperkalaemia.

ADVANTAGE OF (ARBS)

Reduces heart rate and cardiac output

inhibit rennin release

it generate Nitrogen oxide (No)

Reduce vasomotor tone.

CALCIUM CHANNEL BLOACKERS

This drug appears well tolerated by the elderly

Hypertensive patient. They are heterogeneous groups of

drugs with different effects on heart muscle, sinus

node function, atrioventricular-conduction, peripheral

arteries and coronary circulation. The examples of the

drugs are Amlodipine (Norvase), felodipine (plendil),

isradipine (Dynacire CR), nicardipine (cardene). Below

is the discussion of one example to represent others.

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Amlodipine (Novas)

Group: it is a long acting antihypertensive,

vasodilator and Anti-Angina drug.

Mode of Action: it dilates and relaxes blood vessels

thereby allowing blood to flow freely from the heart

and consequently reducing the blood pressure.

Indications: Hypertension, Angina pectoris, coronary

thrombosis.

Dosage: 5-10mg daily during or after meal.

Route of administration: Orally.

Side effects: Mild side effects include Headache,

fatigue, Dizziness, Nausea, Swelling of legs, and

flashing.

Contra-indications: hypersensitivity to

Dihydropyridines.

Nursing Responsibilities: (1). Precautions must be

taken before giving it to pregnant and lactating

mothers, and those with impaired hepatic function. (2).

Where a daily dose is missed, do not take a double dose

the next day. Just take only the day’s dose. However,

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try not to miss a daily dose to obtain the maximum

effect of Amlodipine (Norvase). (3). Monitor the vital

signs closely.

MONOTHERAPY VS COMBINATION THERAPY

Both the 2009-updated ESH/ESC and ACCF/AHA 2011.

Expert consensus document on hypertension in the

elderly recommend the combination of two drugs as

initial treatment whenever hypertensive patients have

high initial blood pressure or a classified as being at

high cardiovascular risk, (Aronow et al, 2011). Trial

evidence of outcome reduction has been obtained

particular for combination of diuretic with an ACE

inhibitors or an angiotensin receptor antagonist and in

recent trials for the ACE inhibitor/calcium antagonist,

combination (the angiotensin receptor

antagonist/calcium antagonist combination also appears

to be effective), (Aronow et al, 2011). Enhanced efficacy,

reduced adverse effects, improved complains as well as

potential organ protections are the key benefits of the

combination therapy.

MEDICATION COMPLIANCE

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Medication compliance is very important in the

treatment of hypertension. Medication compliance can be

defined as the extent to which a patient takes

medication as prescribed. Compliance rates are often

reported as percentage of prescribed does of medication

taken over a period. Unfortunately, a large proportion

of the elderly patients discontinue or takers they

drugs inappropriately. These non-compliances result in

failing to reach guidance-recommended blood pressure

targets. Older age, low risk for cardiovascular events,

competing health problems, low socio-economic status,

complexity (e.g. multiple dosing) side effects and cost

of medication regimen predict non-compliance.

NURSING MANAGEMENT

NURSING ASSESSMENT

A. Respiratory,

In assessing for respiration, you have to check for

shortness of breath after activity, cough with or

without sputum, smoking history by asking the patient

or the patient’s relative, addition sounds as the

patient breath, any signs and symptoms of cyanosis.

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B. Circulation

In assess for circulation you have to check for

increase blood pressure of the patient, history or

signs and symptoms of coronary heart disease, signs and

symptoms of tachycardia, signs and symptoms of

palpitation.

C. Activity and rest.

In assessing for activity and rest, you have to check

for weakness, fatigue, shortness of breath, heart

frequency increase and changes that occur in heart

rhythm.

D. Elimination

Assess for history of kidney disease by examining the

pattern of elimination of the patient.

E. Food/Fluids

Check patient’s pattern of feeding such as those

foods that contain high salt, high fat and cholesterol.

Check for sign’s of fluid and electrolyte imbalance

such as nausea, vomiting, weight changes and edema.

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F. Neuro-Sensory

Check for signs and symptoms such as headache,

throbbing, sub-occipital headache weakness on one side

of the body, visual disturbances (diplopia, blurred

vision) and epistaxis.

G. Pain/Discomfort

Assess for intermittent pain in the limbs, sub-

occipital headache, severe abdominal pain and chest

pain.

H. Ego Integrity

Check fro signs and symptoms such as anxiety,

depression, euphoria, irritability, facial muscle

tension, respiratory haul and increased speech

patterns.

I. Security

Assess the patient’s gait and signs of parenthesis and

postural hypertension.

NURSING DIAGNOSIS

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Risk for ineffective tissue perfusion

Imbalanced nutrition more than body requirement.

Ineffective health maintenance.

Non-compliance with therapeutic regimen

Knowledge deficit

Acute pain

Risk for decreased cardiac output

PLANNING AND GOALS

To help the patient to understand the disease

process and its treatment.

To encourage the patient to participate in a self-

care program.

To reduce the complication or eliminate it.

NURSING INTERVENTION

The objective, of nursing care for patients with

hypertension focuses on lowering and controlling the

blood pressure without adverse effect and low cost

effect. To achieve these goals, the nurses must adhere

to the following:-

Support the patient to adhere to his/her treatment

regimen

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Educate the patient the need to comply to his/her

treatment regimen

Advise the patient on good lifestyles.

The nurse needs to emphasize the importance

controlling hypertension rather than curing it.

The nurse can encourage the patient to consult a

dietitian to help develop a dietary plan for

improving nutritional intake or for weight loss.

Advise the patient to limit alcohol intake.

The nurse should advise the patient to avoid tobacco

because anyone with high blood pressure is already

at high risk for heart disease and smoking worsens

the situation.

Advice the patient to belong to a group for weight

Control, smoking cessation, and stress reduction is

helpful to the patient.

Encourage the patient to engage on regular physical

activity

The nurse should ensure to use proper blood pressure

measurement techniques.

The nurse should provide assistance with social

support.

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Involve family members in educating programs to

enables them support the patient effort to control

hypertension.

Educate the patient the importance of reporting side

effects of any medication to health care providers.

Educate the patient on self blood pressure

monitoring

PREVENTION

1. Nutrition:

Reduce high intake of sodium in diet

Reduce high intake of food that is containing fat.

Increase intake of fruits and vegetables

2. Weight reduction.

Maintain normal body weight (body mass index18.5−24.9km /m2 ¿, by regular cheek of the body weight.

3. Physical Activity

Engage in regular aerobic physical activity such as

brisk walking for at least 30 minutes 3-6days a week.

This will help in reducing the blood pressure by 4-

9mmHg. Avoid sedentary life, help in reducing blood

pressure.

36

4. Moderation Of Alcohol Consumption

Limit the consumption of alcohol to one bottle per week

and whisky one shout per week in most men and to no

more than one drink per day in women and lighten-weight

people.

5. Smoking

Prohibit Smoking to avoid the high risk of hypertension

that may occur by the use of tobacco.

6. Psychosocial

Every individual should be encouraged to express their

anger or should be encouraged to do so since

suppression of anger feeling leads to high risk of

hypertension.

7. Medication

Medication compliance is very necessary to avoid

relapse and complication of the illness. The

patient/client should report any side effect of

medication to his physician immediately.

8. Genetics Counseling

An individual that are from a family that have the

history of hypertension should be advise to go for

37

medical check up regular for early detection and

control of hypertension.

9. Relaxation Techniques

An individual once a while should try to attend

recreation centers, watching of program that makes you

happy to avoid thinking, or issues that will make you

feel unhappy or sad at a time, which will cause slight

rise in blood pressure.

COMPLICATION

If hypertension is not treated:

it can leads to left ventricular hypertrophy

it can leads to myocardial infarction

It can cause cerebrovascular accident (CVA),

stroke, or brain attack.

it can cause renal insufficiency and failure to the

patient

it causes renal hemorrhage

it leads to transient ischemia attack (TIA)

It causes cognitive impairment and dementia to the

patients.

CONCLUSION38

Hypertension is an important risk factor for

cardiovascular morbidity and mortality, especially in

the elderly. Multiple trials have shown that it is safe

to treat hypertension in the elderly; it will decrease

the rate of stroke, heart failure and myocardial

infarction. Hypertension treatment also reduces the

incidence of cognitive impairment and dementia in the

elderly. The adoption of a healthy lifestyle is one of

the cornerstones of hypertension management. Evidence

has shown that several classes of anti hypertension

drugs are effective in preventing cardiovascular

disease, but usually no single drug is adequate to

control hypertension in most elderly people. Guide

individualization of treatment by the presence of

concomitant cardiovascular risk. For all those

aforementioned reasons, physicians should treat

hypertension in their patients regardless of their age.

RECOMMENDATIONS

In view of the above discussion, I recommend the

following:

The public should be properly educated on the

importance of regular check of blood pressure. 39

The health personal especially the Nurses should

teach the public the importance of exercise, eat

foods that are of low salt and fat continent.

Expert medical personal such as the nurses,

doctors, nutritionist and dietician who are qualify

should equally be employed by government to the

rural communities to teach, diagnose and treat the

at risk group for hypertension especially the

elderly.

40

REFERENCES

Abrass, I.B., (1990). The biology and physiology of

aging west J. Med. 153: 641-644.

Aronow, W.S., Fleg, J.L., Pepine, L.J., Artinian, N.T.,

Bakris, G. Ferdinard, K.C., Ann, F.M., Frishman, W.H;

Jaigobine. (2011). Expert consensus document on

hypertension in the elderly a report of the American

college of cardiology foundation Task force on

clinical. Expert consensus documents developed in

collaborative with the American Academy of Neurology,

American Geriatric society, American society or

preventive cardiology, American society of

Hypertension. American society of Nephrology,

Association of Black cardiologist and European

society of Hypertension J. Am coli curdiol. 57:2037-

2114.

Chobanian, A.V., Bakris, G.L., Black, H.R. Cushman,

W.L., Green, L.A; Jones, D.W., Materson, B.J.,

Oparil, S.,Wright, S.T., (2003). The seventh report

of the joint National committee on prevention,

41

Detection, Evaluation, and treatment of High Blood

Pressure. 289:2560-2572.

Cifkova, R., Pitta, J., Lejskouva, M. Lanska V; Zecova,

S. (2008). Blood pressure around the menopause.

Coylewright, M., Reckelhoff, J.F., Onyang, P.,

(2008).Menopause and hypertension and age-old debate.

Davis, B.R., Langford, G.G., Blaufox, M.D., Curb, J.D.,

Polk, B.F., Shulman, N.B., (1987). The association of

postural changes in systematic blood pressure and

mortality in persons with hypertension. The

hypertension detection and follow-up program

experiences.

Epstein, M., (1996).Aging and the kidney. JAM Soc

Nephrol.

Flag, J.C. (1986). Alterations in cardiovascular

structure and function with advancing age.

Hamilton, G.A. (2003). Measuring adherence in a

hypertension clinical trial.

Health united states. (2007). With Chart book on trends

in the health of Americans.

42

Heron, M., Hoyert, D.L., Murphy, S.L., Xu, J.,

Kochanek, K.D. Tejada-vera, B. (2009). Deaths final

data for 2006. Nat. vital state Rep. 2009, 57.1-134.

Hertz, R.P., Unger, A.N., Cornell, J.A; Sauhders, E.

(2005). Racial disparities in hypertension

prevalence, awareness, and management, 165:2095-2104.

Kannel, W.B., Dawher, F.R., Sorlie, P., Wolf, P.A.,

(1976). Components of blood pressure and risk of

atherothrombotic brain infarction. The framing study.

Kario, K., Eguchi, K., Nakagawa, Y., Motal, K.,

Shinada, K. (1998). Relationship between extreme

dippers and orthostatic hypertension in elderly

hypertensive patients.

Kearney, P.M., Whelton, M., Reynolds, K., Muntner, P.,

Whelton, P.K. (2005). Global burden of hypertension

analysis of worldwide data.

Levy, C., Larsan, M.G., Vasan, R.S., Kannel, W.B.,

Hokk. (1996). the progression from hypertension to

congestive heart failure.

Mary, C.T. Psychiatric Mental heart nursing (5th Ed.)

43

Millar, J.A & Lever, A.F. (2000). Implications of pulse

pressure as a predictor of cardiac risk in patients

with hypertension.

Nanda Label hypertension. (Thursday. 19, 2012).

Necl, L., Benowitz, M.D., Basic and clinical

pharmacology. (10th Ed).

O’Rourke, M.F., Hashimoto, J. (2007). Mechanical

factors in arterial aging, a clinical perspective.

Pimenta, E. (2012). Hypertension in women.

Seals, D.R. and Esler, M.D. (2000). Human aging and the

sympathoadrenal system.

Suzanne, C., Smeltzer, Breda, G., Bare, Janice, Hunkle,

Kerry, H., Cheever, Brunner and Suddarth’s, Textbook

of medical;-surgical Nursing. (12th Ed.).

Wasserthal-smoller, S., Anderson, G., Psaty, B.M.,

Black, H.R., Manson, J., Wong, N. Francis, J., Grinm,

R., Kotchen, T., Langer, R: (2000). Hypertension and

its treatment in postmenopausal health initiative

hypertension.

44

World Journal of cardiol. 2012 May 26, 4(5): 135-147

published online 2012 may 26.

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