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Management of hypertension on frail patients

Management of hypertension on frail patients

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1.Based on the article you reviewed concerning older adults and management of hypertensive; identify reasons for change in management treatment of systolic blood pressure (150-250 words – Cite with in-text citations and sources on the Reference page.)

The benefits of lowering blood pressure in old patients were considered controversial for a long period of time. This is ascribed to the fact that some studies demonstrated that lowering blood pressure in old patients led to a reduced death rate; whereas some showed that it contributed immensely to an increased death rate (Lally & Crome, 2007). Also, none of the studies had conducted a study with enough patients of age eighty and above so as to give a precise answer on the importance of the drug therapy for this group. Earlier guidelines involved commencing antihypertensive therapy when (SBP) systolic blood pressure was more than 160, DBP (diastolic blood pressure) was more than 105 or there was an organ likely to be damaged. The HYVET (Hypertension in the Very Early Trial) helped to shed light on the controversy explicated above. The study comprised of three thousand, eight hundred and forty five patients who were eighty years and above old, and had an SBP of 160 and above (DiWang & Lam-Antoniades, 2013). The most favorable blood pressure mark was determined to be 150/80 and it was linked with reduced risk of death from any cause, death from stroke, as well as heart failure (Warwick, Falaschetti, Rockwood, Mitnitski, Thijs, Beckett, Bulpitt & Peters, 2015). It was also realized that a reduction in the blood pressure would result to ischemic strokes. The study results implied that frailty alone should not be the only criterion used to decide whether or not the medication of a person aged eighty and over with an antihypertensive to reduce blood pressure to a mark of 150/80 mmHg is reasonable (DiWang & Lam-Antoniades, 2013).

2.What treatment regimen would you consider  for an older adult who has well controlled diabetes and hypertension? (Cite with in-text citations and sources on the Reference page.)

Hypertension is a common condition in patients suffering from diabetes, affecting between twenty and sixty percent of diabetic patients. In type 2 diabetes, hypertension normally presents itself as part of the metabolic set of symptoms of insulin resistance (DiWang & Lam-Antoniades, 2013). Conversely, in type 1 diabetes, hypertension may reflect the beginning of diabetic nephropathy. Clinical studies have revealed that hypertension increases risks of both micro-vascular and macro-vascular complications such as coronary heart disease, stroke, nephropathy, peripheral vascular disease, retinopathy, as well as neuropathy.

In managing hypertension with diabetes, the following treatment regimens should be put into use. First, the patient should be treated to a diet with moderate sodium restriction. This is essential since moderating sodium helps in reducing blood pressure. Studies have proved that an intake of sodium has led to a reduction in systolic blood pressure of approximately 5mmHg and diastolic blood pressure of 2-3mmHg. The patient should also take part in intense physical activity. For instance, walking for thirty or forty five minutes for four to five days in a week has been demonstrated to lower blood pressure. Alcoholic patients should also be advised to minimize their intake; whereas smokers should be advised to quit as part of the treatment plan. For drug therapy, the patient should be given Angiotensin-Converting Enzyme (ACE) inhibitors since ACE inhibitors lowers blood pressure for individuals with hypertension as a result of their capability to calm down contracted blood vessels (Lally & Crome, 2007). Consequently, it prevents deaths that can likely arise from heart diseases and diabetic patients fall in this group.

3.What laboratory management and follow up is required for an elderly hypertensive patient? An elderly hypertensive diabetic? An elderly hypertensive with renal impairment? (Cite with in-text citations and sources on the Reference page.)

Elderly patients taking ARB’s or ACE inhibitors, renal function should be examined since the treatment could be linked to deteriorating renal function and an increase in serum creatinine (Lally & Crome, 2007). Patients who are dependent on renin-angiotensin aldosterone system, the potassium should be examined since two to five percent of the patients normally develop hyperkalemia. The test should be done two weeks before starting the therapy and two weeks after starting the therapy. Patients on aldosterone antagonists or diuretics should also have their potassium checked once a year (Warwick et.al, 2015). However, if there is any dosage change, then the examination should be conducted twice a year since excessive use of one drug can cause dieresis and electrolyte loss. Consequently, renal function should be examined since diuretics may lead to azotemia, oliguria, as well as increases in creatinine.

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4.How would you address your patient’s management using the Frailty index when selecting a pharmacologic regimen (safety)? (Refer to FRAILTY INDEX).

Frailty refers to a clinical condition that determines a person’s physiological state in a manner that raises their susceptibility to stressors; thus, putting them at great risks for unfavorable health outcomes such as worsened functional impairment, recurrent falls, hospitalization, and even death.

A patient’s frailty can be assessed using the Clinical Frailty Scale. This scale asserts that frailty exists continuously from fit to terminally ill. It highlights the fact that every level of frailty has a varied functioning level, vulnerability and ability that plays an important role in determining the approach necessary for administering care.

When selecting a pharmacologic regimen, the blood pressure of the patient should be redefined. When initiating therapy the systolic BP should be 160 mmHg and it should be reduced to 150mmHg and below. This is ascribed to the fact that high systolic BP has adverse effects such as falls, bradycardia, hyperkalamia, and arrhythmias (Lally & Crome, 2007).

Important factors to be put into consideration when selecting a pharmacologic regimen include the life expectancy, treatment targets, time needed to achieve the treatment benefit, goals of the care against the risk, as well as the patient’s thoughts on the treatment. These factors are collectively known as the poly-pharmacy. They aim at addressing all the outcomes that can negatively impact the treatment process (Lally & Crome, 2007).

5.What is your opinion regarding the differences in management approaches (as reflected in each authors’ articles).

The varied approaches as illustrated by the two authors all point at the same thing. Both the approaches seem to agree that frailty alone should not be the only criterion used to decide whether or not the medication of a person aged eighty and over with an antihypertensive to reduce blood pressure. This is as ascribed to the fact that they tend to highlight the HYVET (Hypertension in the Very Early Trial) study which shed light on the controversy surrounding lowering blood pressure in old patients (DiWang & Lam-Antoniades, 2013).

Warwick et.al (2015) revealed that there is no evidence that links the effects of hypertension treatment and frailty. This came about since adults, the frail and the fit, benefitted from the treatment. This is a clear indication that a patient’s frailty does not affect the treatment he or she receives. On the other hand, DiWang & Lam-Antoniades (2013) concluded that there should a specified blood pressure level that hypertension patients should not go exceed or go below.


DiWang & Lam-Antoniades, M. (2013). Challenges of hypertension management in the frail very elderly with multiple co-morbidities. CGS Journal of CME, 3(1): 5-7. Lally, F. & Crome, P. (2007). Understanding frailty. Postgrad Med J, 83(975); 16-20 Warwick, J., Falaschetti, E., Rockwood, K., Mitnitski, A., Thijs, L., Beckett, N., Bulpitt, C. & Peters, R. (2015). No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Medicine, 13(78).

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