-     Put the patient in the center to determine the benefits and side effects of antihypertensive treatment, thereby determining the target blood pressure and which medication needed to treat, mono-therapy or coordination.

II. THE DEGREE OF AGING

-    When evaluating the degree of aging, keep in mind two kinds of age category

o Chronological age: Elderly in Vietnam is 60 years old or more

60 – 69 : young old

70 – 79 : old old

80 and more: oldest old

o Biological age: The level of physical and mental activity daily (also called functional daily activities)

o Combining chronological age and biological age to determine the degree of aging.

-    The degree of aging is divided into 3 levels:

o Healthy aging (successful or fit)

o Frail: including subclinical weakening (asymptomatic) to severe impairments

§    Physical impairments including daily physical activities from self-care to occupational activities

§    Mental impairments mainly in many degrees of memory deficits (memory disorders, dementia, Alzheimer's)

o End-of-life stage: with expected 1-2 final years of life

-     For healthy aging, blood pressure control can be achieved the same as adults (< 60 years of age). Avoid symptoms of postural hypotension.

-     For frail patients, setting target blood pressure depends on the degree of clinical impairment, the best is around systolic 140-145 mmHg. Monitoring closely for symptoms of postural hypotension.

-    For end-of-life stage, mainly palliative care, avoid hypertensive crisis, avoid hypotension.

Minimum antihypertensive drugs if possible.

III. COMORBIDITIES

-     Elderly hypertensive patients often have comorbidities including chronic complications of hypertension such as coronary artery disease, chronic heart failure, chronic kidney disease; risk factors such as diabetes, sedentary.. ; and comorbidities like osteoarthritis...

-    Pay attention to comorbidities to specify which antihypertensive medication is the most

appropriate (also called mandatory indication).

IV. THE IMPORTANT NOTES

Always remember the triangle disease in elderly patients: hypertension - comorbidities - the degree of aging.

Take the patient in the center to choose the target blood pressure, and which medication. Start with a low dose, increase the dose slowly.

Avoid symptoms of postural hypotension, never let systolic < 120 mmHg and diastolic <60 mmHg.

All current antihypertensive drugs can be used depending on the comorbidities.

If there are no comorbidities, appropriate drugs for the elderly consist of three: diuretics, calcium channel blockers, and inhibition of the renin–angiotensin system (RAAS).

Diuretics. Thiazide-type diuretics are recognized as the cornerstone of antihypertensive therapy because of their extensive record in preventing stroke and cardiovascular events and their low cost. However, questions have been raised about dosing and about the long- term consequences of their adverse metabolic effects. Although "low-dose" thiazide-type diuretics are generally recommended for BP treatment, outcome benefits of diuretics as first-line agents have been demonstrated only at moderate doses (equivalent to ≥ 25 mg hydrochlorothiazide). There are no outcome data for truly "low-dose" thiazides (equivalent to ≤ 12.5 mg hydrochlorothiazide). Further, most outcome trials in the United States, including ALLHAT, have used chlorthalidone, a thiazide-like diuretic that is twice as potent as and has a longer duration of action than hydrochlorothiazide. In ALLHAT, the average dose of chlorthalidone was 20 mg, roughly equivalent to 40 mg of hydrochlorothiazide. On the basis of outcome trials and the observation that it is more effective than hydrochlorothiazide in lowering 24-hr systolic BPs, chlorthalidone deserves consideration in the treatment of hypertension in the elderly.

The downside of this approach is that moderate-dose diuretic therapy increases the incidence of hypokalemia, insulin resistance, and type 2 diabetes. Outcome trials have not shown that diuretic-induced diabetes is associated with cardiovascular disease outcome, but it has been argued that this is an artifact related to their short (< 5 years) duration of follow-up. Extended observation of participants in ALLHAT and other trials is ongoing in an effort to address this issue.

CCBs. These agents have performed particularly well in preventing stroke in elderly hypertensives. A recent meta-analysis found that dihydropyridine CCBs reduce stroke by 10% compared with other active therapies. Much of this advantage may be related to their robust BP-lowering effects, which were evident in both the Antihypertensive Long-term Use Evaluation (VALUE) and ASCOT trials, where 4-5 mm Hg lower brachial artery systolic BP levels were noted in the first few months of CCB-based therapy compared with ARB- or beta-blocker-based treatment. The BP differences contributed to, but may not have fully accounted for, the superior outcome results of CCB treatment in these trials. CCBs are metabolically neutral and, except for peripheral edema, are relatively free of adverse effects. In principle, the lack of adverse metabolic effects may represent a major advantage of CCBs over diuretics for a population in which the metabolic syndrome/insulin resistance is becoming epidemic. However, this theoretical advantage has yet to be substantiated in clinical trials.

On the basis of BP-lowering efficacy and outcomes data, CCBs are acceptable alternatives to diuretics for first-line treatment of hypertension in the elderly and may offer advantages in some patient groups, eg, those with the metabolic syndrome. While acquisition costs are substantially greater for CCBs than for diuretics and some other drug classes, drug costs represent only a fraction of the total cost of care of the hypertensive patient. We await cost-benefit analyses from large trials such as ALLHAT and ASCOT to fully assess the pros and cons of first-line CCB vs diuretic therapy in the elderly hypertensive.