Hypertension Nonpharmacologic Treatment Modalities

There are several reasons to review the role of nonpharmacological treatment modalities in treating geriatric hypertension. The older hypertensive population may in general be characterized as overweight, sedentary, and salt sensitive. Lifestyle modifications targeted toward these characteristics may therefore be of particular benefit in older hypertensive patients. Nonpharmacological therapies may be effective initial therapy; individuals with stage 1 hypertension (systolic blood pressure less than 160 mmHg) who do not have diabetes should complete a 6-month trial of nonpharmacologic therapy before adding an antihypertensive medication if the target blood pressure is not achieved.

In addition, these therapies may be adjunctive in combination with pharmacologic treatments, they may result in concurrent improvements in other cardiovascular risk factors, and there are minimal associated risks (as well the benefit of possibly avoiding adverse side effects associated with antihypertensive medications). A number of lifestyle modifications may be recommended: weight reduction; an aerobic exercise program; dietary alterations to decrease sodium, saturated fat, and cholesterol while maintaining adequate intake of potassium, calcium, and magnesium; smoking cessation; and moderation of alcohol intake.

A randomized trial of nonpharmacologic interventions in older hypertensive subjects that evaluated the effects of dietary sodium restriction and weight loss (the TONE study) demonstrated that relatively modest reductions in dietary sodium intake (~40 mmol/day) and in body weight (~4 kg) were accompanied by a 30% decrease in the need to reinitiate pharmacologic treatment. A meta-analysis of randomized trials assessing the effects of dietary sodium restriction demonstrated that there is a significant reduction in systolic (a mean decrease of 3.7 mmHg for each 100 mmol/day decrease in sodium intake) but not in diastolic blood pressure.

Consistent with these results, a follow-up study to the dietary approaches to stop hypertension (DASH) trial that added a sodium restriction component identified that the DASH diet in combination with sodium restriction (~65 mmol/day intake) resulted in a decrease in SBP of 11.5 mmHg in hypertensive patients in comparison to the control, high-sodium diet. Although diastolic blood pressure was also lower, the magnitude of the effect was less than that for systolic BP. The differential reduction in systolic pressure in response to dietary sodium restriction observed in these studies is particularly well suited for the older hypertensive patient.

There is a high prevalence of obesity in the older population: 26% of black and white men, 36% of white women, and 60% of black women between the ages of 65 and 74 years were characterized as overweight (defined by body mass index ≥27.8 kg/m2 for men and ≥27.3 kg/m2 for women) in the National Health and Nutrition Examination Survey. There is increasing evidence that the distribution of body weight is an important determinant of cardiovascular risk.

In particular, central adiposity has been shown to be associated with hypertension, hyperlipidemia, and insulin resistance. Weight reduction is recommended for hypertensive individuals who are more than 10% above their ideal body weight, and weight loss of the order of 5 kg has been shown to result in small (generally less than 5 mmHg), but significant, decreases in blood pressure.

There are likely additive antihypertensive effects of lower extremity aerobic exercise programs. Although there are special considerations in an older hypertensive patient with regard to screening for the presence of underlying cardiovascular disease and attention to the prevention of injuries, the safety and efficacy of aerobic exercise has been identified in studies of older hypertensive individuals.

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