From my perspective, the older I get the more I value the very old. One question I enjoy asking the over 80-year-old patient group visiting my office is this: What did you learn in life after age 60 that you were totally unaware of before age 60? I am intrigued by the variety of answers to this question. The under-sixty group have been generally exposed to the same life issues; however, at age 60 (or thereabouts), the 80 to 100-year-old group have walked on unexplored territory from our perspective and to me are an interesting and informative group.

In the area of hypertension and high blood pressure management, there has always been some uncertainty as to whether doctors should treat an 85-year-old patient who is found to have high blood pressure, that is a systolic (the upper number) blood pressure greater than 160 or a diastolic (the lower number) blood pressure above 90. Sixty years ago, an eminent cardiologist advised that doctors should not tamper with high blood pressure in the elderly because it may be some sort of protective mechanism. Over the last 50 years, there has actually been some support for that observation in that older patients may actually have adverse effects from blood pressure medications and lowering of their blood pressure. Therefore high blood pressure has not been treated aggressively in the over-80 year old population. However, the changing demographics of the United States make it imperative to be certain regarding the decision to treat high blood pressure in the older patient. In the United States, the over-80 demographic group is the fastest growing group and the numbers are certainly going to grow over the next 30 years. In 1967, it was made clear that antihypertensive therapy reduces heart disease and stroke in the adults aged 40 to 60 years old. Now, after forty years of study, it is clear that treating high blood pressure in very elderly is also favorable for the patient. In a multi-country study of nearly 4000 patients over the age of 80, half were treated to reduce high blood pressure and the other half were followed without treatment for a period of 2 years. The results of the study were recently published in the New England Journal of Medicine. There was a reduction in the rate of stroke by 30% in the treated group. Additionally, overall death rate from all causes fell by 20%, fatal stroke was reduced by 39%. The rate of death from all cardiovascular causes was reduced by 23% and the rate of fatal and nonfatal congestive heart failure was reduced by 64%. Finally, the rate of any cardiovascular event, death from stroke and from all cardiovascular causes, (ie. heart attack plus heart failure) was reduced by 34%. The benefits were seen actually in the first year of treatment and did not change particularly during the second year of the study. This was a signature study for which all the participants can be appropriately applauded because the results affect millions of individuals. There are several issues of concern in the study: namely the 80-year-old and older patients in the study seemed to be a bit healthier than the general population; that is, the death rate, treated or untreated, was generally lower than one might expect for this target population. Patients were excluded from the study if they were in a nursing home, if they had profound debilitation, if they were on multiple medications and if they were apparently nutritionally deficient. Also patients with malignancy and patients who were demented were excluded from the study. However, for the patients entering my office over the age of 80 and whom I am delighted to ask the question about what they learn after the age of 60, I also can answer them affirmatively with confidence when they ask me about the point of treating their high blood pressure. Doctors have learned something new for the very old from this study, and I am always hopeful and delighted to learn something new from our senior citizens.

Dr. Nicholas Costrini writes regularly for the Savannah Morning News. His articles occur every other week in the close-up section. He may be contacted at ncostrini@georgiagi.com.

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