Geriatric Nephrol-ogy

& Hypertension in the elderly

성균관 의과대학교강북삼성병원 신장내과

이 규 백

2010, June/8

The biochemical composition, the physio-logical capacity, the ability to maintain homeostasis Vulnerability to disease processes or death

Aging

Age-friendly Health Care, WHO

2000 년 2050 년 , 노인 ~30%

전염질환 감소 , 만성병과 정신병 증가

노인 만성병

의료비용

사회적인 책임

,Downhill, Iatrogenic

• Fall• Urinary incontinence• Immobility• Infectious process• Oral, dental diseases• Food and nutrition: Sarcopenia 5~13%• Delirium • Dementias: 고령 - 기억력 장애 15~45% • Depression: 고령의 투석환자 -45% 우울증• DM, HTN, CKD, atherosclerosis……

Geriatric syndrome

Geriatric Nephrol-ogy Has Come of Age:At Last, 2009 ASN

Geriatric Nephrology

1. The incidence of new patients with ESRD:

over the age of 65 yr -over 65 yr-old: double in next 20yr -over 85 yr-old: 38% growth during

the 1990s -75 yr-old: average 3.5 chronic dis-ease

2. CKD patients: most of whom are elderly65-74 yr:~25%, 75-85 yr:~35%, 85+yr:~45%

The Coming Pandemic of CKD/ESKD and the Aging Population

70 대가 말기신부전 발병의 절정 !

Geriatric Nephrology

Why Do We Need a Geriatric Nephrology Curriculum?

• This older population will bring their problems to the nephrologists.• Dialysis patients rely on their nephrologists for most of their care.Þ“ 신장내과 의사가 80% 문제 해결” “ 의료 공급자를 단순화 - 비용 , 부작용 줄임”

Drug Dosing and Renal Toxicity in the Elderly Pa-tient

고령환자에서 약물부작용 : 3-10 배신장질환 : 부작용 급증

인식 , 감각 , 기억력

Drug in the Elderly Patient

Drug Dosing and Renal Toxicity in the Elderly Pa-tient

• Review patients past medical history and medication: drug–drug interactions• For GFR<50 ml/min: adjust drugs ac-cording to the renal function• Dosage modification: dose reduction, dosing interval prolongation, or both methods• Consider therapeutic drug monitoring (TDM) in older patients with renal impairment

최소로 단순하게 약을 투여하여야 !

Medication in the elderly

• Elderly patients: at higher risk for the AKI• Hemodynamic, metabolic, and molecular changes increased susceptibility to injury• Multiple etiologies are often opera-tive in the development of AKI.• The outlook for renal recovery is likely impaired in the elderly patient. (단지 28% 회복률 )

Acute Kidney Injury in the Elderly

Acute Kidney Injury in the Elderly

Decision Making

VES: Vulnerable Elders Survey, ADL: Activities of Daily Living

건강 취약 허약

• Healthy/usual( 건강 ): might be a transplant candidate• Vulnerable( 취약 ): typical dialysis candidate, Geriatric assessment and interven-tion plans may slow the progression of geriatric susceptibility factors• Frail( 허약 ): should be considered for a nondialytic treatment plan or a time- limited dialysis trial. Final decisions will hinge on patient preferences, QOL, and contextual issues

ACOVE stage (Assessing Care of Vulnerable Elders)

Dialysis patient disease trajectory

투석환자 사망률 : 24%/ 년 , 입원율 66%/ 년80 대 , 90 대 투석환자 사망률 : 46%/ 년

삶의 궤적

이상적인 치료

The trajectory of care during chronic illness임종 , 존엄사 , well-dying

Hypertensionin the Elderly

President FD Roosevelt dying of a cerebral hemorrhage on April 12, 1945, and his physician, AR McIntire, declaring that “it had come out of the clear sky,” even though Roosevelt was known to have had Hypertension and CRF for more than ten years.

“I’ve also been treat-ing the high choles-terol and then I stopped the medicine because I got my cholesterol down low. And, I had in the past, a little blood pressure problem, which I treated and then I got it down…”Former US President Clinton, awaiting coronary bypass surgery,

calls into Larry King Live from his hospital bed; Sept 3, 2004,

Non-adherence to treat-mentComorbidity, Life style

대한임상노인의학회 2009

-associated with elevated cardiac output, such as anemia, hyperthyroidism, aortic insufficiency, AV fistula, and Paget’s dis-ease of bone.

-most cases are caused by reduced elas-ticity and compliance of large arteries re-sulting from age and from the atheroscle-rosis-associated accumulation of arterial calcium and collagen and the degradation of arterial elastin. Increasing PWV, raising the peak systolic BP.

Isolated systolic hypertension, elderly hypertension

Mean Blood Pressure According to Age and Race or Ethnic Group in U.S. Adults

NEJM 2007;357:789-796

Frequency of Untreated Hyper-tension According to Subtype and Age NEJM 2007;357:789-796

-When BP measurements are el-evated, but the BP is actually normal. -As people get older, the walls of the arteries sometimes get very thick, and calcium may be deposited in the arterial wall. This makes the arteries very stiff and difficult to compress.

Pseudohypertension

Doctors usually suspect pseu-dohypertension in cases where:

-The BP reading is very high over time, but the patient has no signs of organ damage or other Cx. -Attempting to treat the mea-sured high BP causes symp-toms of low BP (dizziness, con-fusion, decreased UO)

The Osler maneuver is performed by palpating the pulseless radial or brachial a. distal to the point of occlu-sion of the a. by the sphygmo- mano-metric cuff. When either of these a. re-mains palpable (despite being pulse-less), the patient is described as “Osler positive.” In contrast, when either a. collapses and becomes impalpable, the patient is “Osler negative.” Osler in 1892, Messerli et al in 1985

Nowadays, Inappropriate, Upper limb PWV, Intraarterial BP

Osler’s maneuver

NEJM 1985;321:1548-1551

White Coat Hypertension

-Patients were 60 years old or more. Systolic BP was 160 mm Hg or greater and diastolic BP was less than 95 mm Hg.-8 trials, 15,693 patients, were followed up for 3.8 years.

Active treatment reduced total mortality by 13% (95% CI 2–22, p=0·02), cardiovascular mortality by 18%, allcardiovascular complications by 26%, stroke by 30%, and coronary events by 23%.Lancet 2000; 355: 865–872

Lancet 2000; 355: 865–872

Summarised results in older patients with isolated sys-tolic hypertension enrolled in 8 trials of antihypertensive drug treatment

Lancet 2000; 355: 865–872

30% 23% 26% 13%

N=15,963F/U for 3.8yr

-Leiden, The Netherlands.-599 inhabitants of the birth-cohort 1912–1914 were enrolled on their 85th birthday. There were no selection cri-teria related to health or demographic characteristics.The mean follow-up was 4.2 years.During follow-up 290 participants died, 119 due to cardiovascular causes.J Hypertension 2006, 24:287–292

Cumulative all-cause mortality depending on systolic and diastolic BP at age 85 years.

N=599F/U for 4.2 yr

J Hypertension 2006, 24:287–292

High BP at baseline (age 85 yr) was not a risk factor for mortality. Baseline BP values below 140/70 mmHg (n = 48) were associated with excess mortality, predominantly in participants with a history of hypertension

Confounding poor health sta-tus! pitfall of observation study

J Hypertension 2006, 24:287–292

Randomly assigned 3845 patients who were 80 years of age or older and had a sustained systolic BP of 160 mm Hg or more to receive either the diuretic inda-pamide (sustained release, 1.5 mg) or matching placebo. The ACE inhibitor perindopril (2 or 4 mg) was added if nec-essary to achieve the target BP of 150/80 mm Hg. N Engl J Med 2008;358:1887-98

N Engl J Med 2008;358:1887-98

Placebo (1912 patients)active-treatment (1933 patients) Median follow-up=1.8 years.

Mean BP According to Study Group

HYVET Study: HTN in the very elderly trial(>80yr)

HYVET Study: HTN in the very elderly trial(>80yr)

N Engl J Med 2008;358:1887-98

N=3845, F/U=1.8 yr

NEJM 2007:357;789-796

Isolated Systolic Hypertension in the Elderly

NEJM 2007:357;789-796

Isolated Systolic Hypertension in the Elderly

Antihypertensive drugsJNC 7, Five major classes: AABCDACE inhibitors, ARB, β-adrenergic blockers, CCB, diuretics

ESH, ESC, British guideline-no preference to diuretics-argue against diuretics and β block-ers

In two thirds of patients with hyper-tension, two or more drugs will be required to achieve target BP levels. “Combination therapy”

Strategies for Improving BP ControlFail to treat:inadequate patient education, physician empathy, and social support; the pres-ence of coexisting diseases; complex dose regimens; problems with transportation of the patient, side effects and the cost of medications.

Cooperation: physician, nurse clinicians, physicians’ assistants, and pharmacistsA low starting dose and a gradual in-crease (e.g., every 2 to 4 weeks): in frail, immobile and diabetes patients

Area of Uncertainty-Clinical studies are not enough.-Exact measurement of BP-Pseudohypertension-Old age? Extreme old age(80 yr)-Target BP? 150/80 mmHg-Systolic BP: >160 mmHg 140-159 mmHg, no stud-ies-Subgroup analysis: heart dz, DM, storke, CKD, not mo-bile pt

SummariesGeriatric Nephrology-Geriatrics; multiple pathology, polypharmacy-Pandemic of CKD/ESKD; cardiovasc cx, infection, multiple cx-Adverse drug reaction-AKI on CKD

Hypertension in the elderly-misconception, non-adherence-pseudoHTN, white coat HTN-isolated hypertension-HYVET study: sys BP>160 target BP 150/80 mmHg-Subgroup?-Target BP? Patient to patent, comorbidity, PseudoHTN