ABSTRACT
I. CLINICAL RELEVANCE A. Epidemiology It is universally appreciated that elderly patients merit special consideration in the diagnosis, evaluation, and treatment of hypertension. However, this germane facet of patient care has not been extended to the specific issue of hypertensive crises in the elderly. It is common for review articles dealing with hypertensive crises to ignore the subtleties of treating the geriatric patient (1-3). Few studies have focused on the effective and safe treatment for dangerously high blood pressure levels in this extremely vulnerable population. This is alarming in view of the rapidly growing geriatric population in the United States. In 1990, this group made up 12.6% of the population (31.4 million), with a projected increase to 19.6% of the population (58.9 million) by the year 2025 (4,5). Over the past four decades the elderly subset of the oldest-old individuals, aged 85 years and older, has increased its numbers by 232% compared with a growth of 39% in the general population (5). Moreover, hypertension is disproportionately represented in the elderly, with a prevalence of more than 50% (6,7). The impact of hypertension on mortality and morbidity in the United States is dramatic and substantial. Hypertension is a major risk factor for both coronary artery disease and cerebrovascular accidents, the first and third leading causes of death annually respectively. Despite this dire state of affairs, many health care providers have not earmarked
blood pressure control as a priority for their elderly patients. More than half of this population remains untreated, and in more than half of the treated patients blood pressure levels are not adequately controlled (8-11). Inadequate blood pressure control increases the risk of detrimental sequelae developing in these individuals. Cautious encouragement comes from one study of patients enrolled in a large health maintenance organization (HMO). From a period from 1967 to 1988, the organization identified between 44% and 53% of its hypertensive enrollees. Treatment for these patients during this period increased from 25% to 60%, and the proportion of patients on treatment and controlled increased from 8% to 34% (9). Despite this report, it is still unclear whether HMOs differ from their fee-for-service counterparts in the quality of care provided to older hypertensive patients (12-14).
