What is the evaluation for a 90-year-old female with hypertension and right hip pain?

From the Guidelines

The evaluation for a 90-year-old female with hypertension and right hip pain should prioritize careful assessment of orthostatic hypotension and consideration of non-pharmacological approaches.

Evaluation Approach

• The patient's blood pressure should be measured in both sitting and standing positions to assess for orthostatic hypotension, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
• A comprehensive medical history should be taken to identify potential secondary causes of hypertension, such as kidney disease, sleep apnea, or hyperthyroidism, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
• The patient's medication list should be reviewed to identify any potential contributors to orthostatic hypotension, such as antihypertensive medications, and to consider alternative therapies that may be better tolerated.

Considerations for Hypertension Management

• BP-lowering treatment should be maintained lifelong, even beyond the age of 85 years, if well tolerated, as recommended by the 2024 ESC guidelines 1.
• Non-pharmacological approaches, such as lifestyle modifications, should be considered as the first-line treatment for orthostatic hypotension, as recommended by the 2024 ESC guidelines 1.
• Careful titration of BP-lowering medications is necessary to avoid exacerbating orthostatic hypotension, as highlighted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline 1.

Additional Evaluations

• Subclinical organ damage should be assessed, including electrocardiography, echocardiography, and ultrasound scanning of carotid arteries, as recommended by the 2007 guidelines for the management of arterial hypertension 1.
• Cognitive tests may be helpful in detecting initial brain deterioration in elderly hypertensives, as mentioned in the 2007 guidelines for the management of arterial hypertension 1.

From the Research

Evaluation of Hypertension in a 90-year-old Female

The evaluation of a 90-year-old female with hypertension involves a comprehensive approach to manage blood pressure and associated risk factors. According to 2, the office evaluation of the hypertensive patient should include a valid estimate of average blood pressure, assessment of target organ damage, and identification of other risk factors.

Key Components of Evaluation

• A focused history and physical examination to assess the principal target organs, including the optic fundi, central nervous system, heart, and kidneys 2
• Laboratory evaluation, including urinalysis, ECG, and determinations of blood hemoglobin/hematocrit, creatinine, potassium, glucose, and cholesterol, including HDL fraction 2
• Accurate blood pressure measurement and a handful of basic tests to determine if the patient has sustained high blood pressure and to identify any target organ damage 3

Considerations for Elderly Patients

• Hypertension in elderly people differs from that in younger people, with predominantly systolic hypertension due to vascular stiffness, reduced baroreflex sensitivity, and increased blood pressure variability 4
• Treatment goals and medication selection for elderly patients may differ from those for younger patients, with a focus on reducing cardiovascular morbidity and mortality and possibly cognitive and functional decline 4
• The presence of co-morbidity, drug interaction, and side effects should be considered in the management of hypertension in the elderly 5

Management of Hypertension in the Elderly

• A careful and individualized approach is needed, considering the biological rather than chronological age for patients >85 years 6
• The use of single-pill combinations to simplify treatment algorithms and increase long-term drug adherence is recommended 6
• A less conservative threshold and lower blood pressure targets may be appropriate for elderly patients, with a focus on patient frailty and tolerability of treatment 6

Right Hip Pain Evaluation

There is no direct evidence in the provided studies to assist in evaluating the right hip pain in a 90-year-old female with hypertension. However, a comprehensive evaluation of the patient's overall health, including a focused history and physical examination, may help identify any underlying conditions that could be contributing to the hip pain.