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Other Comments:
Claasen J et al reported an interesting case report about a very usual dilemma for geriatricians: is-it possible to apply guidelines about antihypertensive treatments to elderly people. Indeed, demented nonagenarians are usually excluded from randomized controlled trials. On the other hand, I perfectly agree with the author that there are no evidences not to treat high blood pressure among elderly, to prevent stroke and disability. The main risk for elderly people is orthostatic hypotension (falls) and it was taken into account by the physicians in this case. Furthermore, the LADIS study disclosed that white matter lesions were predictors of cognitive decline (Verdelho etal, 2010) and progression of leukoaraiosis affects cognition (Schmidt et al, 2007). High blood pressure is the main risk factor for white matter lesions and The PROGRESS MRI study showed that an active blood pressure regimen delayed the progression of white matter lesions (Dufouil et al 2005).
I would like to know how white matter lesions ‘volume and progression were assessed (Fazekas scale?)?
PS: I have not been able to see the MRI (fig 1)
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Competing interests:
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Experience and credentials in the specific area of science:
neurologist and geriatrician.
fied of research: vascular risk factors and cognition
- How to cite: Duron E .treatment of hypertenion in elderly demented people[Review of the article 'Safe Treatment of Hypertension to Guideline Targets in Nonagenarian Vascular Dementia ' by Claassen J].WebmedCentral 2011;1(12):WMCRW00202
The article underlines a problem which is frequently neglected both in research and in clinical practice. The "extreme age" and the mild disability of the case patient makes the clear description even more useful and provocative.
In case description I think that the hypothesis of psuedohypertension should be considered. In fact, although rare and difficult to diagnose (Kuwajima I, J Hypertens, 1990), its presence cannot be excluded "a priori", especially in very old age. Unluckily Osler maneuvre (Messerli FH, N Engl J Med 1985) has been shown to have limited reliability (Belmin J, Am J Med, 1995); however, if other technique are not available (such as measure of pulse wave velocity or the gold standard intra-arterial measurement), I think it should be considered, at least for very old persons with very high blood pressure.
A second point is desirable blood pressure in elderly hypertensives. I think that the conclusion should be more cautious, in light of ESC guidelines (Mancia G et al., J Hypertens, 2009) which acknowledge that, even in light of the cited results of the HYVET study, no RCT supports the reduction of systolic blood pressure (SBP) below 140 mmHg in the very old (as it happened for the case patient, for whom the endpoint SPB was actually 140 mmHg!). In the absence of controlled data, observational data, which associate SBP lower than 140 mmHg to higher mortality in very old subjects should be taken into account (Molander L, J Am Geriatr Soc, 2008). Moreover in HYVET study outcome SBP for treatment group was 144 mmHg. Probably a target SBP of 140-150 mmHg might be advised in the oldest old according to available data (and provided that no orthostatic hypotension is present).
Finally, the need not to lower excessively diastolic blood pressure has to be underlined, due to possible negative prognostic effect of lower values (Ungar A, J Am Geriatr Soc, 2009). This was actually the case of the present case, which had a systo-diastolic hypertension and ended up with an optimal diastolic and pulse pressure; however this is not the case for more freqent cases of isolated systolic hypertension.
It is not possible to view the MRI (fig. 1).
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Research in the field of cognitive decline and vascular risk factors