Fogari Roberto, Zoppi Annalisa
Department of Internal Medicine and Therapeutics, Clinica Medica II, IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
Drugs Aging. 2004;21(6):377-93. doi: 10.2165/00002512-200421060-00003.
Management of hypertension in the elderly should take into account, in particular, the possible negative impact of antihypertensive drugs on the patient's quality of life, the deterioration of which may result in a loss of independence and reduced treatment compliance. Quality of life is recognised as a multifactorial variable and can be subdivided into different domains (symptomatic well-being, emotional, physical, work-social, cognitive and life satisfaction), which are generally explored by means of specific questionnaires or scales. When evaluating elderly patients with hypertension, it is necessary to pay particular attention to specific domains such as symptomatic well-being, cognitive function, activity and sexual function, which have already been diminished by the age itself and the disease. The results of some large trials that specifically evaluated the quality of life effects of long-term therapy of hypertension in older people (Medical Research Council's [MRC] Trial of Hypertension in Older Adults, Systolic Hypertension in the Elderly Program [SHEP], Systolic Hypertension in Europe [Syst-Eur], Study on COgnition and Prognosis in the Elderly [SCOPE]) have shown that antihypertensive treatment as a whole either had no negative impact on quality of life, or even produced some improvement. The question whether some classes of antihypertensive agents are more beneficial or harmful than others in terms of quality-of-life effects remains largely unanswered. Results from long-term trials suggest that treatment with diuretics is not associated with adverse effects on quality of life. Nevertheless, chlortalidone and other diuretics have been more often associated with sexual dysfunction in men, including decreased libido, erectile dysfunction and difficult ejaculation, than other drug classes. Nonselective lipophilic beta-adrenoceptor antagonists, such as propranolol, have been reported to exert some negative effect on quality of life and have been associated with depression, impairment of memory function and adverse effects such as erectile problems. A less unfavourable impact has been described with beta(1)-adrenoceptor antagonists and those with vasodilating properties. Calcium channel antagonists have generally been associated with a positive effect on quality of life, although some trials have shown high rates of adverse effects and withdrawals, particularly with first-generation dihydropyridines. Concern has also been raised about the potential for adverse cognitive effects associated with the use of calcium channel antagonists, but studies on this topic are not univocal. ACE inhibitors have usually been reported to exert favourable effects on quality of life. These drugs seem to be effective in maintaining, or even improving, cognitive function through mechanisms other than blood pressure control. In addition, a number of studies reported favourable impact of ACE inhibitors on sexual function. Angiotensin II receptor antagonists have been associated with good tolerability and low withdrawal rate. They have been demonstrated not to interfere with or even improve cognitive function as well as sexual performance. Although no class of antihypertensive agents presents a clearly superior effect over the others in terms of quality of life, the current impression is that ACE inhibitors and angiotensin II receptor antagonists may offer some advantage, at least in regard to effects on cognitive function and sexual activity.
老年人高血压的管理尤其应考虑到抗高血压药物对患者生活质量可能产生的负面影响，生活质量的恶化可能导致独立性丧失和治疗依从性降低。生活质量被认为是一个多因素变量，可细分为不同领域（症状性幸福感、情绪、身体、工作-社交、认知和生活满意度），通常通过特定问卷或量表进行探究。在评估老年高血压患者时，有必要特别关注一些特定领域，如症状性幸福感、认知功能、活动和性功能，这些方面本身已因年龄和疾病而有所下降。一些专门评估老年人高血压长期治疗对生活质量影响的大型试验（医学研究委员会老年人高血压试验、老年收缩期高血压计划、欧洲收缩期高血压试验、老年人认知与预后研究）结果表明，总体而言，抗高血压治疗对生活质量要么没有负面影响，甚至还会带来一些改善。某些类别的抗高血压药物在生活质量影响方面是否比其他药物更有益或更有害，这一问题在很大程度上仍未得到解答。长期试验结果表明，利尿剂治疗与生活质量不良影响无关。然而，与其他药物类别相比，氯噻酮和其他利尿剂与男性性功能障碍的关联更为常见，包括性欲减退、勃起功能障碍和射精困难。据报道，非选择性亲脂性β肾上腺素受体拮抗剂，如普萘洛尔，对生活质量有一些负面影响，并与抑郁、记忆功能损害以及勃起问题等不良反应有关。β1肾上腺素受体拮抗剂和具有血管舒张特性的药物所产生的不利影响较小。钙通道拮抗剂通常与生活质量的积极影响相关，尽管一些试验显示不良反应和停药率较高，尤其是第一代二氢吡啶类药物。人们还对使用钙通道拮抗剂可能产生的不良认知影响表示担忧，但关于这一主题的研究并不一致。通常报道血管紧张素转换酶抑制剂对生活质量有有利影响。这些药物似乎通过血压控制以外的机制有效地维持甚至改善认知功能。此外，多项研究报道血管紧张素转换酶抑制剂对性功能有有利影响。血管紧张素II受体拮抗剂具有良好的耐受性和低停药率。已证明它们不会干扰甚至改善认知功能以及性功能。尽管在生活质量方面没有一类抗高血压药物明显优于其他药物，但目前的印象是血管紧张素转换酶抑制剂和血管紧张素II受体拮抗剂可能具有一些优势，至少在对认知功能和性活动的影响方面。
