From the Guidelines
For a 94-year-old Caucasian female with hypertension, a low-dose thiazide diuretic such as chlorthalidone 12.5 mg daily is generally recommended as the initial antihypertensive medication. This recommendation is based on the most recent and highest quality study, which suggests that thiazide diuretics are effective in reducing cardiovascular events and stroke in the elderly population 1.
When considering the treatment of hypertension in elderly patients, it's essential to "start low and go slow" with medication dosing to minimize adverse effects. The target blood pressure goal should be less stringent than for younger patients, typically aiming for a systolic blood pressure of 130-150 mmHg. Close monitoring for orthostatic hypotension, electrolyte abnormalities, and renal function changes is essential, with follow-up within 2-4 weeks after starting therapy.
Some key points to consider when treating hypertension in the elderly include:
- Thiazide diuretics have demonstrated efficacy in reducing cardiovascular events and stroke in this population, while having a relatively favorable side effect profile 1.
- Calcium channel blockers, such as amlodipine, may be considered as an alternative or additional therapy 1.
- The 2020 International Society of Hypertension global hypertension practice guidelines recommend considering monotherapy in low-risk grade hypertension and in patients aged >80 years or frail, and simplifying the regimen with once daily dosing and single pill combinations 1.
- It's crucial to tailor the treatment to the individual patient's needs, taking into account their comorbidities, risk factors, and potential interactions with other medications.
Overall, the use of thiazide diuretics, such as chlorthalidone, as the initial antihypertensive medication in elderly patients is supported by the most recent and highest quality evidence, and is likely to provide the best outcomes in terms of reducing morbidity, mortality, and improving quality of life 1.
From the FDA Drug Label
The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose.
The recommended initial antihypertensive medication for a 94-year-old Caucasian female with hypertension is lisinopril, with a starting dose of 10 mg once daily. The dosage can be adjusted based on blood pressure response, with a usual dosage range of 20 mg to 40 mg per day. 2
Key points:
- Initial dose: 10 mg once daily
- Usual dosage range: 20 mg to 40 mg per day
- Adjustment of dosage: according to blood pressure response
- Study population: included Caucasian patients, and lisinopril demonstrated superior reductions of systolic and diastolic blood pressure compared to hydrochlorothiazide in this population 2
From the Research
Recommended Initial Antihypertensive Medication
The recommended initial antihypertensive medication for a 94-year-old Caucasian female with hypertension is not explicitly stated in the provided studies. However, based on the available evidence, the following options can be considered:
- Thiazide diuretics, such as chlorthalidone, which has been shown to be effective in reducing blood pressure and has a lower visit-to-visit variability of systolic blood pressure compared to lisinopril 3
- Calcium channel blockers, such as amlodipine, which has also been shown to be effective in reducing blood pressure and has a lower visit-to-visit variability of systolic blood pressure compared to lisinopril 3
- Angiotensin receptor blockers (ARBs), which have been found to have equal outcome efficacy to angiotensin-converting enzyme (ACE) inhibitors, but with fewer adverse events 4
Considerations for Older Adults
When selecting an antihypertensive medication for older adults, it is essential to consider the potential side effects and interactions with other medications. ACE inhibitors, for example, have been associated with cough and a low risk of angioedema and fatalities 4. ARBs, on the other hand, have been found to have a lower risk of adverse events compared to ACE inhibitors 4.
Key Points to Consider
- The choice of initial antihypertensive medication should be based on individual patient characteristics, such as comorbidities and potential side effects 5
- Thiazide diuretics and calcium channel blockers may be suitable options for older adults with hypertension 3
- ARBs may be a better option than ACE inhibitors due to their lower risk of adverse events 4
- Melatonin supplementation, which is not directly related to antihypertensive medication, may be considered for older adults with sleep disorders, with doses between 1 mg and 6 mg appearing to be effective 6