From the Guidelines
The first line of treatment for hypertension in older adults should begin with lifestyle modifications, including weight loss, dietary changes such as the DASH diet, and increased physical activity, as these nonpharmacologic options are associated with fewer side effects and have other positive effects. According to the American College of Physicians and the American Academy of Family Physicians, clinicians should initiate treatment in adults aged 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events 1.
Key Considerations
- High-quality evidence showed that treating hypertension in older adults to moderate targets (<150/90 mm Hg) reduces mortality, stroke, and cardiac events 1.
- Nonpharmacologic treatment strategies, such as lifestyle modifications, are available for consideration and are typically associated with fewer side effects than pharmacologic therapies 1.
- Effective pharmacologic options include antihypertensive medications, such as thiazide-type diuretics, ACEIs, ARBs, calcium-channel blockers, and β-blockers, but these should be used with caution due to potential adverse effects 1.
Pharmacologic Treatment
If lifestyle modifications are insufficient to control blood pressure, pharmacologic therapy may be necessary. Thiazide diuretics or calcium channel blockers are recommended as initial medication choices for most older adults, as they are generally well-tolerated and have demonstrated effectiveness in reducing cardiovascular events 1. The target blood pressure goal for most older adults is typically less than 150 mm Hg, and treatment should be initiated at lower doses than used in younger patients and titrated gradually to avoid adverse effects 1.
Monitoring and Titration
Regular monitoring of blood pressure, electrolytes, and kidney function is essential when starting antihypertensive medications in older adults. Clinicians should ensure that they are accurately measuring blood pressure before beginning or changing treatment of hypertension, using multiple measurements in clinical settings or ambulatory or home monitoring 1.
From the Research
First-Line Treatment for Hypertension in Older Adults
The first-line treatment for hypertension in older adults involves a combination of lifestyle modifications and pharmacological interventions.
- Lifestyle modifications include regular physical exercise, body weight management, and healthy dietary patterns, as well as stress management and adequate sleep patterns 2.
- Pharmacological interventions may involve the use of diuretics, renin-angiotensin system blockers, and calcium channel blockers, which have all shown benefit on cardiovascular outcomes in older patients 3, 4.
Choice of Antihypertensive Drugs
The choice of antihypertensive drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost 4.
- Diuretics, such as thiazides, are often considered a first-line treatment option due to their effectiveness in reducing mortality and morbidity outcomes, and lowering blood pressure 5.
- Other antihypertensive drug classes, such as beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers, may also be used as first-line agents, but the evidence suggests that they do not have any clinically important advantages over thiazides 5.
Considerations for Older Adults
When treating hypertension in older adults, it is essential to consider the degree of frailty, complex medical comorbidities, and psycho-social factors, and to individualize management strategies 3, 6.
- The American College of Cardiology/American Heart Association recommends that systolic blood pressure be lowered to <140 mm Hg in older persons younger than 80 years and to 140-145 mm Hg if tolerated in adults aged 80 years and older 4.