What are the guidelines for controlling blood pressure in geriatric patients?

From the Guidelines

Geriatric blood pressure control should aim for a target of less than 130/80 mmHg, with treatment initiated when readings consistently exceed 130/80 mmHg, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The goal is to reduce the risk of cardiovascular disease, stroke, and death in older adults. First-line medications include thiazide diuretics, calcium channel blockers, and ACE inhibitors or ARBs. Treatment should start at lower doses than used in younger adults and be titrated gradually to minimize side effects. Lifestyle modifications, such as sodium restriction, regular physical activity, weight management, and limiting alcohol consumption, remain important. Medication regimens should be simplified when possible to improve adherence, and blood pressure should be monitored in both sitting and standing positions to detect orthostatic changes. However, the most recent guideline from 2020 suggests individualizing the target based on frailty, with a goal to reduce BP by at least 20/10 mmHg, ideally to 140/90 mmHg 1. Considering the most recent evidence, the target blood pressure for geriatric patients should be individualized, but generally, a reduction of at least 20/10 mmHg, aiming for less than 140/90 mmHg, is recommended 1. Regular assessment of kidney function, electrolytes, and medication side effects is essential, as older patients have altered pharmacokinetics and increased sensitivity to medications. It is also important to consider the patient's overall health, comorbidities, and life expectancy when making decisions about blood pressure management. In patients with heart failure, renal insufficiency, and type 2 diabetes mellitus, a lower target of less than 130/80 mmHg may be appropriate 1. Ultimately, the goal of blood pressure management in geriatric patients is to improve quality of life, reduce morbidity, and mortality, while minimizing the risk of adverse effects. Key considerations include:

• Individualizing blood pressure targets based on frailty and comorbidities
• Starting treatment at lower doses and titrating gradually
• Simplifying medication regimens to improve adherence
• Monitoring blood pressure in both sitting and standing positions
• Regularly assessing kidney function, electrolytes, and medication side effects.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The guidelines for controlling blood pressure in geriatric patients are not directly stated in the provided drug labels. However, it is mentioned that control of high blood pressure should be part of comprehensive cardiovascular risk management.

• The labels suggest following published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) for specific advice on goals and management 2 3.
• It is also noted that many patients will require more than one drug to achieve blood pressure goals.
• Comprehensive cardiovascular risk management should include, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake.

From the Research

Guidelines for Controlling Blood Pressure in Geriatric Patients

The guidelines for controlling blood pressure in geriatric patients are as follows:

• For patients less than 80 years of age, a systolic blood pressure goal of <140 mmHg is recommended 4.
• For patients 80 years of age or older, a systolic blood pressure goal of 140-150 mmHg is recommended 4.
• In elderly patients with diabetes, a target blood pressure of <140-150/90 mmHg is recommended, provided the patient is in good condition 5.
• In patients with isolated systolic hypertension, the same target is reasonable, provided the diastolic blood pressure is >60 mmHg 5.
• Excessive blood pressure lowering should be avoided in patients with coronary artery disease and in patients with orthostatic hypotension 5.

Blood Pressure Targets

The blood pressure targets for geriatric patients are:

• <140/90 mmHg in adults aged 60-79 years 6.
• 140 to 145 mmHg if tolerated in adults aged 80 years and older 6.
• <150/90 mmHg in adults aged 80 years and older, with a target goal of <140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 6.

Treatment Options

The treatment options for controlling blood pressure in geriatric patients include:

• Angiotensin converting enzyme inhibitors 4, 7.
• Angiotensin receptor blockers 4.
• Calcium channel blockers 4, 7.
• Diuretics 4, 7.
• Beta-blockers, although they may be less effective and have more side effects in elderly patients 7.

Considerations

When controlling blood pressure in geriatric patients, the following considerations should be taken into account:

• The risk of orthostatic hypotension and falls 5, 8.
• The presence of comorbidities, such as diabetes mellitus or chronic kidney disease 5, 6.
• The potential for drug-drug interactions 4.
• The need for individualized treatment and close monitoring of blood pressure 5, 8.