From the Guidelines
For a 91-year-old male with hypertension, a reasonable target blood pressure is less than 150 mm Hg, as recommended by the American College of Physicians and the American Academy of Family Physicians 1. This target acknowledges the physiological changes that occur with advanced age and aims to balance hypertension management with quality of life and functional status. The American College of Physicians and the American Academy of Family Physicians strongly recommend initiating 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, based on high-quality evidence showing reduced mortality, stroke, and cardiac events 1. Key considerations in managing hypertension in this age group include:
- Initiating treatment gradually to avoid complications like orthostatic hypotension, falls, or reduced organ perfusion
- Selecting first-line medications such as long-acting calcium channel blockers or ACE inhibitors, starting at lower doses and titrating slowly based on tolerance and response
- Monitoring blood pressure regularly, ideally at different times of day, with special attention to postural changes
- Balancing hypertension management with quality of life and functional status, recognizing that very elderly patients have different risk-benefit considerations. Treatment decisions should always consider the individual's overall health status, comorbidities, frailty level, and medication burden, as emphasized in the guidelines 1.
From the Research
Target Blood Pressure for a 91-year-old Male with Hypertension
- The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years and to 140-145 mmHg if tolerated in adults aged 80 years and older 2.
- For adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 2.
- A study published in 2016 suggests that in elderly hypertensive patients with diabetes, blood pressure levels should be monitored closely and the treatment should be tailored to prevent excessive fall in blood pressure, with a target blood pressure of <140-150/90 mmHg 3.
- The European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the minority report from the 2013 Eighth Joint National Committee (JNC 8) guidelines, and other guidelines also support reducing blood pressure to less than 140/90 mmHg in adults aged 60 to 79 years of age 2.
- However, the 2013 JNC 8 guidelines recommend reducing blood pressure to less than 150/90 mmHg in adults aged 60 years and older without diabetes mellitus or chronic kidney disease, which is not supported by all experts 2.
- A Cochrane review published in 2020 found that lower blood pressure targets (any target less than or equal to 135/85 mmHg) do not reduce total mortality and total serious adverse events compared to standard blood pressure targets (less than or equal to 140/90 mmHg) in patients with chronic arterial hypertension 4.
Considerations for Elderly Patients
- Elderly patients with hypertension often have comorbidities, organ damage, and cardiovascular disease, which should be taken into account when determining target blood pressure levels 3.
- Orthostatic and postprandial hypotension are common in elderly patients, and excessive blood pressure lowering should be avoided 3.
- Individualized approach to blood pressure management is recommended, taking into account concomitant diseases, orthostatic blood pressure changes, and the general condition of the patient 3.