From the Guidelines
Initiating antihypertensive medication in a 91-year-old patient with hypertension should be individualized, considering their overall health status, functional capacity, and blood pressure readings, with a focus on minimizing potential harms and maximizing quality of life 1. When deciding to start blood pressure medications in a 91-year-old, it's essential to consider their overall health status, functional capacity, and blood pressure readings.
- The patient's blood pressure readings should be consistently elevated, typically above 150/90 mmHg, to warrant initiation of antihypertensive therapy.
- The choice of medication should be based on the patient's comorbidities, potential drug interactions, and side effect profile.
- A low-dose medication such as amlodipine 2.5mg daily, losartan 25mg daily, or hydrochlorothiazide 12.5mg daily can be considered as a starting point.
- The target blood pressure should be less aggressive than for younger patients, aiming for <150/90 mmHg rather than <130/80 mmHg, to minimize the risk of orthostatic hypotension and other adverse effects.
- Close monitoring is crucial after starting therapy, with follow-up within 2-4 weeks to check blood pressure response, assess for side effects, and evaluate kidney function and electrolytes if using ACE inhibitors, ARBs, or diuretics 1. The physiological basis for this approach recognizes that elderly patients often have decreased baroreceptor sensitivity, reduced renal function, and altered drug metabolism, making them more susceptible to adverse effects from antihypertensive medications.
- It's also important to consider non-pharmacological approaches, such as lifestyle modifications, as the first-line treatment for orthostatic hypotension and to minimize potential harms 1.
- The most recent guidelines from the European Heart Journal recommend maintaining BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated, and pursuing non-pharmacological approaches as the first-line treatment of orthostatic hypotension 1.
From the Research
Initiating Antihypertensive Medication in a 91-Year-Old Patient
- The decision to initiate antihypertensive medication in a 91-year-old patient with hypertension should be based on individual clinical characteristics and circumstances 2.
- According to the 2014 evidence-based guideline for the management of high blood pressure in adults, patients aged 60 years or older should be treated to a blood pressure goal of less than 150/90 mm Hg 2.
- However, the guideline does not provide specific recommendations for patients older than 90 years.
- Other studies suggest that combination therapy with multiple classes of antihypertensive drugs may be necessary to achieve adequate blood pressure control in older adults 3, 4.
- The choice of initial antihypertensive medication should be based on the patient's individual characteristics, such as the presence of diabetes, chronic kidney disease, or heart failure 4, 5.
- Beta-blockers, diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers are commonly used antihypertensive medications, and the choice of medication should be based on the patient's specific needs and medical history 3, 5, 6.
- It is essential to carefully consider the potential benefits and risks of antihypertensive medication in older adults, including the risk of adverse effects and interactions with other medications 2, 6.