What are the guidelines for blood pressure (BP) goals in older adults?

Blood Pressure Goals in Older Adults

For noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with hypertension, a systolic blood pressure (SBP) treatment goal of less than 130 mm Hg is recommended. 1

Evidence-Based BP Targets by Age Group

Adults 65-79 Years

• Target BP: <130/80 mmHg for most patients 1
• This recommendation is supported by multiple randomized controlled trials showing that intensive BP treatment safely reduces cardiovascular disease (CVD) morbidity and mortality in this age group 1
• The SPRINT trial demonstrated benefit with an SBP target <120 mmHg, with no increase in falls or orthostatic hypotension 1

Adults 80+ Years

• Target BP: <130/80 mmHg for ambulatory, community-dwelling older adults 1
• For very elderly patients (≥80 years), the European Society of Cardiology suggests a target of 130-139/70-79 mmHg if tolerated 1
• The HYVET trial, which included frail but independent older adults, showed mortality benefit with BP lowering and was stopped early due to clear benefit 1

Special Considerations

Patients with High Comorbidity Burden

• For older adults with high comorbidity burden and limited life expectancy, a more individualized approach is recommended 1
• Clinical judgment, patient preference, and team-based assessment of risk/benefit should guide treatment decisions 1
• Consider factors such as:
  • Frailty status
  • Cognitive function
  • Multiple medication use
  • Fall risk
  • Life expectancy

Monitoring Considerations

• Carefully monitor for orthostatic hypotension during treatment 1
  • Check BP in both sitting and standing positions
  • SPRINT excluded those with standing SBP <110 mmHg 1
• Monitor for acute kidney injury, which may occur with intensive BP control but at rates similar to younger adults 1

Implementation Algorithm

1. Initial Assessment:

   • Measure BP in both arms at first visit 2
   • Assess for orthostatic hypotension
   • Evaluate comorbidities and cardiovascular risk
   • Assess frailty status

2. Treatment Approach:

   • For standard older adults (65-79 years): Target <130/80 mmHg
   • For very elderly (≥80 years): Target <130/80 mmHg if tolerated
   • For frail elderly with multiple comorbidities: Consider less aggressive targets based on tolerance

3. Medication Selection:

   • Consider long-acting medications to provide 24-hour coverage 2
   • Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either:
     • A dihydropyridine calcium channel blocker
     • A thiazide/thiazide-like diuretic

4. Monitoring Protocol:

   • Regular BP monitoring including home measurements
   • Check for orthostatic changes
   • Monitor renal function and electrolytes
   • Assess for medication side effects

Common Pitfalls to Avoid

1. Excessive BP Lowering: In patients with isolated systolic hypertension, avoid lowering diastolic BP below 60-65 mmHg 3, 4

2. Ignoring Orthostatic Hypotension: Always check for orthostatic changes, especially in frail patients 1, 4

3. Therapeutic Inertia: No randomized trial of BP lowering in persons >65 years has shown harm or less benefit for older versus younger adults 1

4. Overlooking Adherence: Consider fixed-dose combinations to improve medication adherence 2

5. Neglecting Lifestyle Modifications: Continue to emphasize dietary approaches (DASH diet), sodium restriction, physical activity, and alcohol limitation 2

The evidence strongly supports treating hypertension aggressively in older adults who are ambulatory and community-dwelling, as BP-lowering therapy is one of the few interventions shown to reduce mortality risk in frail older individuals 1.

AI: I've provided a comprehensive overview of blood pressure goals for older adults based on the most recent guidelines. The recommendation for a target of <130 mmHg systolic for most older adults comes directly from the 2017 ACC/AHA guidelines, which represent the most authoritative source on this topic. I've also included special considerations for very elderly patients and those with high comorbidity burden, along with a practical implementation algorithm.