What is the recommended treatment for hypertension in the elderly?

Treatment of Hypertension in the Elderly

For most elderly patients (≥60 years), initiate antihypertensive treatment when systolic blood pressure is persistently ≥150 mmHg to achieve a target of <150 mmHg to reduce mortality, stroke, and cardiac events. 1

Blood Pressure Targets

• Standard target for most elderly patients: <150/90 mmHg 1
• For elderly patients with specific conditions:
  • History of stroke/TIA: Target <140 mmHg systolic 1
  • High cardiovascular risk: Target <140 mmHg systolic 1
  • Very elderly (≥80 years): 140-145 mmHg systolic if tolerated 1
  • Frail elderly: More lenient goals may be appropriate 2

First-Line Medication Selection

1. Thiazide or thiazide-like diuretics are preferred first-line agents for uncomplicated hypertension in the elderly 1, 3

   • Chlorthalidone or indapamide (thiazide-like) are preferred over HCTZ due to:
     • Better 24-hour BP control
     • Longer half-life
     • More robust cardiovascular risk reduction data 1, 2
   • Start with low doses and titrate gradually 1

2. Calcium channel blockers (particularly dihydropyridines like amlodipine) are also effective first-line options 1, 4

   • Especially useful for isolated systolic hypertension, which is common in elderly

3. ACE inhibitors or ARBs are appropriate alternatives, particularly with specific comorbidities 2, 5

   • Preferred in patients with diabetes, chronic kidney disease, or heart failure
   • Monitor renal function and potassium levels when initiating

Treatment Algorithm

1. Start with lifestyle modifications:

   • Sodium restriction (<2.3g/day)
   • DASH diet (rich in fruits, vegetables, low-fat dairy)
   • Regular physical activity appropriate for age and ability
   • Weight management
   • Limited alcohol consumption 2

2. Initiate pharmacotherapy:

   • Begin with low doses of a single agent (preferably thiazide-like diuretic or long-acting CCB)
   • Titrate dose gradually (every 2-4 weeks) to minimize adverse effects 1

3. If BP remains uncontrolled:

   • Add a second agent from a complementary class (e.g., CCB + ACEi/ARB or diuretic + ACEi/ARB)
   • Consider fixed-dose combinations to improve adherence 1, 2

4. For resistant hypertension:

   • Add a third agent (typically a diuretic if not already prescribed)
   • Consider spironolactone 25mg daily as a fourth agent if needed 2

Special Considerations for Elderly Patients

• Orthostatic hypotension: Measure BP in both sitting and standing positions 2
• Start low, go slow: Begin with lower doses and titrate more gradually than in younger patients 1
• Monitor for adverse effects: Electrolyte disturbances, renal function changes, dizziness 1
• Medication adherence: Simplify regimens when possible (once-daily dosing, fixed-dose combinations) 2
• Polypharmacy concerns: Review all medications for potential interactions 6

Monitoring

• Check blood pressure, renal function, and electrolytes 1-2 weeks after initiating or changing medications 2
• Once stable, monitor every 1-3 months 2
• Assess for orthostatic changes at each visit 2

The evidence clearly demonstrates that treating hypertension in elderly patients, including those over 80 years, significantly reduces cardiovascular morbidity and mortality 1. While there are some differences in guideline recommendations regarding specific BP targets, the benefits of treatment are consistent across multiple trials.