What is the recommended management for hypertension in elderly patients?

Hypertension Management in Elderly Patients

For elderly patients with hypertension, a target systolic blood pressure of 120-129 mmHg is recommended for most patients under 80 years, while a target of 140-145 mmHg is appropriate for those over 80 years, with combination therapy including an ACE inhibitor or ARB plus a calcium channel blocker as first-line treatment. 1

Blood Pressure Targets by Age

• Patients <79 years: Target systolic BP <140 mmHg 1
• Patients 80+ years: Target systolic BP 140-145 mmHg, if tolerated 1
• Most recent recommendation: Target systolic BP 120-129 mmHg for most adults if well tolerated 1
• When target cannot be achieved: Follow the "as low as reasonably achievable" (ALARA) principle 1

Non-Pharmacological Management

Non-pharmacological approaches should always be implemented first or alongside medication, especially in elderly patients:

• Dietary modifications:

  • DASH or Mediterranean diet 1, 2
  • Sodium restriction (<5-6 g/day of salt) 1
  • Potassium-rich foods (unless contraindicated by renal failure or use of potassium-sparing diuretics) 1
  • Limit free sugar consumption to <10% of energy intake 1
  • Avoid sugar-sweetened beverages 1

• Physical activity:

  • Regular aerobic and resistance exercise appropriate for age and ability 2
  • Both types of exercise have demonstrated BP-lowering effects in elderly 2

• Weight management:

  • Maintain healthy body weight 1, 2
  • Weight loss produces larger BP reductions in older adults compared to younger adults 1

• Alcohol moderation:

  • Limit to <100g/week of pure alcohol 1
  • Preferably avoid alcohol consumption for best health outcomes 1

• Smoking cessation:

  • Stop tobacco use completely 1
  • Refer to smoking cessation programs 1

Pharmacological Management

First-Line Therapy

Combination therapy is recommended for most elderly patients with confirmed hypertension (≥140/90 mmHg) 1, 3:

• Preferred initial combinations:

  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB (e.g., amlodipine) 1, 3
  • RAS blocker + thiazide/thiazide-like diuretic 1, 3
  • For Black patients: CCB + thiazide diuretic may be more effective 3

• Fixed-dose single-pill combinations are recommended to improve adherence 1, 3

• Exceptions to starting with combination therapy 1:

  • Patients aged ≥85 years
  • Patients with symptomatic orthostatic hypotension
  • Patients with moderate-to-severe frailty

Medication Titration

• Start at lowest doses in elderly patients and increase gradually 1
• If BP not controlled with two-drug combination, progress to three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1
• Never combine two RAS blockers (ACE inhibitor + ARB) 1

Special Considerations for Elderly

• Avoid excessive diastolic BP lowering (<70-75 mmHg) in elderly patients with coronary heart disease to prevent reduced coronary blood flow 1
• Monitor for orthostatic hypotension, especially in frail elderly 1
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 1
• Check medication timing: Take at the most convenient time of day to establish a habitual pattern 1

Monitoring and Follow-up

• Check BP within 2-4 weeks after medication initiation or adjustment 3
• Monitor serum potassium and renal function within 2-4 weeks after adding ACE inhibitors, ARBs, or diuretics 3
• Consider home BP monitoring to improve adherence and detect orthostatic changes

Common Pitfalls and Caveats

1. Undertreatment: Many elderly patients have poor BP control, especially after age 75, due to misconceptions about hypertension being necessary for organ perfusion 1

2. Medication adherence challenges:

   • Multiple medications increase risk of side effects and reduce adherence 1
   • Use single-pill combinations when possible 1

3. Drug interactions:

   • Be aware of NSAIDs and other medications that can raise BP 1
   • Consider potential interactions with commonly used medications in elderly

4. Orthostatic hypotension risk:

   • Measure BP in both sitting and standing positions
   • Start with lower doses and titrate slowly 1

5. Sodium restriction challenges:

   • Age-related changes in taste may increase salt preference 1
   • Mobility and financial constraints may increase reliance on processed foods 1

6. Diastolic hypoperfusion:

   • Avoid excessive lowering of diastolic BP (<70-75 mmHg) in patients with coronary heart disease 1

By following these evidence-based recommendations and being mindful of the special considerations for elderly patients, hypertension can be effectively managed to reduce cardiovascular morbidity and mortality in this vulnerable population.