What is the recommended management for hypertension in elderly patients?

Hypertension Management in Elderly Patients

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

Blood Pressure Targets by Age Group

• Under 80 years: Target systolic BP 120-129 mmHg if well tolerated 1
• 80+ years: Target systolic BP 140-145 mmHg if tolerated 1
• Follow the "as low as reasonably achievable" (ALARA) principle when targets cannot be achieved 1
• Avoid excessive diastolic BP lowering (<70-75 mmHg) in elderly patients with coronary heart disease to prevent reduced coronary blood flow 1

Pharmacological Management

First-Line Treatment

• Initial therapy: Combination therapy for most elderly patients with confirmed hypertension (≥140/90 mmHg) 1
• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB (e.g., amlodipine) 1
  • RAS blocker + thiazide/thiazide-like diuretic 1
  • For Black patients, CCB + thiazide diuretic may be more effective 1

Special Considerations for Elderly

• Start low, go slow: Begin with lowest doses and titrate gradually 1
• Fixed-dose single-pill combinations: Improve adherence and reduce pill burden 1
• Exceptions to starting with combination therapy:
  • Patients aged ≥85 years
  • Patients with symptomatic orthostatic hypotension
  • Patients with moderate-to-severe frailty 1

Treatment Escalation

• 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

Non-Pharmacological Approaches

• Dietary modifications:

  • DASH or Mediterranean diet 1
  • 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

• Lifestyle modifications:

  • Maintain healthy body weight (weight loss produces larger BP reductions in older adults) 1
  • Limit alcohol consumption to <100g/week of pure alcohol (preferably avoid completely) 1
  • Complete smoking cessation 1
  • Regular physical activity 2

Monitoring and Follow-Up

• Check BP within 2-4 weeks after medication initiation or adjustment 1
• Monitor serum potassium and renal function within 2-4 weeks after adding ACE inhibitors, ARBs, or diuretics 1
• Consider home BP monitoring to improve adherence and detect orthostatic changes 1
• Measure BP in both sitting and standing positions to assess orthostatic hypotension risk 1
• Monitor for orthostatic hypotension, especially in frail elderly 1
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 1

Special Considerations and Cautions

• Orthostatic hypotension: Common in elderly; start with lower doses and titrate slowly 1
• Medication interactions: NSAIDs and other medications can raise BP; consider potential interactions with commonly used medications 1
• Renal function: Elderly patients with renal insufficiency have elevated plasma concentrations of losartan and its active metabolite 3
• Hepatic impairment: Start with lower doses (25 mg for losartan) in patients with mild-to-moderate hepatic impairment 3
• Adherence challenges: Multiple medications increase risk of side effects and reduce adherence; use single-pill combinations when possible 1
• Dietary challenges: Age-related changes in taste may increase salt preference; mobility and financial constraints may increase reliance on processed foods 1

Common Pitfalls to Avoid

• Misconception: Many elderly patients have poor BP control due to misconceptions about hypertension being necessary for organ perfusion 1
• Excessive BP lowering: Avoid excessive diastolic BP lowering (<70-75 mmHg) in patients with coronary heart disease 1
• Medication timing: Establish a habitual pattern by taking medications at the most convenient time of day 1
• Inadequate monitoring: Failure to check for orthostatic hypotension can lead to falls and injuries 1
• Ignoring non-pharmacological approaches: Lifestyle modifications enhance the efficacy of pharmacologic therapy 4

Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mmHg 4, highlighting the importance of comprehensive management strategies for elderly patients with hypertension.