From the Guidelines
Managing hypertension in geriatric patients requires a careful, individualized approach that balances blood pressure control with minimizing adverse effects, with a recommended blood pressure target of less than 130 mmHg for noninstitutionalized, ambulatory, community-dwelling adults aged 65 years or older, as stated in the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The best approach typically involves starting with lifestyle modifications including:
- Sodium restriction (less than 2g daily)
- Regular physical activity appropriate to ability level
- Weight management
- Limiting alcohol consumption When medications are needed, start with low doses and gradually increase ("start low, go slow"). First-line pharmacological options often include:
- Thiazide diuretics (chlorthalidone 12.5-25mg daily)
- Calcium channel blockers (amlodipine 2.5-10mg daily)
- ACE inhibitors (lisinopril 2.5-10mg daily) Blood pressure targets should generally be less aggressive than in younger adults, aiming for systolic pressure below 150 mmHg for most patients over 80, though individualization based on frailty, comorbidities, and fall risk is essential. Regular monitoring for orthostatic hypotension (blood pressure drop when standing), electrolyte abnormalities, and medication side effects is crucial. Polypharmacy concerns are particularly relevant in this population, so medication reconciliation should be performed regularly. The physiological changes of aging, including decreased baroreceptor sensitivity, reduced renal function, and arterial stiffening, make geriatric patients more susceptible to both hypertension and treatment complications, necessitating this more cautious approach 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Optimal Management Strategy for Hypertension in Geriatric Patients
The optimal management strategy for hypertension in geriatric patients involves a combination of lifestyle modifications and pharmacological therapy.
- Lifestyle modifications include:
- Exercise: Aerobic and resistance exercise can reduce blood pressure in elderly individuals 2
- Diet: Restricting salt intake, following the Dietary Approaches to Stop Hypertension (DASH) diet, or a Mediterranean diet pattern can help control blood pressure 2
- Weight loss: Weight loss through exercise and diet control is beneficial for controlling hypertension in elderly individuals 2
- Stress reduction: Anxiety, depression, and insomnia can impact elderly hypertension, and managing these factors can help control blood pressure 2
- Pharmacological therapy:
- Antihypertensive drugs: Diuretics, renin-angiotensin system blockers, and calcium channel blockers have shown benefit on cardiovascular outcomes in older patients 3
- Treatment goals: The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treating noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg 4, 5
Considerations for Geriatric Patients
When managing hypertension in geriatric patients, it is essential to consider the degree of frailty, complex medical comorbidities, and psycho-social factors, and individualize treatment strategies accordingly 3.
- For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment 4, 5
- Randomized clinical trials are needed to inform treatment decisions for frail elderly patients with hypertension living in nursing homes, and for elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs 5