What is the best approach to managing hypertension in elderly individuals?

Managing Hypertension in Elderly Individuals

For elderly patients with hypertension, a stratified approach based on age and frailty status is recommended, with dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents for those ≥85 years or with moderate-to-severe frailty. 1

Age-Stratified Blood Pressure Targets

For patients <85 years without significant frailty:

• Target BP: 120-129 mmHg systolic 1
• Follow same treatment guidelines as younger adults, provided BP-lowering treatment is well tolerated 1

For patients ≥85 years and/or with moderate-to-severe frailty:

• Target BP: "As low as reasonably achievable" (ALARA principle) 1
• If achieving 120-129 mmHg systolic is not possible due to poor tolerance, aim for the lowest achievable systolic BP 1

First-Line Medication Selection

For patients <85 years without significant frailty:

• Standard first-line options apply (similar to younger adults)

For patients ≥85 years and/or with moderate-to-severe frailty:

• First-line options:
  • Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2
  • RAS inhibitors (ACE inhibitors or ARBs) 1
• Second-line option:
  • Low-dose diuretics (if tolerated) 1
• Avoid if possible:
  • Beta-blockers (unless compelling indications exist) 1
  • Alpha-blockers 1

Medication Initiation and Titration

• Start with lower doses in elderly patients (half the usual adult dose) 3
• Titrate medications gradually to avoid adverse effects 3
• For isolated systolic hypertension, thiazide diuretics and dihydropyridine calcium channel blockers are particularly effective 3

Monitoring Considerations

• Screen for orthostatic hypotension before starting or intensifying BP-lowering medication 1
  • Measure BP after 5 minutes sitting/lying, then 1 and/or 3 minutes after standing 1
• Monitor for frailty progression 1
• Consider deprescribing BP medications if BP drops with progressing frailty 1
• Schedule yearly follow-up once BP is controlled and stable 1

Special Considerations

Orthostatic Hypotension

• Use non-pharmacological approaches as first-line treatment for orthostatic hypotension in patients with supine hypertension 1
• Switch medications that worsen orthostatic hypotension rather than simply reducing dosage 1

Frailty Assessment

• Screen older adults for frailty using validated clinical tests 1
• Consider health priorities and use shared decision-making when determining BP treatments and targets for frail patients 1

Combination Therapy

• Most elderly patients will require two or more agents to achieve BP control 3
• When combining medications, be cautious with drug interactions
• Avoid combinations that may increase adverse effects in elderly patients

Lifestyle Modifications

• Sodium restriction (≤2.3 g/day) to optimize medication efficacy 3
• DASH diet high in fruits, vegetables, low-fat dairy, and low in red meat and fats 3
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 3
• Physical activity as tolerated

Common Pitfalls to Avoid

1. Overly aggressive BP lowering - can lead to orthostatic hypotension, falls, and reduced organ perfusion 3
2. Ignoring isolated systolic hypertension - accounts for >90% of hypertension in patients over 70 years and significantly increases cardiovascular risk if untreated 3
3. Failing to screen for orthostatic hypotension - critical before initiating or intensifying therapy 1
4. Not considering medication burden - polypharmacy is common in elderly patients and increases risk of adverse effects
5. Overlooking the impact of NSAIDs - can raise BP and undermine control 3

By following these guidelines and carefully monitoring elderly patients with hypertension, clinicians can effectively manage blood pressure while minimizing adverse effects and improving outcomes related to morbidity, mortality, and quality of life.