What is the recommended treatment for hypertension in geriatric patients?

Recommended Treatment for Hypertension in Geriatric Patients

For geriatric patients with hypertension, the recommended treatment approach is to start with low-dose thiazide diuretics, particularly chlorthalidone, as first-line therapy, with treatment individualized based on frailty status and a target blood pressure of 140/90 mmHg. 1, 2

Diagnosis and Assessment

• Hypertension in geriatric patients is diagnosed when office BP readings are consistently ≥140/90 mmHg, particularly if home BP is ≥135/85 mmHg or 24-hour ambulatory BP is ≥130/80 mmHg 2
• Use validated automated upper arm cuff devices with appropriate cuff size, and measure BP in both arms at the first visit 2
• For elderly patients, frailty assessment is essential as it guides treatment targets and medication choices 2

First-Line Medication Options

• Thiazide diuretics, particularly chlorthalidone, are recommended as first-line treatment for older adults with hypertension due to their superior efficacy in preventing cardiovascular events 1, 3
• Low-dose regimens (12.5-25 mg hydrochlorothiazide or equivalent) are preferred to minimize metabolic side effects while maintaining efficacy 4, 5
• Alternative first-line options include:
  • Dihydropyridine calcium channel blockers (DHP-CCBs) like amlodipine 2, 6
  • Angiotensin receptor blockers (ARBs) or ACE inhibitors 2, 7

Treatment Algorithm for Geriatric Hypertension

1. Initial therapy:

   • For non-Black patients: Start with low-dose ACE inhibitor/ARB or thiazide diuretic 2
   • For Black patients: Start with low-dose ARB, DHP-CCB, or thiazide diuretic 2
   • For patients >80 years or frail: Consider monotherapy with once-daily dosing 2

2. Dose titration:

   • Increase to full dose if BP target not achieved 2
   • Monitor for 3 months to achieve target BP reduction of at least 20/10 mmHg; ideally to 140/90 mmHg 2

3. Combination therapy if needed:

   • Add a second agent from a different class if BP remains uncontrolled 2
   • For non-Black patients: Add thiazide/thiazide-like diuretic if not already prescribed 2
   • For Black patients: Add diuretic or ACE/ARB if not already prescribed 2

4. Third-line therapy if needed:

   • Add spironolactone, or if not tolerated/contraindicated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2

Special Considerations for Geriatric Patients

• Dosing: Start with lower doses and titrate more gradually in elderly patients, especially those >80 years or frail 2
• Medication regimen: Simplify with once-daily dosing and single-pill combinations to improve adherence 2
• Target BP: Individualize based on frailty; generally aim for <140/90 mmHg if tolerated 2
• Monitoring: Check BP control within 3 months of starting therapy 2
• Adverse effects: Monitor closely for postural hypotension, electrolyte disturbances, and other side effects 2

Medication-Specific Considerations

• Thiazide diuretics: Monitor for electrolyte disturbances, particularly hypokalemia; low doses (12.5-25 mg hydrochlorothiazide) may cause fewer metabolic side effects 4, 5
• ACE inhibitors/ARBs: Use with caution in patients with renal impairment; monitor renal function and potassium levels 8
• Calcium channel blockers: May be particularly useful in elderly patients with isolated systolic hypertension; monitor for peripheral edema 9, 6
• Beta-blockers: Generally not recommended as first-line therapy in elderly patients as they are less effective for prevention of stroke and cardiovascular events 1

Common Pitfalls and Caveats

• Avoid alpha-1 blockers and central alpha-2 agonists as initial therapy due to higher risk of adverse effects in older adults 1
• Be cautious with aggressive BP lowering in very elderly or frail patients due to increased risk of falls and orthostatic hypotension 2
• Consider drug-drug interactions, as elderly patients often have polypharmacy 9
• For patients with a history of gout, thiazide diuretics may increase the risk of adverse events and should be used with caution 4