When to reduce antihypertension (blood pressure lowering) dose in elderly patients?

When to Reduce Antihypertensive Dose in Elderly Patients

For elderly patients (>80 years) or frail individuals, antihypertensive medication doses should be reduced when blood pressure targets are achieved with a goal of reducing BP by at least 20/10 mmHg, ideally to 140/90 mmHg, rather than the more aggressive target of <130/80 mmHg recommended for younger adults. 1

Blood Pressure Targets for Elderly Patients

• For elderly patients (>80 years) or frail individuals, the target BP should be individualized with a goal of reducing BP by at least 20/10 mmHg, ideally to 140/90 mmHg 2, 1
• For elderly with good health status, if well tolerated, BP can be further lowered to <130/80 mmHg 1
• Consider monotherapy in low-risk grade hypertension and in patients aged >80 years or frail 2

Specific Situations Requiring Dose Reduction

• When orthostatic hypotension develops (significant drop in BP when standing) 1
• When patients experience symptoms of hypotension such as dizziness, lightheadedness, or falls 1
• When systolic blood pressure falls below 130 mmHg in very elderly (>80 years) or frail patients 2, 1
• When medication side effects become problematic (e.g., electrolyte abnormalities, impaired cognition) 1

Medication Adjustment Approach

• For elderly patients taking ACE inhibitors like lisinopril:

  • Consider reducing to half the usual recommended dose in patients with declining renal function (creatinine clearance ≤30 mL/min) 3
  • For patients on hemodialysis or with creatinine clearance <10 mL/min, the recommended dose is 2.5 mg once daily 3

• For elderly patients taking calcium channel blockers like amlodipine:

  • Elderly patients have decreased clearance of amlodipine with a resulting increase of AUC of approximately 40-60% 4
  • A lower initial dose may be required in elderly patients 4
  • Dose selection should be cautious, usually starting at the low end of the dosing range 4

Monitoring After Dose Adjustment

• Recheck BP within 4 weeks of medication adjustment 5
• Monitor for potential side effects, including electrolyte disturbances if a diuretic is added 5
• Regular BP checks should be performed to ensure target BP is maintained 1

Common Pitfalls to Avoid

• Reducing medication too quickly or completely stopping antihypertensive therapy, which can lead to rebound hypertension 6
• Failing to simplify medication regimens - use once-daily dosing and single-pill combinations when possible to improve adherence 2, 1
• Ignoring comorbidities that may influence BP targets and medication selection 1
• Applying the same aggressive BP targets (<130/80 mmHg) to all elderly patients regardless of frailty status 6, 7
• Overlooking drug interactions from polypharmacy, which are common in elderly patients 7

Special Considerations

• For very old and frail patients (80 years or older), there is limited evidence that intensive antihypertensive therapy is beneficial and may actually be harmful 6
• Low-medium doses of thiazide diuretics, especially when given in combination with potassium-sparing agents, are effective in reducing BP and cardiovascular morbidity and mortality in elderly patients 8
• Beta blockers are less effective than other antihypertensive agents in the elderly and should not be considered as first-line therapy in elderly patients with uncomplicated hypertension 8