Is age considered when initiating medication in patients?

Age Considerations in Medication Initiation

Age is a critical factor that must be considered when initiating medication therapy, with specific age-based thresholds and dosing adjustments recommended across various guidelines.

Blood Pressure Medications and Age Considerations

• For hypertension treatment in adults aged ≥60 years, the American College of Physicians and American Academy of Family Physicians (ACP/AAFP) recommend initiating pharmacological therapy when systolic blood pressure is persistently ≥150 mmHg to achieve a target of <150 mmHg 1
• For adults aged ≥85 years and/or those with moderate-to-severe frailty, the European Society of Cardiology (ESC) guidelines recommend considering BP-lowering treatment only when office BP is ≥140/90 mmHg, with close monitoring of treatment tolerance 1
• For elderly patients with history of stroke or transient ischemic attack, treatment should be initiated to achieve a target systolic BP of <140 mmHg 1
• The ESC/ESH guidelines recommend that for patients aged <65 years, the systolic BP target is 120-129 mmHg, while for those ≥65 years, the target is 130-139 mmHg systolic 1

Medication Selection and Dosing for Older Adults

• When initiating antihypertensive medications in elderly patients, long-acting dihydropyridine calcium channel blockers or RAS inhibitors should be considered as first-line options, followed by low-dose diuretics if necessary 1
• For thiazide diuretics, chlorthalidone or indapamide are preferred over hydrochlorothiazide in elderly patients due to superior cardiovascular risk reduction data and longer duration of action 2
• Initial doses and subsequent dose titration should be more gradual in elderly patients due to greater risk of adverse effects, especially in very old and frail individuals 2
• No dosage adjustment with lisinopril is necessary in elderly patients based on age alone, though renal function must be considered 3

Special Considerations for Different Age Groups

Pediatric Patients

• For children with ADHD, medication initiation should consider age-specific recommendations - methylphenidate is recommended as first-line pharmacologic treatment for preschool children (4-5 years) with moderate-to-severe dysfunction 1
• In pediatric hypertension management, medication should be initiated based on both age and risk factors, with specific dosing recommendations for children based on weight 1

Elderly Patients (≥60-65 years)

• Elderly patients require more careful monitoring for orthostatic hypotension when initiating BP medications - testing for orthostatic hypotension is recommended before starting or intensifying therapy 1
• The presence of frailty should be assessed in older adults when considering medication initiation, as this may influence treatment decisions and targets 1
• For patients aged ≥85 years with hypertension, a higher systolic BP threshold (≥160 mmHg) is recommended by several guidelines before initiating pharmacological therapy 1

Physiological Changes Affecting Medication Use in Older Adults

• Age-related changes in pharmacokinetics (particularly reduced renal clearance) and pharmacodynamics (increased sensitivity to certain medications) necessitate careful medication selection and dosing in elderly patients 4, 5
• Older adults have a higher risk of adverse drug reactions due to multiple factors including reduced organ function, polypharmacy, and age-related changes in body composition 6
• The elderly should be considered as "renally insufficient patients" due to the progressive decline in kidney function with age, requiring appropriate dose adjustments for many medications 7

Monitoring Recommendations

• For elderly patients on antihypertensive medications, more frequent monitoring of electrolytes, renal function, and blood pressure (both sitting and standing) is warranted 2
• When BP is controlled and stable under therapy, at least yearly follow-up for BP and other cardiovascular risk factors should be considered 1
• Close monitoring for adverse effects is particularly important in elderly patients on intensive BP-lowering therapy, with special attention to acute kidney injury, which was more common in the intensive treatment group in the SPRINT trial 1

Practical Approach to Age-Based Medication Initiation

• Evaluate renal function before initiating any medication in elderly patients, using validated estimations such as the Cockcroft-Gault formula 6
• Consider starting with monotherapy at lower doses in elderly patients rather than combination therapy, especially in those ≥85 years or with frailty 1
• When initiating medications in older adults, the "start low, go slow" principle should be applied, with careful titration based on response and tolerability 5
• If BP drops with progressing frailty, consider deprescribing BP-lowering medications and other drugs that can reduce BP 1