What is the recommended management for hypertension in the geriatric population?

Hypertension Management in Geriatric Patients

Treat hypertension aggressively in geriatric patients, as the landmark HYVET trial demonstrated that even in patients ≥80 years old, blood pressure control significantly reduces fatal stroke by 39%, all-cause mortality by 21%, and heart failure by 64%. 1

Blood Pressure Targets

Age-Specific Goals

• For patients <80 years old: Target systolic BP <140 mm Hg 1
• For patients ≥80 years old: Target systolic BP 140-145 mm Hg if tolerated 1
• Avoid excessive diastolic lowering: Keep diastolic BP >70-75 mm Hg in patients with coronary heart disease to prevent reduced coronary perfusion 1
• More recent guidelines suggest: BP <130/80 mm Hg for most adults, with individualization for elderly based on frailty 1

Critical Caveat

The older recommendation of <140/90 mm Hg is based on expert opinion rather than randomized controlled trial data, though HYVET provides strong evidence for benefit even with aggressive treatment in the very elderly 1

Non-Pharmacological Management (First-Line for All Patients)

Dietary Modifications

• Sodium restriction to <5 g/day (approximately 2000 mg sodium): Elderly patients show larger BP reductions with sodium restriction than younger adults 1, 2
• Potassium supplementation: Increase dietary potassium intake from fresh fruits and vegetables (target ≥3000 mg/day), but contraindicated in chronic kidney disease or patients on potassium-sparing diuretics 1
• DASH diet: Rich in fruits, vegetables, low-fat dairy products, and low in saturated fat—proven effective in elderly hypertensive patients 1, 3

Weight Loss and Exercise

• Weight reduction: Produces larger BP declines in older versus younger adults 1, 4
• Regular physical activity: Both aerobic and resistance exercise reduce BP in elderly populations 3
• Exercise benefits: Can reduce the number and dose of antihypertensive medications needed 1

Alcohol and Caffeine

• Limit alcohol consumption: Heavy intake increases BP; moderate consumption appears neutral 3
• Coffee restriction: Intake >3 cups daily increases BP in elderly hypertensive subjects 3

Pharmacological Management

Initiation Strategy

• Start low, go slow: Given age-related changes in drug absorption, distribution, metabolism, and excretion 1
• Consider monotherapy initially: Particularly in low-risk grade 1 hypertension and patients >80 years or frail 1
• Most patients require ≥2 agents: Approximately two-thirds of elderly patients need combination therapy to achieve target BP 1

First-Line Drug Classes (All Proven Effective in Elderly)

The following five classes have demonstrated cardiovascular event reduction in older adults 1:

1. Thiazide/thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
2. ACE inhibitors (e.g., enalapril)
3. Angiotensin receptor blockers (ARBs) (e.g., losartan, candesartan)
4. Calcium channel blockers (e.g., amlodipine)
5. Beta-blockers

Stepwise Treatment Algorithm

For Non-Black Patients: 1

1. Start low-dose ACE inhibitor or ARB
2. Add dihydropyridine calcium channel blocker (DHP-CCB)
3. Increase to full doses
4. Add thiazide/thiazide-like diuretic
5. Add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker)

For Black Patients: 1

1. Start low-dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic
2. Increase to full doses
3. Add diuretic or ACE inhibitor/ARB
4. Add spironolactone (or alternatives as above)

Important Drug Considerations

• Simplify regimens: Use once-daily dosing and single-pill combinations to improve adherence 1
• Monitor for drug interactions: NSAIDs and other medications commonly used by elderly patients can raise BP 1
• Losartan dosing in hepatic impairment: Start at 25 mg in mild-to-moderate hepatic impairment 5

Special Monitoring Considerations in Elderly

Measurement Challenges

• BP variability: More pronounced in elderly due to stiff arteries and decreased baroreflex buffering 1
• Orthostatic hypotension: Check BP during postural changes, after meals, and after exercise 1
• Pseudohypertension: Consider if usual treatment fails to reduce BP, especially with symptoms of postural hypotension 1
• Confirm diagnosis: Use home BP monitoring (≥135/85 mm Hg) or 24-hour ambulatory BP (≥130/80 mm Hg) 1

Follow-Up Timeline

• Achieve target BP within 3 months 1
• Monitor BP control regularly and adjust therapy accordingly 1

Evidence-Based Outcomes

Proven Benefits in Elderly

• Stroke reduction: 36-41% reduction in clinical trials 1
• Heart failure reduction: 54-64% reduction 1
• Myocardial infarction reduction: 23-27% reduction 1
• Overall cardiovascular events: 30-32% reduction 1
• All-cause mortality: 13-21% reduction 1
• Benefits extend to patients >70 and even >80 years old 1

Meta-Analysis Data

A 10 mm Hg SBP reduction decreases cardiovascular events by approximately 20-30% 2

Common Pitfalls to Avoid

• Undertreatment due to age: The misconception that hypertension is adaptive in very old adults has been disproven 1
• Excessive diastolic lowering: Avoid dropping diastolic BP <70 mm Hg in patients with coronary disease 1
• Ignoring lifestyle modifications: These are essential and cannot be replaced by medication alone 1, 6
• Inadequate sodium restriction: Elderly patients are more sensitive to sodium and often rely on processed foods 1
• Polypharmacy without simplification: Use combination pills and once-daily dosing to improve adherence 1