What health recommendations are advised for a 65-year-old with hypertension and diabetes?

Health Recommendations for a 65-Year-Old with Hypertension and Diabetes

For a 65-year-old with both hypertension and diabetes, target a systolic blood pressure of 130-139 mmHg, initiate combination antihypertensive therapy with a RAAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide diuretic, aim for HbA1c <7%, screen annually for kidney disease and depression, and aggressively manage cardiovascular risk factors including lipids. 1, 2

Blood Pressure Management

Target systolic BP of 130-139 mmHg specifically for older adults (≥65 years) with diabetes, avoiding levels below 120 mmHg. 1, 2

• Diastolic BP should be targeted below 80 mmHg but not below 70 mmHg to prevent organ hypoperfusion 2
• Treatment of hypertension is indicated in virtually all older adults with diabetes, as it significantly reduces both microvascular and macrovascular complications 1

First-Line Pharmacological Approach

Initiate combination therapy immediately with a RAAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide-like diuretic. 1, 2

• RAAS blockers are particularly critical if there is any evidence of proteinuria, microalbuminuria, or left ventricular hypertrophy 1
• Most diabetic patients require 2-3 antihypertensive agents to achieve target BP 2
• Never combine an ACE inhibitor with an ARB, as this increases adverse events without additional benefit 3
• If BP remains uncontrolled on dual therapy, add a third agent (the alternative between calcium channel blocker or thiazide diuretic not already used) 3

Glycemic Control

Target HbA1c <7% (or <53 mmol/mol) to decrease microvascular complications, but individualize based on functional status and life expectancy. 1

• For functional, cognitively intact older adults with significant life expectancy, use the same glycemic goals as younger adults 1
• Glycemic goals may be reasonably relaxed for frail older adults with limited life expectancy or significant comorbidities, but always avoid hyperglycemia causing symptoms or acute complications 1
• Consider SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) if eGFR is 30 to <90 mL/min/1.73 m², as they reduce renal endpoints and cardiovascular risk. 1

Cardiovascular Risk Reduction

Target LDL-C <1.4 mmol/L (<55 mg/dL) or achieve at least 50% LDL-C reduction, as patients with both diabetes and hypertension are at very high cardiovascular risk. 1, 2

• Initiate statin therapy as first-line lipid-lowering treatment 2
• If target LDL-C is not reached with maximum tolerated statin dose, add ezetimibe 2
• Consider antiplatelet therapy (aspirin) if life expectancy equals the time frame of primary prevention trials 1

Essential Screening and Monitoring

Screen annually for:

• Kidney disease by assessing eGFR and urinary albumin:creatinine ratio 1
• Depression, as older adults (≥65 years) with diabetes are high-priority for depression screening and treatment 1
• Lower extremity arterial disease (LEAD) with clinical assessment and/or ankle-brachial index (ABI) measurement 1
• Visual complications (retinopathy) and foot complications, as these significantly impair functional status 1

Lifestyle Modifications

Implement the following non-pharmacological interventions: 2, 4

• Reduce sodium intake to approximately 2 g/day (or <2,300 mg/day) 2, 4
• Prescribe moderate-to-vigorous aerobic exercise ≥150 minutes/week plus resistance training 2-3 times/week 2, 4
• Adopt a Mediterranean or DASH dietary pattern rich in vegetables, fruits, and low-fat dairy products 2, 4
• Achieve and maintain healthy BMI (20-25 kg/m²) 3
• Implement smoking cessation if applicable 2

Vaccination and Preventive Care

Administer the following vaccines: 1

• Annual influenza vaccine 1
• Pneumococcal vaccine (at least one lifetime dose; consider one-time revaccination if previously immunized before age 65 and >5 years have passed) 1

Patient Education and Self-Management

Enroll in group-based structured education programs to improve diabetes knowledge, glycemic control, and disease management. 1

• Train in self-monitoring of blood glucose and blood pressure 4
• Educate on recognizing and managing hypoglycemia and hyperglycemia 4
• Provide foot care education, especially given increased risk of LEAD 1

Follow-Up Schedule

Schedule follow-up appointments every 3 months to evaluate metabolic parameters (HbA1c, BP, lipids) and adjust treatment until targets are achieved. 4

• Evaluate microvascular complications (retinopathy, nephropathy, neuropathy) annually 4
• Assess global cardiovascular risk annually 4
• Monitor adherence to pharmacological and non-pharmacological interventions at each visit 4

Critical Pitfalls to Avoid

• Do not use beta-blockers as first-line therapy unless specifically indicated (e.g., post-MI, heart failure with reduced ejection fraction), as they adversely affect insulin sensitivity and lipid profile 2
• Avoid hypoglycemia, as it can trigger arrhythmias and increase cardiovascular risk 1
• Do not set overly aggressive BP targets (<120 mmHg systolic) in older adults, as this increases risk of adverse events 1, 2
• Avoid metformin if renal insufficiency or heart failure is present 1
• Do not use thiazolidinediones in patients with heart failure (NYHA Class III and IV) 1