How to manage an elderly patient with hypertension (high blood pressure) and dizziness?

Management of Elderly Patient with Hypertension and Dizziness

This patient requires immediate evaluation for end-organ damage to distinguish between hypertensive urgency and emergency, but should NOT receive aggressive inpatient blood pressure reduction given the lack of evidence for benefit and potential harm in asymptomatic elderly patients. 1

Initial Assessment Priority

Determine if this is a hypertensive emergency or urgency:

• Hypertensive emergency: BP >180/120 mmHg WITH acute end-organ damage (hypertensive encephalopathy, acute heart failure, myocardial infarction, unstable angina, aortic dissection, acute stroke, acute kidney injury) 1, 2, 3
• Hypertensive urgency: BP >180/120 mmHg WITHOUT acute end-organ damage 2, 3, 4

Critical evaluation steps:

• Physical examination focusing on neurological status, cardiac examination for heart failure, fundoscopic examination for papilledema or hemorrhages 1
• Renal panel to assess kidney function 1
• Electrocardiogram to evaluate for acute coronary syndrome 1
• Neuroimaging, echocardiogram, or chest CT only if symptoms suggest specific organ involvement 1

The dizziness is a critical symptom that may indicate:

• Orthostatic hypotension (measure BP sitting/lying for 5 minutes, then at 1 and 3 minutes after standing) 1
• Cerebrovascular insufficiency from excessive BP reduction
• Pre-existing end-organ damage requiring emergency treatment

Management Based on Classification

If Hypertensive Emergency (with end-organ damage):

Immediate hospitalization to intensive care unit with IV antihypertensives 1, 3

• Target: Reduce BP by 20-25% within the first 1-2 hours, then to 160/100-110 mmHg over next 2-6 hours 2, 3
• Avoid excessive reduction: Do NOT normalize BP acutely in elderly patients due to altered autoregulation and risk of cerebral/myocardial hypoperfusion 5
• IV medication options: Nicardipine infusion starting at 5 mg/hr, titrating by 2.5 mg/hr every 15 minutes up to 15 mg/hr 6

If Hypertensive Urgency (no end-organ damage):

This is the most likely scenario and requires outpatient management with oral medications 1, 2, 3

Do NOT treat aggressively in the hospital:

• No evidence supports inpatient treatment of asymptomatic elevated BP 1
• Observational studies suggest intensive inpatient BP treatment associates with worse outcomes including acute kidney injury, stroke, and myocardial infarction 1
• Gradual BP reduction over 24-48 hours is appropriate 1, 2, 3

Outpatient oral medication approach:

• For elderly patients, start with low-dose long-acting dihydropyridine calcium channel blocker (amlodipine 2.5-5 mg daily) or RAS inhibitor 1, 7
• Elderly patients have 40-60% increased drug exposure, requiring lower initial doses 7
• Target BP reduction of at least 20/10 mmHg, ideally to 140/90 mmHg, individualized for frailty 1
• Follow-up within 1-3 days for hypertensive urgency 1

Special Considerations for Elderly Patients

Age-related factors affecting management:

• Higher BP targets may be appropriate: Guidelines recommend BP goals 10 mmHg higher on average for older adults 1
• Frailty assessment is essential: For patients ≥85 years or with moderate-to-severe frailty, consider treatment only if BP ≥140/90 mmHg and closely monitor tolerance 1
• Orthostatic hypotension is common: Test before intensifying therapy; pursue non-pharmacological approaches first and switch (not de-intensify) medications that worsen orthostatic symptoms 1
• Quality of life prioritization: Guidelines advise individualizing BP care to reduce side effects and promote quality of life in patients with frailty, dementia, or multimorbidity 1

Critical Pitfalls to Avoid

Do not:

• Administer IV antihypertensives for asymptomatic elevated BP without end-organ damage 1
• Reduce BP to normal values acutely in chronic hypertension (risk of hypoperfusion) 5
• Use sublingual medications (unpredictable absorption and excessive BP drops) 5
• Discharge without ensuring outpatient follow-up within days 1
• Ignore the dizziness—it may indicate orthostatic hypotension or cerebrovascular insufficiency requiring medication adjustment rather than intensification 1

Do:

• Confirm BP elevation with repeat measurements in both arms 1
• Screen for medication non-adherence as the most common cause 5
• Evaluate for secondary causes in resistant hypertension 1
• Change infusion site every 12 hours if peripheral IV used 6