What is the acceptable blood pressure range in a patient over 85 years old with hypertension?

From the Guidelines

For patients over 85 years old, an acceptable blood pressure target is generally below 150/90 mmHg, though individualization is important. This is based on the strongest and most recent evidence from the American College of Physicians and the American Academy of Family Physicians, which recommends initiating treatment in adults aged 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events 1.

Key Considerations

• Treatment should begin with lifestyle modifications including reduced sodium intake, regular physical activity, weight management, and limited alcohol consumption.
• If medications are needed, start with low doses and increase gradually.
• Common first-line medications include thiazide diuretics (like chlorthalidone 12.5-25 mg daily), calcium channel blockers (amlodipine 2.5-10 mg daily), or ACE inhibitors (lisinopril 2.5-40 mg daily).
• Monitor for orthostatic hypotension by checking blood pressure while sitting and standing, especially when initiating or adjusting medications.
• Regular follow-up is essential to assess medication effectiveness and potential side effects.

Rationale

The goal is to reduce cardiovascular risk while maintaining quality of life and functional independence in this vulnerable age group. Older patients often have reduced vascular compliance and may experience adverse effects like dizziness, falls, or cognitive impairment with lower blood pressure levels. Therefore, a slightly higher blood pressure target is recommended for older adults compared to younger adults. The American College of Cardiology and the American Heart Association also support this approach, emphasizing the importance of individualized care and careful monitoring for adverse effects in older adults 1.

From the Research

Acceptable Blood Pressure in Patients Over 85 Years Old

• The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends a blood pressure of less than 140/90 mmHg in adults aged 60-79 years and a systolic blood pressure of 140 to 145 mmHg if tolerated in adults aged 80 years and older 2.
• For adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 2.
• The 2013 JNC 8 guidelines recommend reducing blood pressure to less than 140/90 mmHg in adults aged 60 years and older with diabetes mellitus or chronic kidney disease, but to less than 150/90 mmHg in adults aged 60 years and older without diabetes mellitus or chronic kidney disease 2.
• A study published in 2016 suggests that in elderly patients with diabetes, the target blood pressure should be based on concomitant diseases, orthostatic blood pressure changes, and the general condition of the patients, with a recommended target of <140-150/90 mmHg 3.
• Another study published in 2013 recommends a systolic blood pressure goal of <140 mmHg in patients less than 80 years of age and a systolic blood pressure goal of 140-150 mmHg in patients 80 years of age or older 4.
• A Cochrane review published in 2017 found that there is insufficient evidence to know whether a higher blood pressure target (less than 150 to 160/95 to 105 mmHg) or a lower blood pressure target (less than 140/90 mmHg) is better for older adults with high blood pressure 5.

Blood Pressure Targets

• The European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the minority report from the 2013 Eighth Joint National Committee (JNC 8) guidelines, the 2013 Canadian Hypertension Education Program guidelines, the 2011 UK guidelines, the 2014 American Society of Hypertension (ASH)/International Society of Hypertension (ISH) guidelines, and the 2015 AHA/ACC/ASH scientific statement on treatment of hypertension in patients with coronary artery disease all support reducing blood pressure to less than 140/90 mmHg in adults aged 60 to 79 years of age 2.
• A study published in 2007 found that combination therapy with amlodipine plus valsartan or lisinopril plus hydrochlorothiazide was well tolerated and efficacious in achieving blood pressure goals in adult patients with stage 2 hypertension 6.