What is the best intervention for an elderly adult with pre-existing anxiety and hypertension (high blood pressure) prior to undergoing surgery?

Preoperative Anxiety Management with Hypertension in Elderly Adults

For an elderly adult with anxiety-induced hypertension before surgery, the best intervention is to proceed with surgery if blood pressure is <180/110 mmHg while continuing current antihypertensive medications, and address the anxiety with non-pharmacological interventions rather than adding anxiolytic medications that could complicate perioperative management.

Blood Pressure Thresholds for Surgical Decision-Making

The critical decision point is whether blood pressure is above or below 180/110 mmHg:

• Proceed with surgery if blood pressure is <180/110 mmHg, as this does not significantly increase perioperative cardiovascular risk 1, 2
• Defer surgery if blood pressure is ≥180/110 mmHg to optimize blood pressure control first 1, 2
• For blood pressure 160-179/100-109 mmHg, proceed with surgery but inform the primary care physician to optimize the antihypertensive regimen postoperatively 2

The British and Irish joint guidelines provide clear evidence that patients with stage 1 or 2 hypertension without target organ damage do not have increased perioperative cardiovascular risk 1. The American Heart Association and American College of Cardiology support proceeding with surgery for blood pressure <160/100 mmHg 2.

Perioperative Medication Management

Continue all current antihypertensive medications through the morning of surgery with the following specific considerations:

• Continue beta-blockers, calcium channel blockers, and clonidine to avoid rebound hypertension and withdrawal syndromes 2, 3, 4
• Consider holding ACE inhibitors/ARBs on the day of surgery due to intraoperative hypotension risk, but restart as soon as clinically feasible postoperatively 2
• Resume all antihypertensive medications as soon as the patient can take oral medications postoperatively 2

Beta-blockers should never be abruptly discontinued in elderly patients, as this can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 4. Clonidine withdrawal can cause sympathetic discharge and acute hypertensive crisis 3.

Anxiety Management Strategy

Avoid adding benzodiazepines or other anxiolytic medications in elderly patients before surgery:

• Benzodiazepines should generally be avoided when treating anxiety in the elderly due to increased fall risk, cognitive impairment, and respiratory depression 5
• Beta-blockers should not be used specifically for anxiety management in this population 5
• Antipsychotics carry a black box warning for increased mortality in elderly patients and should not be used 5

Instead, implement non-pharmacological anxiety management:

• Provide clear preoperative education and counseling about the surgical procedure
• Ensure adequate pain control planning
• Consider involving anesthesia team early for preoperative consultation to address patient concerns
• Optimize the surgical environment to reduce anxiety triggers

The evidence shows that anxiety is a common cause of excessive hypertension, and anxiolytic treatment can lower blood pressure 6. However, in the perioperative setting for elderly patients, the risks of adding sedating medications (increased fall risk, delirium, respiratory depression, drug interactions) outweigh potential benefits 5.

Specific Antihypertensive Optimization for Elderly Patients

If blood pressure requires optimization before surgery (≥180/110 mmHg), use age-appropriate first-line agents:

• For patients >55 years: Start with a calcium channel blocker (e.g., amlodipine 5-10 mg daily) 1
• Alternative if CCB not tolerated: Use a thiazide-like diuretic (chlorthalidone 12.5-25 mg once daily or indapamide 1.5 mg modified-release) 1
• Avoid ACE inhibitors/ARBs as first-line in patients >55 years unless specific indications exist 1

For patients already on antihypertensive therapy with inadequate control, add a second agent from a different class rather than increasing the dose of the current medication 1.

Critical Perioperative Monitoring

Elderly hypertensive patients demonstrate more labile hemodynamics during anesthesia:

• Expect pronounced blood pressure increases with airway instrumentation and sympathetic activation 1
• Anticipate hypotension after induction of anesthesia due to reduced systemic vascular resistance 1
• Maintain mean arterial pressure ≥60-65 mmHg or systolic blood pressure ≥90 mmHg intraoperatively to reduce myocardial injury risk 2

Common Pitfalls to Avoid

• Do not acutely lower blood pressure in the days immediately before surgery for mild to moderate elevations, as this does not reduce operative risk and may cause harm 7
• Do not discontinue beta-blockers or clonidine perioperatively due to severe withdrawal risks 3, 4
• Do not add benzodiazepines for anxiety management in elderly patients due to increased adverse event risk 5
• Do not delay surgery unnecessarily for blood pressure <180/110 mmHg, as the risks of surgical delay may outweigh benefits 1, 2

Special Considerations for Frailty and Comorbidities

Assess for frailty, orthostatic hypotension, fall risk, and cognitive impairment before initiating or intensifying antihypertensive therapy:

• These factors are common in elderly patients and significantly impact treatment decisions 8, 9
• Blood pressure targets may need individualization in very frail patients (>80 years with significant comorbidities) 1
• Standing blood pressure should be measured to assess for orthostatic hypotension before surgery 1