Blood Pressure Goals for Geriatric Patients
For geriatric patients aged 65-80 years in good health, target blood pressure should be <140/90 mmHg, and for those over 80 years or frail elderly, individualize based on tolerability with a minimum target of <150/90 mmHg. 1, 2
Age-Stratified BP Targets
Patients 65-80 Years Old
- Target BP <140/90 mmHg is appropriate for relatively healthy older adults 1, 2
- If well-tolerated and the patient is at high cardiovascular risk, consider targeting <130/80 mmHg 1, 3
- Ensure diastolic BP does not fall below 60-65 mmHg, particularly in isolated systolic hypertension 4, 5
Patients Over 80 Years Old
- Target BP of 140-150/90 mmHg is reasonable for the very elderly 6, 7
- Consider monotherapy initially in patients >80 years or those who are frail 1
- More conservative targets reduce risk of orthostatic hypotension and falls 4, 7
Critical Assessment Factors Before Setting Targets
Frailty Assessment
- Frail elderly patients require less aggressive BP targets regardless of chronological age 1, 2
- Frailty indicators include: multiple comorbidities, functional dependence, cognitive impairment, and history of falls 4, 7
- In frail patients, excessive BP lowering may cause more harm than benefit through increased fall risk and cerebral hypoperfusion 7
Orthostatic Hypotension Screening
- Always check BP in both sitting and standing positions before intensifying therapy 4, 5
- A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic upon standing indicates orthostatic hypotension 4
- Symptoms of lightheadedness should prompt evaluation and possible medication reduction 4
Comorbidity Considerations
- Patients with diabetes: target <140/90 mmHg, avoiding diastolic <60 mmHg 5
- Patients with coronary artery disease: avoid excessive BP lowering to prevent myocardial hypoperfusion 5
- Patients with chronic kidney disease or cardiovascular disease may benefit from <140/90 mmHg if tolerated 1, 8
Treatment Initiation Strategy
Starting Therapy in Elderly Patients
- If BP is >20/10 mmHg above goal, initiate with two antihypertensive drugs 8
- For BP 140-159/90-99 mmHg in low-risk elderly, start with lifestyle modifications for 3-6 months before adding drugs 1
- For BP ≥160/100 mmHg, start drug treatment immediately regardless of age 1
Medication Selection
- First-line options include: ACE inhibitors/ARBs, calcium channel blockers, or thiazide-like diuretics 1, 6
- Consider monotherapy initially in patients >80 years to minimize adverse effects 1
- Use once-daily dosing and single-pill combinations to improve adherence 1, 2
Monitoring and Titration
Follow-Up Timeline
- Recheck BP within 2-4 weeks after any medication adjustment 2, 3
- Achieve target BP within 3 months of initiating or modifying therapy 1, 3
- Monitor for orthostatic hypotension at each visit 4, 5
Laboratory Monitoring
- Check serum potassium and creatinine 2-4 weeks after starting ACE inhibitors/ARBs or diuretics 2, 9
- Monitor for hypokalemia with thiazide diuretics, especially at higher doses 2
- Assess renal function regularly, as elderly patients are more susceptible to acute kidney injury 2
Common Pitfalls to Avoid
Overly Aggressive Treatment
- Do not pursue BP <120/80 mmHg in routine elderly patients outside of carefully monitored high-risk scenarios 8
- Excessive diastolic lowering (<60 mmHg) may worsen coronary perfusion 4, 5
- More aggressive targets increase adverse events including falls, syncope, and acute kidney injury 4
Undertreating Based on Age Alone
- There is no age threshold above which antihypertensive therapy should be withheld 6, 7
- Even patients >80 years benefit from BP reduction if systolic BP >160 mmHg 7
- Base treatment decisions on functional status and frailty, not chronological age alone 1, 7
Ignoring Isolated Systolic Hypertension
- Isolated systolic hypertension is the most common form in elderly patients 6
- Treat if systolic BP ≥140 mmHg, but monitor diastolic BP closely 6, 5
- If diastolic BP approaches 60 mmHg during treatment, consider accepting higher systolic targets 4, 5
Special Populations
Very Frail or Institutionalized Elderly
- Accept higher BP targets (150-160/90 mmHg) to minimize treatment burden 7
- Prioritize quality of life over aggressive cardiovascular risk reduction 7
- Consider deprescribing if BP consistently <130/70 mmHg with multiple medications 7