From the Guidelines
The goal for geriatric hypertension management is to target a systolic blood pressure (SBP) of 130-139 mmHg in older people (aged >65 years), as recommended by the 2019 ESC guidelines 1. This target is based on the latest evidence and aims to balance the benefits of blood pressure control with the potential risks of overtreatment. Key considerations in geriatric hypertension management include:
- Individualizing blood pressure targets based on frailty, comorbidities, and fall risk
- Starting with lifestyle modifications, such as sodium restriction, regular physical activity, weight management, and limiting alcohol consumption
- Using medications, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), when necessary, and titrating slowly to minimize adverse effects
- Monitoring for orthostatic hypotension, electrolyte abnormalities, and renal function changes
- Simplifying medication regimens to improve adherence and reducing the risk of polypharmacy
- Regular follow-up every 1-3 months to assess efficacy and adverse effects, as recommended by the American College of Physicians and the American Academy of Family Physicians 2. The benefits of controlling hypertension in older adults include reduced risk of stroke, heart failure, cardiovascular events, and cognitive decline, though these benefits must be balanced against potential medication side effects and quality of life considerations. In older adults, the diastolic blood pressure (DBP) target is <80 mmHg, but not <70 mmHg, as recommended by the 2019 ESC guidelines 1. Overall, the management of geriatric hypertension requires a careful and individualized approach, taking into account the unique needs and circumstances of each patient.
From the Research
Geriatric Hypertension Goals
- The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years and to 140-145 mmHg if tolerated in adults aged 80 years and older 3.
- Other guidelines, including the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the 2013 Canadian Hypertension Education Program guidelines, and the 2011 UK guidelines, also recommend reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years 3.
- 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 3, 4.
- The 2013 Eighth Joint National Committee (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 3.
- A study published in 2019 found that the benefits of blood pressure control were demonstrated even with a minimal blood pressure control (systolic BP <150 mmHg) and continued to be reported for a systolic BP <120 mmHg 5.
- A Cochrane review published in 2017 found that there is insufficient evidence to know whether a higher blood pressure target (less than 150-160/95-105 mmHg) or a lower blood pressure target (less than 140/90 mmHg) is better for older adults with high blood pressure 6.
- A study published in 2001 found that diuretics and calcium-blocking drugs are more effective in elderly patients at lowering systolic blood pressure, while beta-blockers were relatively ineffective and had more side effects 7.