Hypertension Management in Older Adults

Blood Pressure Targets

The American College of Physicians recommends a target systolic blood pressure of less than 150 mmHg to reduce mortality, stroke, and cardiac events risk in adults aged 60 years or older with hypertension, with an absolute risk reduction of 1.64% for mortality, 1.13% for stroke, and 1.25% for cardiac events 1
For patients with a history of stroke or transient ischemic attack, or at high cardiovascular risk, a more intensive target of less than 140 mmHg is considered 2, 3
The European Society of Cardiology recommends a target of 120-129/70-79 mmHg for patients 70 years or older if well tolerated, following the "as low as reasonably achievable" principle if not well tolerated, although this citation is from a less preferred source, it is included for completeness 4

The American Heart Association recommends implementing dietary changes such as the DASH diet, and promoting regular physical activity appropriate for age and capabilities 1
For systolic BP persistently at or above 150 mmHg, pharmacologic treatment should be initiated 1
First-line medication options include thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, and dihydropyridine calcium channel blockers 5

For non-black patients, start with low-dose ACEI/ARB, and increase to full dose if inadequate response, then add thiazide/thiazide-like diuretic if BP remains uncontrolled, and consider adding a dihydropyridine calcium channel blocker 5
For black patients, start with low-dose ARB plus dihydropyridine CCB or thiazide/thiazide-like diuretic, and increase to full dose if needed, then add diuretic or ACEI/ARB if BP remains uncontrolled 5

Consider using single-pill combinations to improve medication adherence, and monitor for orthostatic hypotension when initiating or adjusting therapy, although these citations are from a less preferred source, they are included for completeness 4
Assess for frailty, which may warrant more conservative BP targets, and consider slower medication titration in elderly patients 4
For patients with multiple comorbidities, consider drug interactions and treatment burden 1

Ensure accurate BP measurement using validated devices with appropriate cuff size, and consider multiple measurements in clinical settings 1, 5
Follow up within 2-4 weeks after medication changes, and aim to achieve target blood pressure within 3 months, although these citations are from a less preferred source, they are included for completeness 4
Consider home blood pressure monitoring to assess treatment efficacy 5

Therapeutic inertia, ignoring potential medication adherence issues, and continuing ineffective monotherapy when combination therapy is indicated, although these citations are from a less preferred source, they are included for completeness 4
Excessive BP lowering causing orthostatic symptoms in elderly patients, and using medications with unfavorable side effect profiles in elderly patients, such as certain beta-blockers 4, 6