Hypertension in the Elderly

Aka: Hypertension in the Elderly, High Blood Pressure Management in Older Adults, Antihypertensive Management in Geriatric Patients

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II. Pathophysiology:

  1. Vascular changes seen in the elderly
    1. Increased vascular resistance
    2. Reduced plasma renin activity
    3. Increased Left Ventricular Hypertrophy
  2. Benefits of Blood Pressure control in even in those over 80-90 years old
    1. Fewer cardiovascular events
    2. Decreased Congestive Heart Failure exacerbations
    3. Decreased overall mortality
  3. Risks of Blood Pressure control in older adults
    1. See precautions below

III. Exam

  1. See Hypertension Criteria
  2. See Hypertension Evaluation

IV. Precautions: Pitfalls in the elderly

  1. Avoid abruptly and significantly lowering Blood Pressures in older patients
    1. End-organ hypoperfusion may result in cerebral ischemia or Myocardial Ischemia
    2. Orthostatic Hypotension, Dizziness and increased Fall Risk may occur
      1. Consider raising target to <150/90
      2. Decrease Antihypertensive dose if diastolic Blood Pressure falls <60 mmHg
    3. Antihypertensive may cause Electrolyte abnormalities (e.g. Hyponatremia, Hypokalemia)
    4. Antihypertensives also risk Acute Kidney Injury
  2. Avoid basing Blood Pressure management on the first hurried Blood Pressure reading on clinic arrival
    1. See Blood Pressure for proper measurement guidelines
  3. Pseudohypertension occurs due to calcified arteries
    1. Calcified arteries are more difficult to compress

V. Management: General Measures

  1. See Hypertension Management for general guidelines
  2. Avoid NSAIDs (increases Blood Pressure and risks NSAID Renal Adverse Effects)
  3. Maintain hydration to prevent Orthostatic Hypotension
  4. Isolated Systolic Hypertension is common in elderly
    1. Goal systolic BP <140 mmHg (consider <150 mmHg if orthostatic Hypertension risk)
    2. Consider two Antihypertensives if SBP >160 mmHg or DBP>100 mmHg
  5. Consider Ambulatory Blood Pressure Monitoring
    1. May better identify hypotensive episodes

VI. Management: First-Line Antihypertensives

  1. Thiazide Diuretics are the preferred Antihypertensive
  2. Thazide Diuretics decrease morbidity and mortality
    1. Cerebrovascular Accident
    2. Congestive Heart Failure
    3. Myocardial Infarction
  3. Observe closely for adverse effects in elderly
    1. Dehydration
    2. Orthostatic Hypotension
    3. Hypokalemia
      1. Check Serum Potassium frequently
      2. Consider combining with Potassium-Sparing Diuretic

VII. Management: Second-Line Antihypertensives

  1. Beta Blockers
    1. Reduce morbidity and mortality in the elderly
    2. Consider in vascular disease and CHF
    3. Use specific agents: Atenolol, Metoprolol
  2. ACE Inhibitors or Angiotensin Receptor Blocker
    1. Consider in CAD, CVA, CHF, Diabetes, CRF
    2. Observe closely for adverse effects
      1. Dehydration or decreased Circulatory Volume
      2. Heart Failure
      3. Renal Artery Stenosis
  3. Calcium Channel Blockers
    1. Consider in Coronary Disease and Diabetes Mellitus
    2. Consider in black and salt-sensitive patients
    3. Observe for Orthostatic Hypotension with Nifedipine
    4. Avoid short-acting agents

VIII. Use with caution: Central alpha Agonists (e.g. Clonidine)

  1. These agents do not reduce morbidity or mortality
  2. Adverse effects are more common in the elderly
    1. Sedation
    2. Dry Mouth
    3. Depressed mood
    4. Hypotension
    5. Rebound Hypertension if abruptly stopped

IX. References

  1. (2019) Presc Lett 26(9): 49-50
  2. Chobanian (2003) Hypertension 42:1206-52 [PubMed]
  3. Dickerson (2005) Am Fam Physician 71(3):469-76 [PubMed]

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