The management of hypertension in the elderly involves several key considerations, including the initiation of treatment, choice of antihypertensive agents, and setting of blood pressure (BP) targets.
Initiation of treatment
- For patients aged 65–79 years, antihypertensive therapy is recommended to be initiated at an office BP of ≥140/90 mmHg
- For patients aged ≥80 years, pharmacotherapy is recommended to be initiated at an office systolic blood pressure (SBP) of ≥160 mmHg, with consideration for initiation at a lower SBP threshold of 140–160 mmHg
- In patients aged ≥85 years or with clinically significant moderate-to-severe frailty or limited predicted lifespan (<3 years), BP-lowering treatment should be initiated only from ≥140/90 mmHg under close monitoring of treatment tolerance
Choice of antihypertensive agents
- In patients aged ≥85 years and/or with moderate-to-severe frailty, long-acting dihydropyridine calcium channel blockers (CCBs) or renin–angiotensin system (RAS) inhibitors are recommended, followed if necessary by a low-dose diuretic if tolerated. β-blockers and α-blockers are generally not preferred unless compelling indications exist
- In older patients, treatment should start with lower doses and be up-titrated slowly
Blood pressure targets
- For patients aged 65–79 years, the primary goal of treatment is to lower BP to <140/80 mmHg, with consideration for lowering BP to <130/80 mmHg if treatment is well tolerated
- For patients aged ≥80 years, the primary goal of treatment is to lower office BP to 140–150 mmHg SBP and <80 mmHg diastolic blood pressure (DBP)
- In patients aged ≥85 years, personalized and more lenient BP targets (such as <140 mmHg) should be considered
Special considerations
- In patients with reduced functional/autonomy status and/or dementia, treatment should be individualized
- In frail patients, the SBP and DBP thresholds for initiating pharmacotherapy should be individualized
- In patients with low SBP (<120 mmHg) or in the presence of severe orthostatic hypotension or a high frailty level, treatment reduction should be considered
In conclusion, the management of hypertension in elderly patients requires individualized care, careful monitoring, and balancing the benefits of treatment with potential risks, considering the patient's clinical status and preferences.