Management of hypertension in the elderly

Hypertension in older people is defined by the same thresholds as in the young, but the pattern differs: systolic BP rises with age while diastolic BP plateaus or falls after about 60 years.

Prevalence rises steeply with age. In India, LASI Wave 1 found hypertension in about 46% of adults aged 45 and above, with only about 32% achieving control — awareness and control are the weak links, not availability of drugs.

Ageing changes that cause hypertension: arterial wall stiffness from collagen deposition and elastin loss, reduced nitric oxide bioavailability, impaired baroreceptor sensitivity, and reduced plasma renin activity.

Always measure standing (orthostatic) BP as well as sitting, because postural hypotension is common and treatment can worsen it. Pathy's advises orthostatic measurement at every visit.

Three pitfalls must be excluded before labelling a patient hypertensive: white-coat hypertension (common in the elderly), masked hypertension, and pseudo-hypertension (falsely high cuff readings from incompressible calcified arteries).

Use a large cuff for large arms, take the average of at least two readings on two occasions, and confirm with home or ambulatory BP monitoring where possible.

Treatment reduces stroke, heart failure and mortality at every age. HYVET (patients over 80, SBP ≥160 mmHg) showed a 30% fall in stroke, 21% fall in all-cause death and 64% fall in heart failure.

SPRINT-Senior (age ≥75) showed intensive control (SBP <120) reduced cardiovascular events and death compared with a target of <140.

Cerebrovascular disease is an indication for, not a contraindication to, antihypertensive therapy.

Counter-evidence exists in the very frail: SBP below 120 mmHg is associated with higher mortality in those over 85, and the PARTAGE study showed excess mortality in nursing-home residents on multiple antihypertensives with low achieved BP.

Salt restriction, a fruit-vegetable-low-fat-dairy (DASH-type) diet, potassium-, calcium- and magnesium-rich foods, weight optimisation, aerobic exercise, smoking cessation and alcohol limitation.

Review and rationalise drugs that raise BP: NSAIDs, decongestants and glucocorticoids. Regular medication review reduces polypharmacy and improves adherence.

Golden rule: "start low, go slow", use once-daily long-acting agents, and monitor BP, creatinine and potassium after each dose change.

Thiazide/thiazide-like diuretics are first-line, especially for isolated systolic hypertension. Chlorthalidone 12.5–25 mg is preferred over hydrochlorothiazide. Watch hypokalaemia, hyponatraemia, hyperuricaemia and hyperglycaemia; avoid in gout.

Calcium channel blockers are superior for stroke prevention; diuretics are superior for heart failure prevention; beta blockers are inferior for preventing major cardiovascular events and should be reserved for compelling indications (ischaemic heart disease, heart failure, atrial fibrillation).

ACE inhibitors / ARBs are preferred in heart failure and in diabetes with albuminuria. Never combine an ACE inhibitor with an ARB in older people — the risk of acute kidney injury and hyperkalaemia rises sharply.

Pathy's key message: lower BP in proportion to the patient's functional level. Indiscriminate application of a single tight target to frail, multimorbid elders "may do more harm than good" — risks are falls, cognitive decline, acute kidney injury and hyperkalaemia.

Practical targets: aim for <130/80 mmHg in the robust, independent elder; accept <140/90 mmHg in the frail or care-home resident; consider deprescribing at the end of life. Assess frailty (e.g. Clinical Frailty Scale) before setting the target.