Lowering systolic blood pressure (BP) can benefit even very old patients with hypertension (reducing CV events, heart failure, and death). But older adults may be at higher risk for more side effects from antihypertensive medications, such as dizziness, electrolyte problems, and bumps in serum creatinine. Use the same general approach to manage hypertension in all adults, including lifestyle changes. But consider some nuances in older patients.
Tailor blood pressure goals to your patient. For many elderly patients over 75 years, aim for a systolic blood pressure less than 120 mmHg, if they tolerate treatment well and are motivated. Relax the goal to less than 140/90 or even 150/90 for older patients at high fall risk, with orthostatic hypotension, or even higher for those with severe dementia, limited life expectancy, etc. Explain hurried blood pressure checks can lead to over-treatment. Encourage home blood pressure monitoring. Suggest a properly sized cuff, sitting quietly first, etc.
Rely on thiazides, ACEIs, ARBs, or calcium channel blockers. Confirm medication adherence before recommending higher doses or adding medications. To step up, consider combining moderate doses of antihypertensive drugs to try to limit side effects, instead of pushing the dose of one medication. Encourage older patients on an ACEI, ARB, or thiazide to stay hydrated. Avoid NSAIDs to reduce risk of acute kidney injury. For further information, see topic on Recommendation for safety use of chronic NSAIDs. Advise close monitoring of sodium, potassium, and renal function and ask about side effects. See algorithm of monitoring ACEIs and ARBs. For example, listen for thiazide patients who report confusion, headache, or nausea which may suggest hyponatremia.
Be ready to help deprescribe medications if patients report dizziness or lightheadedness, despite rising slowly. And consider backing off if diastolic blood pressure drops below 60 mmHg.. going too low may increase cardiovascular risk. Look for obvious blood pressure medications to taper off, such as clonidine or a beta-blocker, unless there's a compelling indication (heart failure, etc).
REFERENCES
Musini VM, Tejani AM, Bassett K, Puil L, Wright JM. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database Syst Rev. 2019 Jun 5;6(6):CD000028. Available at: https://pubmed.ncbi.nlm.nih.gov/31167038
Hypertension Canada. Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2018 May;34(5):506-525. Available at: https://pubmed.ncbi.nlm.nih.gov/29731013
Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA; Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21;166(6):430-437. Available at: https://pubmed.ncbi.nlm.nih.gov/28135725
Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA. 2016 Jun 28;315(24):2673-82. Available at: https://jamanetwork.com/journals/jama/fullarticle/2524266