# 013 Hypertension in the Elderly

Fast Facts and Concepts #013 PDF

AUTHORS: Yana Thaker, Suzanne Gehl MD, Kathyrn Denson MD, Jennifer Scheeler, MD, Bambi Wessel

OBJECTIVES

1. Identify blood pressure goals in patients >65 years old.
2. List four JNC7 considerations for treatment of hypertension.
3. List four medications and the specific conditions for which they are indicated, based on patient co-morbidities.
4. List four practical lifestyle recommendations for the management of hypertension.

ACGME Competencies: Patient Care, Medical Knowledge

Context:   Follow-up visit of a patient in the nursing home or other outpatient setting

Action: Determine initial appropriate treatment option for an elderly hypertensive patient with medical co-morbidities.

Incidence/Prevalence: 60% of Americans > 60 years are diagnosed with hypertension (SBP > 140/90), but only 27% have their blood pressure controlled to the ideal range with medication. Meta-analysis data has shown that treating hypertension is imperative for preventing strokes and cardiovascular events.

Underlying Science: Geriatric patients require unique considerations when managing their hypertension as normal aging processes can contribute to abnormal findings.

Examples include:

Pseudohypertension: falsely positive elevated blood pressure readings due to the incompressibility of a calcified artery.

Orthostatic hypotension: decrease in blood pressure from lying (sitting), to standing, caused by a decrease in baroreflex response. 

Clinical Recommendations:

1. Recommended blood pressure goal in patients >65 years: < 140/90 mm Hg.
2. Recommended blood pressure goal in patients>65 years with diabetes or chronic kidney disease: < 130/80 mmHg.
3. Recommended blood pressure goal in patients >80: < 150/80 mmHg.

Considerations when treating:

1. Treat isolated systolic BP.
2. Thiazide diuretics are considered first line treatments.
3. Co-morbidities and risk factors (outlined in Table 1) determine second line treatments.
4. Combinations of two or more anti-hypertensives may be necessary for those with systolic pressures > 160 mmHg or diastolic pressure > 100 mmHg.
5. Chosen anti-hypertensive must be titrated slowly to prevent hypotension and other side effects.
6. Life-style modifications listed in Table 2 should be recommended as part of the management of hypertension.  These modifications can be as effective as pharmacological therapies in certain individuals.
7. Consider the patient’s goals, beliefs, previous experiences with treatment and the cost of medication prior to treating.

Table 1: Anti-hypertensive medications indicated for specific disease states. A comprehensive list of anti-hypertensives and combinations therapies are available in the JNC 7 report.

Table 2: Life-style modification recommendations. *DASH – Dietary Approaches to Stop Hypertension

Tables were adapted from the listed references.

References:

1. Bechett, N. S., Peters, R., Fletcher, A. E., et al. Treatment of hypertension in patients 80 years
2. of age or older. NEJM. 2008 May 1; 358: 1887-1898.
3. Chobanian, A.V., Bakris, G.L., Black, H.R., et al. The Seventh Report of the Joint National
4. Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003 May 21; 289(17): 2560-2572.
5. Dickerson, L. M and Gibson, M. V. Management of hypertension in older persons. Am Fam
6. Physician. 2005 Feb 1; 71(3):469-476.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Yana Thaker, Suzanne Gehl MD, Kathyrn Denson MD, Bambi Wessel, Fast Fact #013: Hypertension in the Elderly, February, 2012, Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Disclaimer:Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.