High blood pressure (BP) in the elderly

• hypertension is common in those aged over 60 years (elderly)
• hypertension in the elderly is associated with an increased risk of coronary heart disease and stroke
• treatment of elderly hypertension will reduce the risk of a major coronary event by 20% and the incidence of stroke by almost 40%
• it is important to note that older people show greater BP variability, and thus it is particularly important that multiple measurements are taken on several occasions to confirm the diagnosis of hypertension
  • standing and seated measurements are important during the initial assessment and after initiating drug therapy, because of the high prevalence of orthostatic hypotension
• in this age group thiazide/thiazide-like diuretics are particularly effective at lowering BP in older people, as are dihydropyridine calcium channel blockers
• NICE have recommended that (2):
  • for adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level
  • for adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity

Notes:

• a meta-analysis from the Blood Pressure Lowering Treatment Trialists' Collaboration indicated that reducing blood pressure with antihypertensive drugs reduces CV risk to a similar degree in both younger (<65 years) and older (>65 years) people irrespective of which drug regimen is used (3)
• HYVET study was a large double-blind, randomised, placebo-controlled trial, which showed that antihypertensive treatment with a thiazide-like diuretic (indapamide) and/or an ACE inhibitor (perindopril) reduced the risk of death from stroke or any cause in patients aged 80 years or older (4)
  • note though that the study sample was a relatively healthy group with low prevalence of diabetes mellitus and coronary artery disease. Patients with heart failure or dermentia and those requiring nursing care were excluded - thus the relative benefits and risks of treating frail elderly people with multiple comorbid conditions were not addressed by this trial (and may never be known) (5)

Reference:

• (1) Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004 - BHS IV. J Hum Hypertens 2004;18: 139-85
• (2) NICE (March 2022). Management of hypertension in adults in primary care
• (3) Blood Pressure Lowering Treatment Trialists? Collaboration. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008;336:1121-3.
• (4) Becket NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-98
• (5) Commentary. Antihypertensive therapy with indapamide and perindopril reduced mortality in patients >= 80 years. Evidence Based Medicine 2008; 13(5): 136.