Hypertension (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 has 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 a low prevalence of diabetes mellitus and coronary artery disease. Patients with heart failure or dementia 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.