6.4 Hypertension in Elderly

The definition of hypertension in the elderly is the same as in general adult population. The prevalence of hypertension increases with age. Hypertension in the elderly is an increasingly important public health concern as our population ages. According to the Bangladesh Non-Communicable Disease (NCD) Risk Factor Survey 2022, percentage with hypertension in adults aged 18-69 years, is 23.5% in general, 24.1% in men and 23.0% in women⁴. Other reports stated a prevalence of ~60% over the age of 60 years and ~75% over the age of 75 years²⁰. For the purposes of these Guidelines, older is defined as ≥ 65 years and the very old as ≥ 80 years ¹¹. According to ESH guidelines, in older patients treated for hypertension should be lower to less than 140/ 80 mmHg, but not below an SBP of 130 mmHg¹¹.

Special features of hypertension in elderly

Advanced age has been a barrier to the treatment of hypertension because of concerns about potential poor tolerability, and even harmful effects of BP-lowering interventions in people in whom mechanisms preserving BP homeostasis and vital organ perfusion may be more frequently impaired. However, evidence from RCTs has shown that in old and very old patients, antihypertensive treatment substantially reduces CV morbidity and CV and all-cause mortality. Moreover, treatment has been found to be generally well tolerated. However, older patients are more likely to have comorbidities such as renal impairment, atherosclerotic vascular disease, and postural hypotension, which may be worsened by BP-lowering drugs. Older patients also frequently take other medications, which may negatively interact with those used to achieve BP control. Other important factors are -

Blood pressure may be falsely high due to excessive arterial stiffness (pseudo-hypertension).
Isolated systolic hypertension (SBP ≥140 mmHg and DBP <90 mmHg) is more common.
White-coat hypertension is more common in the elderly.
Postural hypotension and hypertension are more commonly seen.
Co-morbidities are common.
Adverse effects of drugs are more probable.

Management

Clinical assessment and diagnosis

Recommendations for BP measurements in elderly patients are like those for the general population. Postural hypotension, i.e., a drop in systolic BP of >20 mmHg upon standing, is a common problem in the elderly. Blood pressure should therefore be measured in both the seated/supine and standing positions. If there is a significant postural drop, the standing BP is used to guide treatment decisions. Ambulatory BP monitoring is indicated when hypertension diagnosis or response to therapy is unclear from office visits, when syncope or hypotensive disorders are suspected, and for evaluation of vertigo and dizziness. Home BP measurements may be important to avoid potential hazards of excessive BP reduction in older people. Initial assessment should follow the general principles of evaluation of hypertensive patients stated in the earlier section.

Goals of treatment

The general recommended BP goal in uncomplicated hypertension is <140/90 mm Hg. Provided the treatment is well tolerated in older patient (>65 years) SBP should be targeted to between 130 and 140 mmHg and DBP < 80 mmHg. Treated SBP should not be targeted to <120 mmHg¹¹. Patients with diabetes mellitus, chronic kidney disease, coronary artery disease or heart failure should have a BP <130/80 mmHg¹¹.

Non-pharmacological Treatment

Lifestyle modification may be the only treatment necessary for milder forms of hypertension in the elderly. Reduction of excess body weight increased physical activity, no-added salt, increased potassium intake and avoidance of mental stress are recommended. Associated risk factors of ischaemic heart disease, i.e., smoking, must be given up.

Pharmacological Treatment

It is recommended that older patients are treated according to the algorithm shown in Figures 4 and 5 in section 5. In very old patients, it may be appropriate to initiate treatment with monotherapy. In all older patients, when combination therapy is used, it is recommended that this is initiated at the lowest available doses¹¹. In all older patients, and especially very old or frail patients, the possible occurrence of postural BP should be closely monitored and symptoms of possible hypotensive episodes checked by ABPM. Unless required for concomitant diseases, loop diuretics and alpha-blockers should be avoided because of their association with injurious falls.

A key emphasis in treating older patients, and especially the very old, is to carefully monitor for any adverse effects or tolerability problems associated with BP-lowering treatment. Renal function should be frequently assessed to detect possible increases in serum creatinine and reductions in eGFR as a result of BP-related reductions in renal perfusion.