DANGER! Regulating high blood pressure in older patients

By Dr. Randolph Howes, MD, PhD

Older adults frequently have more than one chronic disease and therefore require careful management to ensure proper care and improve or maintain quality of life.

High blood pressure is one of the most common diseases in the elderly and increases the chances of developing kidney damage, heart disease, and many other serious health problems. Hypertension (defined as a blood pressure over 140/90 mm Hg) affects more than two out of three individuals over 75 years of age. However, there has been a tendency not to treat these elevations in blood pressure with blood pressure lowering (anti-hypertensive) medications. This is due to a common misconception that a normal systolic pressure is “100 plus your age.” Furthermore, too great of a reduction of blood pressure may be poorly tolerated in older people. For example, only 25 % of patients with systolic pressures as high as 180-185 mm Hg currently are being treated. It is suggested not to lower the diastolic (lower number) pressure below 55-60 mm Hg, which may increase side effects by reducing the circulation of blood.

The target blood pressure for most people is now 120/80 mmHg.

However, the ideal blood pressure goal for very old people is not yet clear because there have been few blood pressure studies that included this age group. In fact, getting the blood pressure down this much in very old people has not been found to reduce their risk of dying.

In addition, many individuals over the age of 65 may feel dizzy, fall or pass out when they stand suddenly, due to blood pressure that is suddenly too low.

This condition, known as postural or orthostatic hypotension, poses a danger of fractures and other serious injury. This is especially a concern in frail older people who often suffer as well from thinning bones (osteoporosis). Therefore, many doctors now set a target of 140/90 mmHg, 150/80 mmHg, or 150/85 mmHg for older individuals.

Blood pressure medications should be started slowly in older people and increased gradually, to avoid any sudden drop in blood pressure levels.

The new controversial Systolic Blood Pressure Intervention Trial (SPRINT) showed that high risk adults with hypertension had a significant reduction in cardiovascular events and death when treated to an aggressive systolic blood pressure (BP) target of 120 mm Hg instead of 140 mm Hg.

However, a major concern is that they appear to be much more likely to falling or passing out when blood pressure drops too low.

In the America that I love, physicians balance the risks and benefits of intensive blood pressure lowering. It is recommended that medications be started at low doses and increased slowly to avoid a too rapid or excessive lowering of blood pressure.