Chapter 82: Hypertension

This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #18

Learning Objectives

• Understand what key age-related physiologic changes account for the progressive increase in the prevalence of hypertension with age.

• Explain the mechanisms for greater blood pressure variability with age, and understand why a hypertension diagnosis should never be based on a single elevated measurement.

• Determine the benefit-based systolic blood pressure (SBP) treatment goal based on age, comorbidities, and cardiovascular risk factors.

• Understand that arterial stiffness is an independent cardiovascular risk factor.

• Select the best thiazide-type diuretic to treat geriatric hypertension.

Key Clinical Points

1. The prevalence of hypertension increases steadily with age.

2. Older people develop systolic hypertension due to the age-related increase in arterial stiffness. Systolic blood pressure and pulse pressure, both closely associated with arterial stiffness, confer the greatest significance as cardiovascular and cerebrovascular risk factors.

3. Age-related changes in systems that regulate blood pressure result in greater blood pressure variability. Therefore, careful attention is needed to accurately measure and diagnose hypertension, as well as monitoring for adverse drug events—especially postural hypotension—throughout treatment.

4. The diagnosis of hypertension should be based on the average of a minimum of nine blood pressure readings that have been obtained on three separate office visits or derived from 24-hour ambulatory or home blood pressure monitoring results.

5. Older hypertensive individuals commonly have physiologic characteristics that respond effectively to lifestyle modifications.

6. The focus of therapy should be on lowering the systolic blood pressure to the patient’s benefit-based target goal. Applying benefit-based therapy to the majority of adults age 60 to 80 who are at high cardiovascular disease risk would in general favor a systolic blood pressure goal of less than 140 mm Hg, and for some a goal of 120 mm Hg may be considered.

7. Thiazide-type diuretic drugs—notably chlorthalidone—are preferred as the initial drug in most patients. Combination therapy with low doses of one or more agents should be considered if needed to control blood pressure below the target level.

8. Current blood pressure control rates are inadequate. Systems approaches that incorporate geriatric approaches to team care combined with quality improvement strategies need to be adopted to improve treatment outcomes.