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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 and cognitive impairment risk factors.

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

  • Select the best thiazide-type diuretic and other medication classes 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. SBP and pulse pressure, both closely associated with arterial stiffness, confer the greatest significance as cardiovascular and cognitive impairment 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 SBP to the patient’s benefit-based target goal. Applying benefit-based therapy to the majority of adults age 65 or older who are at high cardiovascular disease or cognitive impairment risk favors a SBP goal of less than 130 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 class in most patients. Combination therapy with low doses of one or more agents should be considered if needed to achieve the target SBP 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.


High blood pressure has the greatest impact on global attributable mortality of any risk factor. Compared with all other specific risks quantified in the Global Burden of Disease, Injuries, and Risk Factor studies, systolic blood pressure (SBP) of at least 110 to 115 mm Hg was the leading global contributor to preventable death in 2015. Three demographic changes—(1) the prevalence of elevated SBP (≥ 110–115 and ≥ 140 mm Hg) has increased substantially in the past 25 years, (2) the age-associated increase in blood pressure, and (3) the worldwide demographic increase in the aging population—are conspiring to create an enormous, emerging public health impact. In addition to the well-ascribed hypertension risk for cardiovascular disease (CVD) and stroke, it is also a significant risk factor for chronic kidney disease, atrial fibrillation, congestive heart failure (CHF) with ...

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