Treating Hypertension in Older People

The challenge of treating systolic hypertension

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A majority of people over the age of 65 have hypertension (high blood pressure), which is a major risk factor for stroke, coronary artery disease (CAD), heart failure and kidney disease.It's equally important that both older people and younger people have their hypertension treated. But many older people face two special challenges in achieving adequate blood pressure control: first, many of them chiefly have systolic hypertension.
Second, older people more often have difficulty tolerating antihypertensive therapy.

Systolic Hypertension in the Elderly

Most older people with hypertension primarily have elevations in their systolic blood pressure, while their diastolic pressure remains normal or nearly normal. This is because as we age, our blood vessels become "stiffer," so the systolic blood pressure (the pressure in the arteries while the heart muscle is beating) goes up. A systolic blood pressure of 140 mm Hg is considered to be the upper limit of normal.

Furthermore, in people over the age of 65, a high systolic blood pressure increases cardiovascular risk more than a high diastolic pressure. (The opposite is true in younger people.) In fact, systolic hypertension more than doubles your risk of heart attack and stroke. So treating systolic hypertension is important.

But treating systolic hypertension can present a special problem: namely, in reducing the systolic blood pressure, it's important not to simultaneously reduce the diastolic blood pressure too much. This is because in older people with CAD, reducing the diastolic pressure below 60 or 65 mm Hg has been associated with an increase in heart attacks and strokes.

So the trick in treating systolic hypertension is to reduce the systolic pressure to below 140 mm Hg — or as close to 140 mm Hg as possible — while keeping the diastolic pressure above 60 or 65 mm Hg.

Hypertension Therapy in Older People

As with anyone else with hypertension, the first step in treating high blood pressure in older people is to institute the lifestyle changes that can reduce your blood pressure, including weight loss, salt restriction, exercise and smoking cessation.

If your blood pressure remains elevated after a month or two of lifestyle modification, your doctor will probably recommend drug therapy.

In older people, using antihypertensive drugs safely can be tricky. Not only must care be taken to avoid reducing the diastolic pressure too much, but some older people, particularly those who mainly have systolic hypertension, can develop orthostatic hypotension (a fall in blood pressure upon standing up) with some blood pressure medications.

Postprandial hypotension (a fall in blood pressure right after eating) can also be seen in older people on hypertension medication. Hypotension — whatever may be causing it — can lead to blackouts and falls, and must be avoided.

So the name of the game is to go slowly in order to avoid side effects. When initiating blood pressure medication in older people, a single drug should be used, and it should be started at a low dose — often, at a dose that is roughly half the dose which might be used in a younger patient.

Treatment is usually begun with a thiazide diuretic, a long-acting calcium blocker, or an ACE inhibitor. If the drug is tolerated without side effects, the dosage may be increased after a few weeks if necessary. If the higher dose still is not achieving good blood pressure control, most doctors will next switch to a different medication, rather than add a second drug. Combination drug therapy is generally used only when several attempts at single drug therapy prove to be inadequate.

After any change in therapy — increasing the dose of a drug, switching to a different medication, or adding a second medication — your doctor should carefully check for orthostatic hypotension. This is done by measuring your blood pressure while you are lying down, and then while you are standing up, while looking for a significant drop in pressure. It's also always important to tell your doctor about any dizziness you may experience when you stand up, or after eating.

The goal is to gradually bring your blood pressure down to target levels, over weeks or months (rather than in days) while taking care during this time to avoid lowering your blood pressure too much. Achieving this goal often takes numerous trials with one or more drugs, and several dosage adjustments.


If you are an older person, chances are good that you have hypertension. While hypertension is a significant problem, and while treating it may present challenges, it's still the case that with care and patience (on your part as well as your doctor's), there is an excellent chance that your hypertension will be brought under control without any troublesome side effects, and your risk of serious cardiovascular problems will be greatly reduced.


Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation 2011; 123:2434.

Chobanian AV. Clinical practice. Isolated systolic hypertension in the elderly. N Engl J Med 2007; 357:789.

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