In a recent issue of JAMA, a paper entitled “Updated guidelines for the management of high blood pressure” 4 states that hypertension is a major risk factor for cardiovascular disease and stroke, but approximately 50% are not adequately controlled. In a recent issue of the Philadelphia Inquirer, two distinguished physicians (RT Townsend, Hypertension Program, Hospital University Penn Program, and Muriel L Jessup, Penn Heart and Vascular Center) recommended treatment for people older than 60 years, those with a systolic blood pressure of 150 mmHg, those with diabetes or kidney disease, and those with a blood pressure greater than 140/90 mmHg. Moving on to consideration of the specifics of this letter, I will present evidence for “less is more” in order to prevent the serious complications of hypertension in the elderly and other age groups. This is not a bad maxim when writing a prescription. Perhaps one might consider the mantra of the legendary coach of the Green Bay Packers, ie, “When you throw a foot ball, three things could happen, and two are bad”. 3 My feeling is “less is more” in this group of patients. Primary care physicians, nurse practitioners, and others caring for the elderly must recalibrate which target and which range to use to treat this group of patients. I will continue to emphasize orthostatic hypotension, since during sleep, the elderly – either under medication treatment, or not – frequently get out of bed during the night to urinate, which is associated with the usual drop in blood pressure during sleep. 2 In medical practice today, blood pressure is measured by a nurse or health worker using an automated blood pressure device, but not after a short rest, sitting or standing (as recommended to measure orthostatic hypotension, particularly if the patient is on treatment with antihypertensive medications).
When treating hypertension in patients over the age of 85 years, the usual target blood pressure is 150/80 mmHg for reduction of the risk of stroke, heart attack, and other cardiovascular events.
1 Clearly, this is a small percentage, but not an insignificant number.
In 2010, individuals aged over 85 years were estimated to comprise 1.85% of the US population, with an estimate of 2.03% projected for 2025. Treating hypertension in patients over the age of 85 years, ie, the “old-old”, presents a challenge that is different from that encountered when treating any other age group.
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