Managing Hypertension in Older Adults

Abstract

Purpose of review: The population of older adults 60-79 years globally is projected to double from 800 million to 1.6 billion between 2015 and 2050, while adults ≥ 80 years were forecast to more than triple from 125 to 430 million. The risk for cardiovascular events doubles with each decade of aging and each 20 mmHg increase of systolic blood pressure. Thus, successful management of hypertension in older adults is critical in mitigating the projected global health and economic burden of cardiovascular disease.

Recent findings: Women live longer than men, yet with aging systolic blood pressure and prevalent hypertension increase more, and hypertension control decreases more than in men, i.e., hypertension in older adults is disproportionately a women's health issue. Among older adults who are healthy to mildly frail, the absolute benefit of hypertension control, including more intensive control, on cardiovascular events is greater in adults ≥ 80 than 60-79 years old. The absolute rate of serious adverse events during antihypertensive therapy is greater in adults ≥ 80 years older than 60-79 years, yet the excess adverse event rate with intensive versus standard care is only moderately increased. Among adults ≥ 80 years, benefits of more intensive therapy appear non-existent to reversed with moderate to marked frailty and when cognitive function is less than roughly the twenty-fifth percentile. Accordingly, assessment of functional and cognitive status is important in setting blood pressure targets in older adults. Given substantial absolute cardiovascular benefits of more intensive antihypertensive therapy in independent-living older adults, this group merits shared-decision making for hypertension targets.

Keywords: Antihypertensive medications; Cardiovascular events; Hypertension; Isolated systolic hypertension; Lifestyle change; Older adults.

Fig. 1

The numbers and percentages of adults 60–79 and ≥ 80 years globally in 2015 and 2050. Legend. The global numbers of adults 60–79 and ≥80 years in 2015 and 2050 (top panel), respective percentages of the total global population (middle panel), and numbers with hypertension (bottom panel) are shown. The projected increases are large and have important implications for the global health and economic burden of hypertension and related cardiovascular disease

Fig. 2

Projected number of cardiovascular disease events in 2015 and 2050 in older adults with and without antihypertensive therapy. Abbreviations: CVDE, cardiovascular disease events; CVDE-S, estimated number of CVDE with standard antihypertensive therapy; CVDE-I, estimated number of CVDE with intensive antihypertensive therapy

Fig. 3

Systolic BP in adults by age group in men and women [17]. Legend. In the MESA longitudinal cohort study, systolic BP increased more with aging in women than men for all adults and only for those on BP meds (antihypertensive medications). Thus, the prevalence of hypertension increases more with age in women than men and control rates fall more than in men

Fig. 4

Provides guidance for assessing levels of frailty. Randomized trials of antihypertensive therapy have typically excluded individuals with moderate and severe frailty. Legend. A global clinical measure of fitness and frailty in elderly people. The clinical frailty scale defines nine levels of fitness and frailty with key features of each level provided above [14]