Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Drugs & Aging
Published in: Drugs & Aging 5/2014

01-05-2014 | Current Opinion

Treatment of Hypertension in Older Persons: What Is the Evidence?

Author: John E. Morley

Published in: Drugs & Aging | Issue 5/2014

Login to get access

Abstract

Evidence for treatment of hypertension in older people is limited to placebo-controlled studies that reduced blood pressure in persons over 60 years who had systolic blood pressure >160 mmHg. Generally, physicians measure blood pressure poorly, failing to look for white coat or masked hypertension, orthostasis, postprandial hypotension, or pseudohypertension. There is evidence that if 24-hour ambulatory blood pressures were obtained, the treatment goal should be substantially lower. Sleep apnea, pain, nocturnal hypoglycemia, drugs, excess aldosterone production, and pheochromocytoma should all be considered as causes of hypertension in older persons. Evidence supports a low-dose diuretic or an angiotensin converting enzyme inhibitor as appropriate first-line therapies in older persons.
Literature
1.
Cheung BM, Ong KL, Mann YB, et al. Prevalence, awareness, treatment, and control of hypertension: United States National Health and Nutrition Examination Survey 2001–2002. J Clin Hypertens (Greenwich). 2006;8:93–8.
2.
Ostchega Y, Dillon CF, Hughes JP, et al. Trends in hypertension prevalence, awareness, treatment, and control in older U.S. adults: Data from the National Health and Nutrition Examination Survey, 1998 to 2004. J Am Geriatr Soc. 2007;55:1056–65.PubMed
3.
Burt VL, Shelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National health and Nutritional Examination Survey, 1988–1991. Hypertension. 1995;25:305–13.PubMed
4.
Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA. 2010;303:2043–50.PubMed
5.
Moser M. From JNC, 1 to JNC 7—what have we learned? Prog Cardiovasc Dis. 2006;48:303–15.PubMed
6.
7.
James PA, Opanl S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA. 2014;311:507–20.PubMed
8.
Mallery LH, Ransom T, Steeves B, et al. Evidence-informed guidelines for treating frail older adults with type 2 diabetes: From the diabetes care program of Nova Scotia (DCPNS) and the palliative and therapeutic harmonization (PATH) program. J Am Med Dir Assoc. 2013;14:801–8.PubMed
9.
Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14:392–7.PubMed
10.
von Haehling S, Anker SD, Doehner W, et al. Frailty and heart disease. Int J Cardiol. 2013;168:1745–7.
11.
12.
McGuiness B, Todd S, Passmore P, Bullock R. Blood pressure lowering in patients without prior cerebrovascular disease for prevention of cognitive impairment and dementia. Cochrane Database Syst Rev. 2009;(4):CD004034. doi:10.​1002/​14651858.​CD004034.​pub3.
13.
Peters R, Beckett N, Forette F, HYVET investigators, et al. Incident dementia and blood pressure lowering in the hypertension in the very elderly trial cognitive function assessment (HYVET-COG): A double-blind, placebo controlled trial. Lancet Neurol. 2008;7:683–9.PubMed
14.
Morley JE. Mild cognitive impairment—a treatable condition. J Am Med Dir Assoc. 2014;15:1–5.PubMed
15.
Schall P, Wehling M. Treatment of arterial hypertension in the very elderly: a meta-analysis of clinical trials. Arzneimittelforschung. 2011;61:221–8.PubMed
16.
Morley JE. Hypertension: is it overtreated in the elderly. J Am Med Dir Assoc. 2010;11:147–52.PubMed
17.
Mattila K, Haavisto M, Rajala S, Heikinheimo R. Blood pressure and five year survival in the very old. Br Med J Clin Res Ed. 1988;296:887–9.PubMedCentralPubMed
18.
Sorensen KH, Hilden T. Increased total mortality and decreased functional capacity are associated with low systolic blood pressure among elderly women. Scand J Prim Health Care. 1988;6:105–10.PubMed
19.
Beckett NS, Peters R, Fletcher AE, HYVET Study Group, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–98.PubMed
20.
Bulpitt CJ, Beckett N, Peters R, et al. Does white coat hypertension require treatment over age 80? Results of the hypertension in the very elderly trial ambulatory blood pressure side project. Hypertension. 2013;61:89–94.PubMed
21.
Peters R, Beckett N, Burch L, et al. The effect of treatment based on a diuretic (indapamide) +/− ACE inhibitor (perindopril) on fractures in the hypertension in the very elderly trial (HYVET). Age Ageing. 2010;39:609–16.PubMed
22.
Butt DA, Mamdani M, Austin PC, et al. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med. 2012;172:1739–44.PubMed
23.
Berry SD, Zhu Y, Choi H, et al. Diuretic initiation and the acute risk of hip fracture. Osteoporos Int. 2013;24:689–95.PubMedCentralPubMed
24.
Morley JE. Frailty, falls and fractures. J Am Med Dir Assoc. 2013;14:149–51.PubMed
25.
Lalande A, Roux C, Graulet AM, et al. The diuretic indapamide increases bone mass and decreases bone resorption in spontaneously hypertensive rats supplemented with sodium. J Bone Miner Res. 1998;13:1444–50.PubMed
26.
Giusti A, Barone A, Pioli G, et al. Alendronate and indapamide alone or in combination in the management of hypercalciuria associated with osteoporosis: a randomized controlled trial of two drugs and three treatments. Nephrol Dial Transplant. 2009;24:1472–7.PubMed
27.
Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des. 2009;15(29):3384–95.PubMed
28.
Yamada M, Nishiguchi S, Fukutani N, et al. Prevalence of sarcopenia in community-dwelling Japanese older adults. J Am Med Dir Assoc. 2013. pii: S1525-8610(13)00504-5 (Epub ahead of print).
29.
Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14:531–2.PubMed
30.
Roman D, Mahoney K, Mohamadi A. Sarcopenia: what’s in a name? J Am Med Dir Assoc. 2013;14:80–2.PubMed
31.
Morley JE, Abbatecola AM, Argiles JM, Society on Sarcopenia, Cachexia and Wasting Disorders Trialist Workshop, et al. Sarcopenia with limited mobility: an international consensus. J Am Med Dir Assoc. 2011;12:403–9.PubMed
32.
Sumukadas D, Witham MD, Struthers AD, McMurdo ME. Effect of perindopril on physical function in elderly people with functional impairment: a randomized controlled trial. CMAJ. 2007;177:867–74.PubMedCentralPubMed
33.
Hutcheon SD, Gillespie ND, Crombie IK, et al. Perindopril improves six minute walking distance in older patients with left ventricular systolic dysfunction: a randomized double blind placebo controlled trial. Heart. 2002;88:373–7.PubMedCentralPubMed
34.
Sumukadas D, Band M, Miller S, et al. Do ACE inhibitors improve the response to exercise training in functionally impaired older adults? A randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013 (Epub ahead of print).
35.
Duboc D, Meune C, Pierre B, et al. Perindopril preventive treatment on mortality in Duchenne muscular dystrophy: 10 years’ follow-up. Am Heart J. 2007;154:596–602.PubMed
36.
Franklin SS, Thijs L, Hansen TW, International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators, et al. Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Hypertension. 2012;59:564–71.PubMedCentralPubMed
37.
Anzal M, Palmer AJ, Starr J, Bulpitt CJ. The prevalence of pseudohypertension in the elderly. J Hum Hypertens. 1996;10:409–11.PubMed
38.
Zuschke CA, Pettyjohn FS. Pseudohypertension. South Med J. 1995;88:1185–90.PubMed
39.
Iwanczyk L, Weintraub NT, Rubenstein LZ. Orthostatic hypotension in the nursing home setting. J Am Med Dir Assoc. 2006;7:163–7.PubMed
40.
Luukinen H, Koski K, Laippala P, Kivela SL. Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med. 1999;159:273–80.PubMed
41.
Beckett NS, Connor M, Sadler JD, et al. Orthostatic fall in blood pressure in the very elderly hypertensive: results from the hypertension in the very elderly trial (HYVET)—pilot. J Hum Hypertens. 1999;13:839–40.PubMed
42.
Morley JE. Is low blood pressure dangerous? J Am Geriatr Soc. 1991;39:1239–40.PubMed
43.
Deegan BM, O’Connor M, Lyons D, O’Laighin G. Development and evaluation of new blood pressure and heart rate signal analysis techniques to assess orthostatic hypotension and its subtypes. Physiol Meas. 2007;28:N87–102.PubMed
44.
Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: Are they preventable? J Am Med Dir Assoc 2006;7(3 Suppl):S53–S58, 52.
45.
Morley JE. Falls—where do we stand? Mol Med. 2007;104:63–7.
46.
Jansen RW, Kelly-Gagnon MM, Lipsitz LA. Intraindividual reproducibility of postprandial and orthostatic blood pressure changes in older nursing-home patients: relationship with chronic use of cardiovascular medications. J Am Geriatr Soc. 1996;44:383–9.PubMed
47.
Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. 1995;122:286–95.PubMed
48.
Morley JE. Postprandial hypotension—the ultimate Big Mac attack. J Gerontol A Biol Sci Med Sci. 2001;56:M741–3.PubMed
49.
Edwards BJ, Perry HM 3rd, Kaiser FE, et al. Relationship of age and calcitonin gene-related peptide to postprandial hypotension. Mech Ageing Dev. 1996;87:61–73.PubMed
50.
Jian ZJ, Zhou BY. Efficacy and safety of acarbose in the treatment of elderly patients with postprandial hypotension. Chin Med J (Engl). 2008;121:2054–9.
51.
Lee A, Patrick P, Wishart J, et al. The effects of miglitol on glucagon-like peptide-1 secretion and appetite sensations in obese type 2 diabetics. Diabetes Obes Metab. 2002;4:329–35.PubMed
52.
Franklin SS. Elderly hypertensives: how are they different? J Clin Hypertens. 2012;14:779–86.
53.
Franklin SS, Thijs L, Hansen TW, et al. Significance of white-coat hypertension in older person with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Hypertension. 2012;59:565–71.
54.
Franklin SS, Khan SA, Wong ND, et al. Is pulse pressure useful in predicting risk for coronary heart disease? The Framingham Heart Study. Circulation. 1999;100:354–60.PubMed
55.
Protogerou AD, Safar ME, Iaria P, et al. Diastolic blood pressure and mortality in the elderly with cardiovascular disease. Hypertension. 2007;50:172–80.PubMed
56.
Franklin SS, Chow VH, Mori AD, Wong ND. The significance of low DBP in US adults with isolated systolic hypertension. J Hypertens. 2011;29:1101–8.PubMed
57.
Gonzaga CC, Calhoun DA. Resistant hypertension and hyperaldosteronism. Curr Hypertens Rep. 2008;10:496–503.PubMed
58.
Mulatero P, Bertello C, Verhovez A, et al. Differential diagnosis of primary aldosteronism subtypes. Curr Hypertens Rep. 2009;11:217–23.PubMed
59.
Azizan EA, Poulsen H, Tuluc P, et al. Somatic mutations in ATP1A1 and CACNA1D underlie a common subtype of adrenal hypertension. Nat Genet. 2013;45:1055–60.PubMed
60.
Veldhuis JD, Sharma A, Roelfsema F. Age-dependent and gender-dependent regulation of hypothalamic–adrenocorticotropic–adrenal axis. Endocrinol Metab Clin North Am. 2013;42:201–25.PubMed
61.
Kopetschke R, Slisko M, Kilisli A, et al. Frequent incidental discovery of phaeochromocytoma: data from a German cohort of 201 phaeochromocytoma. Eur J Endocrinol. 2009;161:355–61.PubMed
62.
Dominguez LJ, Bevilacqua M, Dibella G, Barbagallo M. Diagnosing and managing thyroid disease in the nursing home. J Am Med Dir Assoc. 2008;9:9–17.PubMed
63.
Yokokawa K, Tahara H, Kohno M, et al. Hypertension associated with endothelin-secreting malignant hemangioendothelioma. Ann Intern Med. 1991;114:213–5.PubMed
64.
Das AM, Khayat R. Hypertension in obstructive sleep apnea: risk and therapy. Expert Rev Cardiovasc Ther. 2009;7:619–26.PubMed
65.
Onen SH, Lesourd B, Ouchchane L, et al. Occult nighttime hypertension in daytime normotensive older patients with obstructive sleep apnea. J Am Med Dir Assoc. 2012;13:752–6.PubMed
66.
Resnick HE, Phillips B. Documentation of sleep apnea in nursing homes: United States 2004. J Am Med Dir Assoc. 2008;9:260–4.PubMed
67.
Haus DC, Foster GL, Nielo FJ, et al. Age-dependent associations between sleep-disordered breathing and hypertension: importance of discriminating between systolic/diastolic hypertension and isolated systolic hypertension in the Sleep Heart Health Study. Circulation. 2005;111:614–21.
68.
Lukas A, Mayer B, Fialová D, et al. Pain characteristics and pain control in European nursing homes: cross-sectional and longitudinal results from the Services and Health for Elderly in Long TERm care (SHELTER) study. J Am Med Dir Assoc. 2013;14:421–8.PubMed
69.
70.
Sinclair A, Morley JE. How to manage diabetes mellitus in older persons in the 21st century: applying these principles to long term diabetes care. J Am Med Dir Assoc. 2013;14:777–80.PubMed
71.
Morley JE. Depression in nursing home residents. J Am Med Dir Assoc. 2010;11:301–3.PubMed
72.
Pilz S, Tomaschitz A, Ritz E, Pieber TR. Medscape. Vitamin D status and arterial hypertension: a systematic review. Nat Rev Cardiol. 2009;6:621–30.PubMed
73.
Morley JE. Anorexia of aging: a true geriatric syndrome. J Nutr Health Aging. 2012;16:422–5.PubMed
74.
Soenen S, Chapman IM. Body weight, anorexia, and undernutrition in older people. J Am Med Dir Assoc. 2013;14:642–8.PubMed
75.
Morley JE. Weight loss in older persons: new therapeutic approaches. Curr Pharm Des. 2007;13:3637–47.PubMed
76.
Morley JE. Pathophysiology of the anorexia of aging. Curr Opin Clin Nutr Metab Care. 2013;16:27–32.PubMed
77.
78.
Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013;173:1058–64.PubMed
79.
Mitka M. IOM report: evidence fails to support guidelines for dietary salt reduction. JAMA. 2013;309:2535–6.PubMed
80.
O’Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium potassium excretion and risk of cardiovascular events. JAMA. 2011;306:2229–38.PubMed
81.
Stolarz-Skrzypek K, Liu Y, Thijs L, et al. Blood pressure, cardiovascular outcomes and sodium intake, a critical review of the evidence. Acta Clin Belg. 2012;67:403–10.PubMed
82.
Cohen HW, Hailpern SM, Fang J, Alderman MH. Sodium intake and mortality in the NHANES II follow-up study. Am J Med. 2006;119:275.e7–14.PubMed
83.
Wright JT Jr, Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293:1595–608.PubMed
84.
Gunathilake R, Oldmeadow C, McEvoy M, et al. Mild hyponatremia is associated with impaired cognition and falls in community-dwelling older persons. J Am Geriatr Soc. 2013;61:1838–9.PubMed
85.
Miller M, Morley JE, Rubenstein LZ. Hyponatremia in a nursing home population. J Am Geriatr Soc. 1995;43:1410–3.PubMed
86.
Thomas DR, Cote TR, Lawhorne L, Dehydration Council, et al. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008;9:292–301.PubMed
87.
Silver AJ, Morley JE. Role of the opioid system in the hypodipsia associated with aging. J Am Geriatr Soc. 1992;40:556–60.PubMed
88.
Moser M, Feig PU. Fifty years of thiazide diuretic therapy for hypertension. Arch Intern Med. 2009;169:1851–6.PubMed
89.
Yusuf S, Teo KK, Pogue J, ONTARGET Investigators, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547–59.PubMed
90.
Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892–903.PubMed
91.
Anonymous. Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ. 1992;304:405–12.
92.
Fraser HS. Reserpine: a tragic victim of myths, marketing, and fashionable prescribing. Clin Pharmacol Ther. 1996;60:368–73.PubMed
93.
Griebenow R, Pittrow DB, Weidinger G, et al. Low-dose reserpine/thiazide combination in first-line treatment of hypertension: efficacy and safety compared to an ACE inhibitor. Blood Press. 1997;6:299–306.PubMed
94.
Krönig B, Pittrow DB, Kirch W, et al. Different concepts in first-line treatment of essential hypertension. Comparison of a low-dose reserpine-thiazide combination with nitrendipine monotherapy. German Reserpine in Hypertension Study Group. Hypertension. 1997;29:651–8.PubMed
95.
Messerli FH. Vasodilatory edema: a common side effect of antihypertensive therapy. Curr Cardiol Rep. 2002;4:479–82.PubMed
96.
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31:2115–27.
97.
Rakugi H, Ogihara T, Goto Y, Ishii M, JATOS Study Group. Comparison of strict- and mild-blood pressure control in elderly hypertensive patients: a per-protocol analysis of JATOS. Hypertens Res. 2010;33:1124–8.PubMed
98.
Supiano MA. Healthy people aged 80 and older with systolic blood pressure greater than 150 mmHg should be treated. J Am Geriatr Soc. 2013;61:1199–200.PubMed
99.
Tolson D, Rolland Y, Andrieu S, et al. International Association of Gerontology and Geriatrics: a global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc. 2011;12:184–9.PubMed
100.
Lopez D, Flicker L, Dobson A. Validation of the frail scale in a cohort of older Australian women. J Am Geriatr Soc. 2012;60:171–3.PubMed
101.
Hyde Z, Flicker L, Almeida OP, et al. Low free testosterone predicts frailty in older men: the health in men study. J Clin Endocrinol Metab. 2010;95:3165–72.PubMed
102.
Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc. 2012;60:1478–86.PubMed
103.
Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16:601–8.PubMed
104.
Ravindrarajah R, Lee DM, Pye SR, et al. The ability of three different models of frailty to predict all-cause mortality: results from the European Male Aging Study (EMAS). Arch Gerontol Geriatr. 2013;57:360–8.PubMed
105.
Welsh T, Gladman J, Gordon AL. The treatment of hypertension in care home residents: a systematic review of observational studies. J Am Med Dir Assoc. 2014;15:8–16.PubMed
106.
Aronow WS. Treatment of hypertension in the elderly. J Am Med Dir Assoc. 2013;14:847.PubMed
107.
Koka M, Joseph J, Aronow WS. Adequacy of control of hypertension in an academic nursing home. J Am Med Dir Assoc. 2007;8:538–40.PubMed
108.
Mossello E, Pieraccioli MC, Zanieri S, et al. Ambulatory blood pressure monitoring in older nursing home residents: diagnostic and prognostic role. J Am Med Dir Assoc. 2012;13:760.e1–5.PubMed
Metadata
Title
Treatment of Hypertension in Older Persons: What Is the Evidence?
Author
John E. Morley
Publication date
01-05-2014
Publisher
Springer International Publishing
Published in
Drugs & Aging / Issue 5/2014
Print ISSN: 1170-229X
Electronic ISSN: 1179-1969
DOI
https://doi.org/10.1007/s40266-014-0171-7

Other articles of this Issue 5/2014

Drugs & Aging 5/2014 Go to the issue

Short Communication

Attitudes of Older Adults to Their Participation in Clinical Trials: A Pilot Study

Adis Drug Evaluation

Intravitreal Aflibercept (Eylea®): A Review of Its Use in Patients with Macular Oedema Secondary to Central Retinal Vein Occlusion

Original Research Article

Trends in Inappropriate Drug Therapy Prescription in the Elderly in Sweden from 2006 to 2013: Assessment Using National Indicators

Original Research Article

Medication Reconciliation: A Prospective Study in an Internal Medicine Unit

Therapy in Practice

Chronic Hepatitis C in the Aged: Much Ado About Nothing or Nothing to Do?

Short Communication

Gait Changes with Anti-Dementia Drugs: A Prospective, Open-Label Study Combining Single and Dual Task Assessments in Patients with Alzheimer’s Disease

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits