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Clinical Crossroads |

A 91-Year-Old Woman With Difficult-to-Control Hypertension:  A Clinical Review

Lewis A. Lipsitz, MD, Discussant1,2,3
[+] Author Affiliations
1Director, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
2Chief, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
3Professor of Medicine, Harvard Medical School, Boston, Massachusetts
JAMA. 2013;310(12):1274-1280. doi:10.1001/jama.2013.277027.
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Published online

Importance  Hypertension is common among people older than 65 years, affecting nearly two-thirds of men and three-fourths of women by age 75 years. Treatment goals and medication selection for this population may differ from those for younger patients.

Objective  To discuss the presentation, pathophysiology, and optimal treatment of hypertension among elderly persons.

Evidence Review  MEDLINE was searched from 1990 to 2013. A hand search of bibliographies from guidelines and review articles from 2000 to 2013 was also used to identify studies of hypertension treatment in patients older than 65 years.

Findings  Hypertension in elderly people differs from that in younger people in that (1) hypertension is predominantly systolic because of vascular stiffness; (2) it is associated with reduced baroreflex sensitivity, which increases blood pressure variability and vulnerability to hypotension during common daily activities; (3) it is associated with cognitive and functional decline as well as adverse cardiovascular outcomes; and (4) hypertension may be beneficial in frail people older than 85 years. Treatment of healthy patients up to age 85 years with most antihypertensive medications reduces cardiovascular morbidity and mortality and possibly cognitive and functional decline.

Conclusion and Relevance  Although patients in their 90s have not been studied, any ambulatory and independent patient older than 80 years should have multiple blood pressure measurements taken during their usual daily activities, and if these show persistent hypertension, these patients should be treated judiciously.

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