Treatment of hypertension in older people

Hypertension is a major modifiable risk factor for cardiovascular events and mortality, particularly in older people. Effective blood pressure lowering reduces the risk of death and cardiovascular events, including stroke and acute myocardial infarction. The absolute benefits of blood pressure reduction are greater with increasing age. In older people (≥ 65 years), blood pressure lowering should be considered if clinic systolic blood pressure is consistently ≥ 150 mmHg. Reduction of systolic blood pressure initially to < 150 mmHg, and then to < 140 mmHg if tolerated, improves outcomes and is generally safe. Choices of blood pressure lowering medications are similar to those in younger people with the exceptions that beta‐blockers may be relatively ineffective with predominant systolic hypertension and some older people may be intolerant of diuretics. Ongoing monitoring is essential to assess for adequacy of blood pressure control, tolerability of medications and adherence to treatment. Temporary adjustments to therapy may be required with intercurrent illness. Refractory systolic hypertension due to large artery stiffness is a particular problem in older people. Understanding the pathophysiological changes of ageing and their impact on medication efficacy and safety are important. In frail older patients, particularly those with very limited life expectancy, treatment decisions should be individualised and the effects of any treatment carefully monitored.