Hypertension in the Elderly

  • Ahmed H. Abdelhafiz
  • Rachel Marshall
  • Joseph Kavanagh
  • Meguid El Nahas


As the population ages, the prevalence of hypertension is increasing worldwide. Hypertension is well recognised as a significant cardiovascular risk factor increasing the likelihood of major adverse cardiovascular events (MACE). In older people, it is also recognised to increase the risk of renal as well as cognitive dysfunction. Consequently, blood pressure (BP) control is associated with reduced risk of MACE as well as inhibiting the progression of chronic kidney disease (CKD) with more recent guidelines suggesting lower BP targets (<130/80 mmHg) could further enhance cardiovascular protection. The relationship between BP control and the preservation of cognitive function, however, remains unclear. Moreover, this lower target may not be appropriate for older patients, due to the heterogeneity of functional status and burden of comorbid health status within this population. The increased prevalence of frailty, falls, autonomic dysfunction, dementia, polypharmacy and the predominance of isolated systolic hypertension in older patients needs to be carefully considered when deciding to treat hypertension. More intensive BP control, if well tolerated, may be appropriate in functionally able older persons whilst relaxed BP targets are reasonable in individuals with physical and/or cognitive decline. Individualised BP targets in older people are imperative to maintain quality of life. This chapter reviews the management challenges of hypertension in this rapidly growing and diverse elderly population.


Hypertension Elderly Frailty Comorbidities Pathogenesis Diagnosis Targets Management 


  1. 1.
    Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23.CrossRefGoogle Scholar
  2. 2.
    Abdelhafiz AH, Ahmed S, El Nahas M. Microalbuminuria: marker or maker of cardiovascular disease. Nephron Exp Nephrol. 2011;119(suppl 1):e6–e10.CrossRefGoogle Scholar
  3. 3.
    Danaei G, Finucane MM, Lin JK, et al. National, regional and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet. 2011;377:568–77.CrossRefGoogle Scholar
  4. 4.
    Mukhtar O, Jackson SHD. Risk: benefit of treating high blood pressure in older adults. Br J Clin Pharmacol. 2013;75(1):36–44.CrossRefGoogle Scholar
  5. 5.
    Berrut G, Andrieu S, Araujo De Carvalho I, et al. Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Societe Francaise de Geriatrie et de Gerontologie) workshop-Athens January 20–21, 2012. J Nutr Health Aging. 2013;17:688–93.CrossRefGoogle Scholar
  6. 6.
    Laurent S, Cockcroft J, van Bortel L, et al. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006;27:2588–605.CrossRefGoogle Scholar
  7. 7.
    Mitchell GF. Arterial stiffness and hypertension. Hypertension. 2014;64:13–8.CrossRefGoogle Scholar
  8. 8.
    Zubcevic J, Jun JY, Kim S, et al. Altered inflammatory response is associated with an impaired autonomic input to the bone marrow in the spontaneously hypertensive rat. Hypertension. 2014;63:542–50.CrossRefGoogle Scholar
  9. 9.
    Walsh T, Donnelly T, Lyons D. Impaired endothelial nitric oxide bioavailability: a common link between aging, hypertension and atherogenesis? J Am Geriatr Soc. 2009;57:140–5.CrossRefGoogle Scholar
  10. 10.
    Ferreira I, Beijers HJ, Schouten F, et al. Clustering of metabolic syndrome traits is associated with maladaptive carotid remodeling and stiffening: a 6-year longitudinal study. Hypertension. 2012;60:542–9.CrossRefGoogle Scholar
  11. 11.
    Stepnowsky C, Ancoli-Israel S. Sleep and its disorders in seniors. Sleep Med Clin. 2008;3:281–93.CrossRefGoogle Scholar
  12. 12.
    Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA. 2002;287:1003–10.CrossRefGoogle Scholar
  13. 13.
    Krause T, Lovibond K, Caulfield M, et al. Management of hypertension: summary of NICE guidance. BMJ. 2011;343:d4891.CrossRefGoogle Scholar
  14. 14.
    Lloyd-Sherlock P, Beard J, Minicuci N, et al. Hypertension among older adults in low and middle-income countries: prevalence, awareness and control. Int J Epidemiol. 2014;43:116–28.CrossRefGoogle Scholar
  15. 15.
    Mozaffarian D, Benjamin EJ, Go AS, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Bromfield SG, Bowling CB, Tanner RM, et al. Trends in hypertension prevalence, awareness, treatment, and control among US adults 80 years and older, 1988–2010. J Clin Hypertens (Greenwich). 2014;16:270–6.CrossRefGoogle Scholar
  17. 17.
    National Center for Health Statistics (US). Health, United States, 2007: with chart book on trends in the Health of Americans. Hyattsville: National Center for Health Statistics (US); 2007.Google Scholar
  18. 18.
    Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich). 2014;16:14–26.CrossRefGoogle Scholar
  19. 19.
    Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31:1281–357.CrossRefGoogle Scholar
  20. 20.
    Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017; Scholar
  21. 21.
    Hauk L. Pharmacologic treatment of hypertension: ACP and AAFP release recommendations for adults 60 years and older. Am Fam Physician. 2017;95:588–9.PubMedGoogle Scholar
  22. 22.
    Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years. A randomized clinical trial. JAMA. 2016;315:2673–82.CrossRefGoogle Scholar
  23. 23.
    Safar H, Chahwakilian A, Boudali Y, et al. Arterial stiffness, isolated systolic hypertension, and cardiovascular risk in the elderly. Am J Geriatr Cardiol. 2006;15:178–82.CrossRefGoogle Scholar
  24. 24.
    Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation. 2006;113:1213–25.CrossRefGoogle Scholar
  25. 25.
    Yavuz BB, Yavuz B, Tayfur O, et al. White coat effect and its clinical implications in the elderly. Clin Exp Hypertens. 2009;31:306–15.CrossRefGoogle Scholar
  26. 26.
    Cacciolati C, Hanon O, Alpérovitch A, et al. Masked hypertension in the elderly: cross-sectional analysis of a population-based sample. Am J Hypertens. 2011;24:674–80.CrossRefGoogle Scholar
  27. 27.
    James PA, Oparil 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 (JNC 8). JAMA. 2014;311:507–20.CrossRefGoogle Scholar
  28. 28.
    Spence JD. Pseudo-hypertension in the elderly: still hazy, after all these years. J Hum Hypertens. 1997;11:621–3.CrossRefGoogle Scholar
  29. 29.
    Applegate WB, Davis BR, Black HR, et al. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort. J Am Geriatr Soc. 1991;39:1057–64.CrossRefGoogle Scholar
  30. 30.
    Holt-Lunstad J, Jones BQ, Birmingham W. The influence of close relationships on nocturnal blood pressure dipping. Int J Psychophysiol. 2009;71:211–7.CrossRefGoogle Scholar
  31. 31.
    Lewington S, Clarke R, Qizilbash N, Prospective Studies Collaboration, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–13.CrossRefGoogle Scholar
  32. 32.
    Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957–67.CrossRefGoogle Scholar
  33. 33.
    Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435–43.CrossRefGoogle Scholar
  34. 34.
    Ruixing Y, Weixiong L, Hanjun Y, et al. Diet, lifestyle, and blood pressure of the middle-aged and elderly in the Guangxi Bai Ku Yao and Han populations. Am J Hypertens. 2008;21:382–7.CrossRefGoogle Scholar
  35. 35.
    Faselis C, Doumas M, Pittaras A, et al. Exercise capacity and all-cause mortality in male veterans with hypertension aged ≥70 years. Hypertension. 2014;64:30–5.CrossRefGoogle Scholar
  36. 36.
    Aburto NJ, Ziolkovska A, Hooper L, et al. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ. 2013;346:f1326. Scholar
  37. 37.
    Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ. 1988;297:319–28.Google Scholar
  38. 38.
    Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials. BMJ. 2013;347:f5680. Scholar
  39. 39.
    Thomopoulosa C, Paratib G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 4. Effects of various classes of antihypertensive drugs-overview and meta-analyses. J Hypertens. 2015;33:195–211.CrossRefGoogle Scholar
  40. 40.
    Palmer SC, Mavridis D, Navarese E, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet. 2015;385:2047–56.CrossRefGoogle Scholar
  41. 41.
    The ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547–59.CrossRefGoogle Scholar
  42. 42.
    Tomlinson LA, Abel GA, Chaudhry AN, et al. ACE inhibitor and angiotensin receptor-II antagonist prescribing and hospital admissions with acute kidney injury: a longitudinal ecological study. PLoS One. 2013;8(11):e78465. Scholar
  43. 43.
    National Institute of Health and Clinical Excellence. Hypertension: clinical management of primary hypertension in adults. London: NICE; 2011.. NICE clinical guideline 127Google Scholar
  44. 44.
    HOPE Study Investigators. The HOPE study (heart outcomes prevention evaluation). J Renin-Angiotensin-Aldosterone Syst. 2000;1(1):18–20.CrossRefGoogle Scholar
  45. 45.
    Warwick J, Falaschetti E, Rockwood K, et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med. 2015;13:78.CrossRefGoogle Scholar
  46. 46.
    van Bemmel T, Gussekloo J, Westendorp RG, et al. In a population based prospective study, no association between high blood pressure and mortality after age 85 years. J Hypertens. 2006;24:287–92.CrossRefGoogle Scholar
  47. 47.
    Poortvliet RK, Blom JW, de Craen AJ, et al. Low blood pressure predicts increased mortality in very old age even without heart failure: the Leiden 85-plus study. Eur J Heart Fail. 2013;15:528–33.CrossRefGoogle Scholar
  48. 48.
    Poortvliet RK, de Ruijter W, de Craen AJ, et al. Blood pressure trends and mortality: the Leiden 85-plus study. J Hypertens. 2013;31:63–70.CrossRefGoogle Scholar
  49. 49.
    Mattila K, Haavisto M, Rajala S, et al. Blood pressure and five year survival in the very old. BMJ (Clin Res Ed). 1988;296:887–9.CrossRefGoogle Scholar
  50. 50.
    Satish S, Freeman DH Jr, Ray L, et al. The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc. 2001;49:367–74.CrossRefGoogle Scholar
  51. 51.
    Odden MC, Peralta CA, Haan MN, et al. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med. 2012;172:1162–8.CrossRefGoogle Scholar
  52. 52.
    Tinetti ME, Han L, Lee DSH, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588–95.CrossRefGoogle Scholar
  53. 53.
    Callisaya L, Sharman JE, Close J, et al. Greater daily defined dose of antihypertensive medication increases the risk of falls in older people—a population-based study. J Am Geriatr Soc. 2014;62:1527–33.CrossRefGoogle Scholar
  54. 54.
    Corrao G, Mazzola P, Monzio Compagnoni M, et al. Antihypertensive medications, loop diuretics, and risk of hip fracture in the elderly: a population-based cohort study of 81,617 Italian patients newly treated between 2005 and 2009. Drugs Aging. 2015;32:927–36.CrossRefGoogle Scholar
  55. 55.
    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.CrossRefGoogle Scholar
  56. 56.
    Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159–68.. 2173-4PubMedGoogle Scholar
  57. 57.
    Office for National Statistics. Deaths registered in England and Wales (series DR) 2016. London: ONS; 2017.Google Scholar
  58. 58.
    Alzheimer’s Association. 2016 Alzheimer’s disease facts and figures. Alzheimer’s Dement. 2016;12(4):459–509.CrossRefGoogle Scholar
  59. 59.
    Rait G, Walters K, Bottomley C, et al. Survival of people with clinical diagnosis of dementia in primary care: cohort study. BMJ. 2010;341:c3584.CrossRefGoogle Scholar
  60. 60.
    Barnes DE, Cauley JA, Lui LY, et al. Women who maintain optimal cognitive function into old age. J Am Geriatr Soc. 2007;55:259–64.CrossRefGoogle Scholar
  61. 61.
    Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol. 2011;10:819–28.CrossRefGoogle Scholar
  62. 62.
    Qiu C, Winblad B, Fratiglioni L. The age-dependent relation of blood pressure to cognitive function and dementia. Lancet Neurol. 2005;4:487–99.CrossRefGoogle Scholar
  63. 63.
    Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet. 1998;352:1347–51.CrossRefGoogle Scholar
  64. 64.
    Tzourio C, Anderson C, Chapman N, et al. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med. 2003;163:1069–75.CrossRefGoogle Scholar
  65. 65.
    Lithell H, Hansson L, Skoog I, et al. The Study on COgnition and Prognosis in the Elderly (SCOPE); outcomes in patients not receiving add-on therapy after randomization. J Hypertens Engl. 2004;22:1605–12.CrossRefGoogle Scholar
  66. 66.
    Peters R, Beckett N, Forette F, 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.CrossRefGoogle Scholar
  67. 67.
    Di Bari M, Pahor M, Franse LV, et al. Dementia and disability outcomes in large hypertension trials: lessons learned from the systolic hypertension in the elderly program (SHEP) trial. Am J Epidemiol. 2001;153:72–8.CrossRefGoogle Scholar
  68. 68.
    Beishon LC, Harrison JK, Harwood RH, et al. The evidence for treating hypertension in older people with dementia: a systematic review. J Hum Hypertens. 2014;28:283–7.CrossRefGoogle Scholar
  69. 69.
    Sabayan B, Oleksik AM, Maier AB, et al. High blood pressure and resilience to physical and cognitive decline in the oldest old: the Leiden 85-plus study. J Am Geriatr Soc. 2012;60:2014–9.CrossRefGoogle Scholar
  70. 70.
    Qiu C, Winblad B, Fratiglioni L. Low diastolic pressure and risk of dementia in very old people: a longitudinal study. Dement Geriatr Cogn Disord. 2009;28:213–9.CrossRefGoogle Scholar
  71. 71.
    Ogliari G, Westendorp RG, Muller M, et al. Blood pressure and 10-year mortality risk in the Milan Geriatrics 75+ Cohort Study: role of functional and cognitive status. Age Ageing. 2015;44:932–7.CrossRefGoogle Scholar
  72. 72.
    Mossello E, Pieraccioli M, Nesti N, et al. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med. 2015;175:578–85.CrossRefGoogle Scholar
  73. 73.
    Franklin SS, Jacobs MJ, Wong ND, et al. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives. Hypertension. 2001;37:869–74.CrossRefGoogle Scholar
  74. 74.
    Burt VL, Harris T. The third national health and nutrition examination survey: contributing data on aging and health. Gerontologist. 1994;34(4):486–90.CrossRefGoogle Scholar
  75. 75.
    Denardo SJ, Gong Y, Nichols WW, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med. 2010;123:719–26.CrossRefGoogle Scholar
  76. 76.
    Ooi WL, Hossain M, Lipsitz LA. The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med. 2000;108:106–11.CrossRefGoogle Scholar
  77. 77.
    Poon OI, Braun U. High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther. 2005;30:173–8.CrossRefGoogle Scholar
  78. 78.
    Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383–9.CrossRefGoogle Scholar
  79. 79.
    Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269–76.CrossRefGoogle Scholar
  80. 80.
    Seeman TE, Singer BH, Rowe JW, et al. Price of adaptation–allostatic load and its health consequences. Arch Intern Med. 1997;157:2259–68.CrossRefGoogle Scholar
  81. 81.
    Karlamangla AS, Singer BH, McEwen BS, Rowe JW, Seeman TE. Allostatic load as a predictor of functional decline: MacArthur studies of successful aging. J Clin Epidemiol. 2002;55:696–710.CrossRefGoogle Scholar
  82. 82.
    Benetos A, Labat C, Rossignol P, et al. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents the PARTAGE study. JAMA Intern Med. 2015;175:989–95.CrossRefGoogle Scholar
  83. 83.
    Rajpura J, Nayak R. Medication adherence in a sample of elderly suffering from hypertension: evaluating the influence of illness perceptions, treatment beliefs, and illness burden. J Manag Care Pharm. 2014;20:58–65.PubMedGoogle Scholar
  84. 84.
    Ebrahim S, Fahey T, Schroeder K. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systemic review of randomized controlled trials. Arch Intern Med. 2004;164(7):722–32.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Ahmed H. Abdelhafiz
    • 1
    • 2
  • Rachel Marshall
    • 1
  • Joseph Kavanagh
    • 1
  • Meguid El Nahas
    • 3
  1. 1.Department of Geriatric MedicineRotherham General HospitalRotherhamUK
  2. 2.Department of Elderly MedicineRotherham General HospitalRotherhamUK
  3. 3.Global Kidney AcademySheffieldUK

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