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Hypertension care: Striking the proper balance
APCToday, 09/16/09

Langan RC et al. – Treating high blood pressure in elderly patients is a complicated proposition: While it’s important to mitigate hypertension’s negative effects, physicians need to be mindful that for this patient population, antihypertensive therapy itself involves elevated risks and unique concerns:

• drug–drug interactions, exacerbated by the multiple medications that many older patients take;
• the side effect profile of antihypertensive agents, including orthostatic hypotension and the possibility of exacerbating an already heightened risk of falls; and
• uncertainty about when to initiate therapy, which drugs to choose if a second antihypertensive agent is needed, and when (or whether) a patient is too old to benefit from treatment.

Practice recommendations:

• Treat systolic hypertension in the elderly to reduce their risk of cardiovascular events and mortality (Strength of recommendation (SOR): B – Inconsistent or limited–quality patient–oriented evidence).
• Don’t shy away from treating the very old. Hypertension treatment is beneficial even in patients who are 80 years of age or older (SOR: B).
• Don’t prescribe an angiotensin–converting enzyme inhibitor and an angiotensin receptor blocker for elderly patients without heart failure; the combination increases the risk of adverse effects without reducing cardiovascular events (SOR: B).

Caution patients to avoid NSAIDs, OTC cough and cold preparations, and excessive caffeine, all of which may elevate their blood pressure. Avoid using alpha–blockers, centrally acting alpha–agonists, or vasodilators to treat hypertension in elderly patients. When it’s necessary to add a second antihypertensive, choose agents that have complementary mechanisms of action. It is prudent to avoid agents associated with volume depletion in a patient with a history of a hip fracture from a fall.