Curr Hypertens Rep (2017) 19:88
DOI 10.1007/s11906-017-0785-3
BLOOD PRESSURE MONITORING AND MANAGEMENT (J COCKCROFT, SECTION EDITOR)
Managing Hypertension in Patients Aged 75 Years and Older
Yogita Rochlani 1 & Mohammed Hasan Khan 1 & Wilbert S. Aronow 1
# Springer Science+Business Media, LLC 2017
Abstract On the basis of the available data, we would
diagnose a normal blood pressure in elderly persons in-
cluding those 75 years of age and older if the blood pres-
sure was below 120/80 mmHg. We would diagnose hy-
pertension in elderly persons including those aged
75 years and older if the systolic blood pressure was
130 mmHg and higher or if the diastolic blood pressure
was 80 mmHg and higher. We would treat these elderly
patients with hypertension to a blood pressure goal of less
than 130/80 mmHg if the blood pressure was obtained by
automated blood pressure monitoring in a quiet room. We
would consider treating high-risk persons aged 75 years
and older to a blood pressure goal of less than 120/
80 mmHg if they were carefully monitored for serious
adverse events. If the blood pressure is more than 20/
10 mmHg above the goal blood pressure, we would initi-
ate antihypertensive drug therapy with two antihyperten-
sive drugs. The initial drug of choice for the treatment of
hypertension in adults aged 75 years and older should be
based on co-morbidities, co-incidental indications, tolera-
bility, and cost.
Keywords Hypertension . Elderly . Blood pressure .
Antihypertensive drug therapy
This article is part of the Topical Collection on Blood Pressure
Monitoring and Management
* Wilbert S. Aronow
wsaronow@aol.com
1
Cardiology Division, Department of Medicine, Westchester Medical
Center and New York Medical College, Macy Pavilion, Room 141,
Valhalla, NY 10595, USA
Introduction
Cardiovascular disease is a leading cause of mortality and
accounts for nearly a third of deaths worldwide [1].
Hypertension is a leading risk factor implicated in the
development of cardiovascular disease and chronic kidney
disease [1]. Hypertension affects over a billion individuals
across the globe, and its prevalence varies by geography,
but has had an overall upward trend over the last few
decades [2]. The incidence of hypertension increases with
age, and elderly patients predominantly have isolated sys-
tolic hypertension [3]. Hypertension has also been associ-
ated with development of coronary artery disease, conges-
tive heart failure, peripheral arterial disease, ischemic and
hemorrhagic stroke, aortic dissection, and aneurysms in
elderly patients [4]. Studies show that lowering blood
pressure has a significant effect on lowering rates of myo-
cardial infarction, stroke, and congestive heart failure in
elderly patients [3–6, 7••]. Various national and interna-
tional societies for hypertension recommend different
treatment blood pressure goals for patients older than
75 years with hypertension.
Historically, blood pressure targets for elderly patients
have been lenient. However, evidence now suggests that
the elderly population benefits from maintaining similar
blood pressure targets as the younger population. One of
the landmark studies for the treatment of hypertension, the
Systolic Blood Pressure Intervention Trial (SPRINT),
showed in persons aged 75 years and older with hyper-
tension that compared with a systolic blood pressure goal
of less than 140 mmHg, lowering the systolic blood pres-
sure goal to less than 120 mmHg caused a significantly
greater reduction in the primary endpoint of myocardial
infarction, other acute coronary syndrome, stroke, heart
failure, or cardiovascular death and death in hypertensive
88 Page 2 of 8
patients by 34%, all-cause mortality by 33%, heart failure
by 38%, and the primary endpoint or death by 32% [7••,
8••]. In this paper, we review the evidence behind the
current blood pressure goals and treatment strategies in
the elderly population and outline an approach to treating
hypertension in patients aged 75 years and older.
Prevalence and Implications
Between 1980 and 2008, the global population estimate
for those with hypertension has increased from 600 mil-
lion to one billion persons [1]. About one third of the
global adult population has been reported to have a diag-
nosis of hypertension [9]. The rise in the prevalence of
hypertension has been attributed to an increase in the ag-
ing population, unhealthy diets, and sedentary lifestyles
resulting in obesity, alcohol use, smoking, and emotional
stressors [1].
Blood pressure increases linearly with age. Aging is as-
sociated with an increase in arterial wall stiffness as a result
of atherosclerosis, calcium deposition, decreased sensitivity
to the action of vasodilators, and endothelial dysfunction
[3]. In the elderly population, decreased arterial wall com-
pliance results in a rise in systolic blood pressure, while the
diastolic blood pressure begins to trend down, resulting in
isolated systolic hypertension.
Long-standing hypertension causes end-organ damage
presenting as left ventricular hypertrophy, congestive
heart failure, stroke, vascular disease, and renal dysfunc-
tion [4]. A meta-analysis of 61 studies that included over
one million patients with hypertension showed that an
increase in systolic blood pressure was associated with
cardiovascular and all-cause mortality [10]. In the cardio-
vascular cohort study that included 2520 participants, iso-
lated systolic hypertension was associated with a 34%
increase in coronary artery disease, a 33% increase in
stroke, and a26% increase in heart failure [10]. Isolated
systolic hypertension has been shown to be associated
with an increased risk of cardiovascular events, stroke,
and heart failure in the elderly population in other studies
as well [5, 11–16].
The age-adjusted prevalence of hypertension is 64% in
men over age 65 years and 78% women over age 65 years
[17]. Elderly patients are less likely to be diagnosed with
hypertension [18] and are also less likely to achieve blood
pressure goals while on treatment for hypertension [19].
The elderly patient population is vulnerable to the many
complications of hypertension and usually has other con-
comitant co-morbidities that increase morbidity and mor-
tality. Co-morbidities, polypharmacy, high cost of care,
and medication interactions can result in inadequate treat-
ment of hypertension in elderly patients [20].
Curr Hypertens Rep (2017) 19:88
Definitions and Current Guidelines
Blood pressure goals have been a moving target over the last
three decades. The blood pressure threshold to initiate therapy
and on-treatment blood pressure goals has been prescribed by
various national and international organizations in the field of
hypertension. However, these goals are not very clearly de-
fined for the elderly population, and there are conflicting data
on whether we should have intensive or lenient blood pressure
control in the elderly. Below, we discuss the guidelines for the
treatment of hypertension in the elderly from 2011 to 2017.
The American College of Cardiology Foundation/
American Heart Association 2011 expert consensus document
on hypertension in the elderly recommended that the blood
pressure be lowered to less than 140/90 mmHg in adults youn-
ger than 80 years of age and to 140–145/< 90 mmHg if toler-
ated in adults aged 80 years and older [4]. The European
Society of Hypertension/European Society of Cardiology
2013 guidelines for the management of hypertension recom-
mended a target blood pressure lower than 140/90 mmHg in
adults younger than 80 years and a systolic blood pressure
between 140 and 150 mmHg in adults aged 80 years and older
provided they are in good physical and mental conditions
[21].
The 2013 Eighth Joint National Committee (JNC 8) guide-
lines for the management of hypertension recommended a
target blood pressure below 150/90 mmHg in adults aged
60 years and older without diabetes mellitus or chronic kidney
disease and below 140/90 mmHg if they had either diabetes
mellitus or chronic kidney disease [22]. The JNC 8 minority
report recommended that blood pressure in patients aged
60 years and older should be below 140/90 mmHg [23]. The
association of Black Cardiologists and the Working Group on
Women’s Cardiovascular Health recommended a target blood
pressure below 140/90 mmHg in adults between 60 and
79 years of age and below 150/90 mmHg in those aged
80 years and older [24].
The 2013 Canadian Hypertension Education Program
guidelines recommended reducing the blood pressure to less
than 140/90 mmHg in elderly persons younger than 80 years
of age and to less than 150/90 mmHg in persons aged 80 years
and older [25]. The American Society of Hypertension/
International Society of Hypertension 2014 hypertension
guidelines recommended reducing the blood pressure to less
than 140/90 mmHg in elderly persons younger than 80 years
and to less than 150/90 mmHg in persons aged 80 years and
older [26••].
The American Heart Association/American College of
Cardiology/American Society of 2015 guidelines for the man-
agement of hypertension in patients with coronary artery dis-
ease recommended a target blood pressure goal below 140/
90 mmHg in patients aged 80 years and younger with coro-
nary artery disease and with an acute coronary syndrome and
Curr Hypertens Rep (2017) 19:88
below 150/90 mmHg if they are above 80 years old [27••].
These guidelines also stated that consideration can be given to
reduce the blood pressure to less than 130/80 mmHg in these
patients [27••]. Caution should be used in reducing the dia-
stolic blood pressure below 60 mmHg in elderly persons with
coronary artery disease and in diabetics with coronary artery
disease [27••]. The Canadian 2016 hypertension guidelines
recommended a systolic blood pressure lower than
120 mmHg in all high-risk adults 50 years of age and older
with an automated office systolic blood pressure measurement
of 130 mmHg and higher [28••].
The National Heart Foundation of Australia 2016 hyper-
tension guidelines recommended in selected high cardiovas-
cular risk persons a systolic blood pressure goal of less than
120 mmHg to reduce cardiovascular events with close moni-
toring for treatment-related adverse effects [29••]. The
American College of Physicians/American Academy of
Family Physicians 2017 guidelines for the management of
hypertension recommended a target systolic blood pressure
lower than 150 mmHg in all adults 60 years of age and older
with the systolic blood pressure reduced to less than
140 mmHg if they have a history of stroke of transient ische-
mic attack or are otherwise at high cardiovascular risk [30••].
The 2017 American College of Cardiology/American Heart
Association plus nine other professional societies’ hyperten-
sion guidelines will be published in 2017.
Need for Treatment and Goals in Elderly Patients
Controlling blood pressure is beneficial for prevention of car-
diovascular events and stroke in the elderly population as
supported by the evidence presented in this section. A system-
atic review and meta-analysis of 123 randomized antihyper-
tensive drug studies, which included 613,815 participants,
demonstrated that every 10 mmHg reduction in systolic blood
pressure significantly decreased major cardiovascular events
by 20%, coronary heart disease by 17%, stroke by 27%, and
heart failure by 28%, which in the populations studied reduced
all-cause mortality by 13% [31••].
The Swedish Trial in Old Patients with Hypertension
(STOP-Hypertension) compared antihypertensive therapy
versus placebo in 1627 Swedish men and women aged 70–
84 years with systolic blood pressures between 180 and
230 mmHg and diastolic blood pressures of 90 mmHg and
higher [32]. This study showed significant reduction in stroke
morbidity and mortality (53 vs. 29, p = 0.0081) and all-cause
mortality (63 vs. 36, p = 0.0079) in the treatment arm as
compared to the placebo arm [32]. A similar randomized trial
in the UK also showed significant reduction in stroke, coro-
nary events, and all cardiovascular events in 4396 patients
between ages 65 and 74 years, treated with diuretics for
Page 3 of 8 88
systolic blood pressures between 160 and 209 mmHg and
diastolic blood pressures less than 115 mmHg [33].
The Systolic Hypertension in Elderly Program (SHEP) was
a randomized, double-blind, placebo-controlled trial designed
to study the effect of antihypertensive treatment of isolated
systolic hypertension on strokes in persons over 60 years of
age [34]. This trial randomized 4736 persons older than
60 years of age with a systolic blood pressure of 160 mmHg
and higher and a diastolic blood pressure less than 90 mmHg,
to atenolol and chlorthalidone versus placebo. The mean age
of the patients in this trial was 71.6 years. The mean blood
pressure was 170.3/76.7 mmHg. Treatment of isolated systolic
hypertension in this trial caused a significant reduction in non-
fatal stroke of 37%, in non-fatal myocardial infarction of 33%,
and in congestive heart failure of 54%. Cardiovascular and
cerebrovascular mortality was lowered by 20 and 29%, re-
spectively, in the treatment arm, but this did not meet statisti-
cal significance [34]. Other large randomized, placebo-
controlled trials besides SHEP [11–13, 34] have also demon-
strated that treatment of elderly patients with isolated systolic
hypertension reduces cardiovascular and cerebrovascular
events [14–16].
A meta-analysis of 15,693 patients with isolated systolic
hypertension aged 60 years and older followed for a median of
3.8 years showed that drug treatment for hypertension reduced
all-cause mortality by 13% (p = 0.02), cardiovascular mortal-
ity by 18% (p = 0.01), all cardiovascular events by 26%
(p < 0.0001), stroke by 30% (p < 0.001), and coronary events
by 23% (p = 0.001) [16]. Patients with a systolic blood pres-
sure greater than 160 mmHg, patients aged 70 years and older,
men, and those with a known history of previous cardiovas-
cular complications derived the most benefit from antihyper-
tensive treatment, confirming the benefit of treating isolated
systolic hypertension in elderly patients [16].
In a subgroup meta-analysis of 1670 randomized clinical
trial participants from antihypertensive trials over 80 years of
age, Geuyffier et al. reported that treatment of hypertension in
this population led to a 35% reduction in strokes, a 22% re-
duction in cardiovascular events, a 39% reduction in incident
heart failure, and a non-significant reduction in cardiovascular
death and all-cause mortality [35]. A more recent meta-
analysis of hypertensive patients aged 80 years and older
showed that treatment of hypertension also showed that treat-
ment of hypertension resulted in a significant reduction in
stroke, cardiovascular events, and heart failure, but no signif-
icant difference in mortality [36].
In the Hypertension in the Very Elderly Trial, 3845 patients
aged 80 years and older, mean age 83.6 years, with a systolic
blood pressure of 160 mmHg or higher were randomized to
antihypertensive therapy with indapamide ± perindopril or
placebo [6]. The mean blood pressure was 173/90.8 mmHg.
At 2-year follow-up, the mean blood pressure in the treatment
arm was 15/6.1 mmHg lower than in the placebo arm.
88 Page 4 of 8
Treatment of hypertension in this population resulted in a 30%
reduction in the rate of fatal or nonfatal stroke (p = 0.06), a
39% reduction in the rate of death from stroke (p = 0.05), a
21% reduction in all-cause mortality (p = 0.02), a 23% reduc-
tion in the rate of death from cardiovascular causes (p = 0.06),
and a 64% reduction in the rate of heart failure (p < 0.001) [6].
The on-treatment goal for elderly patients with hyperten-
sion has been under considerable debate. This section will
discuss some of the studies that have looked into an on-
treatment target for elderly persons being treated for hyperten-
sion. In the Valsartan in Elderly Isolated Systolic
Hypertension (VALISH) study, Yano et al. showed that
treating older adults to a systolic blood pressure goal of
130–144 mmHg was associated with the most reduction in
cardiovascular events (coronary artery disease, stroke, heart
failure, cardiovascular death) and all-cause mortality com-
pared with treating to a systolic blood pressure goal of over
145 mmHg or below 130 mmHg [37••]. This study was con-
ducted in Japan on 3035 adults with a mean age of 76 years
with a systolic blood pressure of 160 mmHg or higher and a
diastolic blood below 90 mmHg [37••].
The Reasons for Geographic and Racial Differences in
Stroke (REGARDS) study, a population-based observational
study of stroke incidence in Southern USA (North Carolina,
South Carolina, Georgia, Alabama, Mississippi, Tennessee,
Arkansas, and Louisiana), included 1839 patients aged
75 years and older (mean age 79.3 years) receiving antihyper-
tensive treatment [38]. The results from this study showed that
there was an increase in coronary heart disease (non-fatal
myocardial infarction and coronary heart disease death),
stroke, and cardiovascular disease (coronary heart disease
and stroke) at systolic blood pressure levels of 140 mmHg
and higher in patients aged 75 years and older and increased
all-cause mortality in this patient population with systolic
blood pressures less than 120 mmHg [38]. This study con-
cluded that all patients with hypertension older than 55 years
of age should be treated with antihypertensive agents to a goal
systolic blood pressure of 120 to 139 mmHg and a diastolic
blood pressure of 70 to 90 mmHg [38].
The Secondary Prevention of Small Subcortical Strokes
(SPS3) investigators evaluated the effects of different blood
pressure targets on recurrent strokes in patients with a recent
lacunar stroke [39••]. The study included 3020 patients ran-
domized into two groups: a systolic blood pressure target of
130 to 149 mmHg or to less than 130 mmHg. Trial partici-
pants had a mean age of 63 ± 11 years. The results showed a
non-significant rate reduction in all strokes (hazard ratio 0.81;
95% CI 0.64–1.03, p = 0.08) and in composite outcome of
myocardial infarction and vascular death (hazard ratio 0.84;
95% CI, 0.68–1.04, p = 0.32), but a significant decrease in
intracranial hemorrhage in patients in the target group of a
systolic blood pressure less than 130 mmHg hazard ratio
(0.37; 95% CI, 0.15–0.95, p = 0.03). The investigators
Curr Hypertens Rep (2017) 19:88
concluded that a systolic blood pressure target of less than
130 mmHg is likely to be beneficial in patients with recent
lacunar strokes [39••, 40].
The SPRINT trial was designed with the idea of identi-
fying an appropriate on-treatment blood pressure goal in
patients receiving antihypertensive medications. The trial
randomized 9631 persons aged 50 years and older with in-
creased cardiovascular risk and a systolic blood pressure of
130 to 180 mmHg to either an intensive systolic blood pres-
sure target of less than 120 mmHg or to a standard systolic
blood pressure target of less than 140 mmHg treatment strat-
egies [7••, 8••]. The study excluded diabetics and those with
history of a prior stroke, symptomatic heart failure within
the past 6 months, a left ventricular ejection fraction less
than 35%, and an estimated glomerular filtration rate of less
than 20 ml/min/1.73 m2 [7••, 8••]. After a median follow-up
of 3.26 years, the study was stopped prematurely because of
the significant 25% reduction in the primary composite out-
come of myocardial infarction, acute coronary syndromes,
stroke, heart failure, and death from cardiovascular causes
in the intensive systolic blood pressure treatment arm
(p < 0.001) [7••]. The risk of all-cause death was 27% lower
in the intensive systolic blood pressure arm as compared to
the standard systolic blood pressure control arm (p = 0.003)
[7••]. Intensive systolic blood pressure treatment also re-
duced heart failure by 38% (p = 0.002), cardiovascular
death by 43% (p = 0.005), and the primary composite out-
come or death by 22% (p < 0.001) [7••].
The SPRINT trial included 2636 persons aged 75 years and
older (mean age 79.9 years) [8••]. Of these 2636 persons,
33.4% randomized to a systolic blood pressure target below
120 mmHg and 28.4% of those randomized to a systolic blood
pressure target below 140 mmHg were frail. At 3.14-year
median follow-up, a systolic blood pressure target of less than
120 mmHg reduced the primary composite endpoint of myo-
cardial infarction, other acute coronary syndromes, stroke,
heart failure, or cardiovascular death by 34% (p = 0.001),
all-cause mortality by 33% (p = 0.009), heart failure by 38%
(p = 0.003), and the primary composite outcome or death by
32% (p < 0.001) [8••]. The absolute cardiovascular event rates
were lower for the systolic blood pressure target of less than
120 mmHg treatment group within each frailty stratum. The
incidence of serious adverse events was not significantly dif-
ferent in the standard and intensive treatment arms in this
elderly population [8••].
Overall, 16.8 million US adults and 8.2 million US
adults with treated hypertension meet SPRINT eligibility
criteria [41]. These criteria were applied to the 1999 to
2006 National Health and Nutrition Examination Survey
and linked with the National Death Index through
December, 2011 [42••]. This study showed that intensive
lowering of systolic blood pressure of all eligible US
adults could prevent 107,500 deaths per year and 46,100
Curr Hypertens Rep (2017) 19:88
cases of heart failure per year but increase serious adverse
events [42••].
The Heart Outcomes Prevention Evaluation (HOPE)-3 trial
randomized 12,705 persons (49% Asians, 20% whites, 27%
Hispanics, and 2% blacks), mean age 65.7 years, without car-
diovascular disease and at intermediate risk to treatment with
candesartan 16 mg plus hydrochlorothiazide 12.5 mg daily or
to placebo [43]. Less than 40% of these persons had hyper-
tension, and the baseline mean blood pressure was 138.1/
81.9 mmHg. The treatment arm had a 6.0/3.0 mmHg drop in
blood pressure as compared to the placebo group [43]. At 5.6-
year median follow-up, there was no significant reduction in
the composite endpoint of cardiovascular death, nonfatal
myocardial infarction, or nonfatal stroke between the treat-
ment and placebo arms [43]. In the subgroup of patients with
a systolic blood pressure higher than 143.5 mmHg (mean
154.1 ± 8.9 mmHg), there was a significant reduction in the
composite endpoint of cardiovascular death, nonfatal myocar-
dial infarction, or nonfatal stroke by 27% (95% CI, 6 to 44%)
[43].
There are many reasons for the difference in results be-
tween the HOPE-3 trial and SPRINT trial [44]. Less than
40% of the HOPE-3 participants had hypertension. The par-
ticipants in the HOPE-3 trial had a lower cardiovascular risk
profile and were treated with a single low-dose combination
pill for blood pressure lowering with no clear on-treatment
blood pressure targets. The systolic blood pressure reduction
in the SPRINT trial was 14.8 mmHg lower with intensive
systolic blood pressure reduction, whereas the reduction in
systolic blood pressure in the HOPE-3 trial was only
6.0 mmHg. Chlorthalidone was the diuretic used in SPRINT
and has been demonstrated to decrease cardiovascular events
in clinical trials, whereas hydrochlorothiazide 12.5 mg daily
used in the HOPE-3 trial has not been demonstrated to de-
crease cardiovascular events [44].
Approach to Treatment of Hypertension in Elderly
Persons
On the basis of the available data, we would diagnose a nor-
mal blood pressure in elderly persons including those 75 years
of age and older if the blood pressure was below 120/
80 mmHg. We would diagnose hypertension in elderly per-
sons including those aged 75 years and older if the systolic
blood pressure was 130 mmHg and higher or if the diastolic
blood pressure was 80 mmHg and higher. We would treat
these elderly patients with hypertension to a blood pressure
goal of less than 130/80 mmHg if the blood pressure was
obtained by automated blood pressure monitoring in a quiet
room. We would consider treating high-risk persons aged
75 years and older to a blood pressure goal of less than 120/
80 mmHg if they were carefully monitored for serious adverse
Page 5 of 8 88
events [45]. If the blood pressure is more than 20/10 mmHg
above the goal blood pressure, we would initiate antihyper-
tensive drug therapy with two antihypertensive drugs [46].
The initial drug of choice for the treatment of hypertension
in adults aged 75 years and older should be based on co-mor-
bidities, co-incidental indications, tolerability, and cost [4]. A
meta-analysis of 147 randomized trials of 464,000 persons
with hypertension found that except for the major effect of
beta blockers given after myocardial infarction in decreasing
coronary events and a minor additional effect of calcium chan-
nel blockers in decreasing stroke, all major antihypertensive
drug classes diuretics, angiotensin-converting enzyme inhibi-
tors, angiotensin receptor blockers, beta blockers, and calcium
channel blockers caused a similar decrease in coronary events
and stroke for a given decrease in blood pressure [47].
A recent meta-analysis compared the efficacy of the major
antihypertensive drug classes on cardiovascular outcomes and
demonstrated that with similar reductions in blood pressure,
there were similar improvements in cardiovascular outcomes
[48]. Each of the antihypertensive class of drugs has additional
indications for benefits outside of their antihypertensive ef-
fects. The initial drug of choice is an angiotensin-converting
enzyme inhibitor or angiotensin receptor blocker in elderly
patients with diabetes mellitus [49] and/or chronic kidney dis-
ease [50]. Beta blockers are indicated in the treatment of hy-
pertension in the setting of ventricular and supraventricular
arrhythmias, congestive heart failure, prior myocardial infarc-
tion, stable ischemic heart disease, acute coronary syndromes,
hyperthyroidism, migraine, essential tremor, and preoperative
hypertension [51]. Among beta blockers, atenolol should be
avoided [52–55]. Most elderly patients would benefit from
initiation of combination therapy with any two antihyperten-
sive drugs among beta blockers, thiazide-type diuretics (espe-
cially chlorthalidone), calcium channel blockers, and either an
angiotensin-converting enzyme inhibitor or angiotensin re-
ceptor blocker due to a higher prevalence of co-morbidities,
higher likelihood of need for multiple antihypertensive agents,
and lower individual drug doses resulting in a lower adverse
effect profile [56]. Additional drugs including a mineralocor-
ticoid antagonist can be added if blood pressure goals are not
met.
Conclusion
Based on the evidence reviewed in this paper, it is clear that
elderly patients benefit from treatment of hypertension to re-
duce cardiovascular and cerebrovascular events and mortality.
Although blood pressure targets in elderly patients have been
debated, the results from the SPRINT trial have created a
paradigm shift. After review of the available scientific data,
we support lowering of blood pressure in patients aged
75 years and older to less than 130/80 mmHg. The initial drug
88 Page 6 of 8
of choice for the treatment of hypertension in adults aged
75 years and older should be based on co-morbidities, co-
incidental indications, tolerability, and cost [4].
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interests.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by the
authors.
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Papers of particular interest, published recently, have been
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