SANTISSIMA TRINIDAD HOSPITAL

PINAGBAKAHAN CITY OF MALOLOS, BULACAN

TEL (044) 791 -7331

Hypertension in Older Persons

Prevalence

The prevalence of hypertension among older persons, blood pressure (BP)

measurement using optimal technique should be done at every clinic visit. If the first
reading is elevated, repeat measurement and documentation of both readings
should be done.

Diagnosis

After taking the blood pressure measurement twice, the patient is classified as
follows:

Prehypertension : 120-139 mmHg systolic or

80-89 mmHg diastolic
Stage 1 hypertension : 140-159 mmHg systolic or
90-99 mmHg diastolic
Stage 2 hypertension : ≥160 mmHg systolic or ≥100
mmHg diastolic

When making a diagnosis of hypertension, it is important to consider medications

and other causes that may be increasing the patient’s blood pressure.

Examples include:

 Medications such as adrenal steroids, estrogen, sympathomimetics, NSAIDs,

and appetite suppressants. Consider eliminating, switching to another
medication, or decreasing the dose.
 Alcohol, illicit drugs (e.g., cocaine and other stimulants) and smoking
 Sodium
 Obstructive sleep apnea (OSA). Consider this as a potential cause of elevated
blood pressure if symptoms consistent with OSA are present.

Initial diagnostic workups

 ECG
 Cholesterol screening (lipid profile)
 Diabetes screening (FBS)
 Potassium and creatinine
 Sodium

Additional workup may be needed if the patient has a comorbidity (e.g., diabetes,
atherosclerotic cardiovascular disease).
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

The following are generally not necessary for routine follow-up of a hypertension
diagnosis: urinalysis, blood chemistry, hematocrit, general electrolytes (Cl, Ca, Mg),
BUN, and liver function tests. If the patient has an abrupt increase in BP
measurement, consider laboratory workup for secondary hypertension.

Treatment Goals

Eligible population Goal

General population through age 79 BP lower than 140/90 mmHg
General population aged 80 and older 1 BP lower than 150/90 mmHg
Patients with diabetes BP lower than 140/90 mmHg
Patients with ASCVD BP lower than 140/90 mmHg
Patients with chronic kidney disease BP lower than 130/80 mmHg
(CKD) with albuminuria2 without BP lower than 140/90 mmHg
2
albuminuria
1
Consider using this goal for frail elderly patients and patients under age 80 who are
not tolerating pharmacologic treatment.
2
Whether moderately increased (30-300 mcg/mg, previously called
“microalbuminuria’) or severly increased (>300 mcg/mg, previously called
“macroalbuminuria”).

Initiating Treatment

Diagnosis Lifestyle modifications Drug treamtment1

Prehypertension At diagnosis Drug treatment not
recommended
Stage 1 hypertension At diagnosis Consider at or before 6
months of lifestyle
modifications if BP goals
unmet
Stage 2 hypertension At diagnosis At diagnosis
1
For frail elderly patients, standing blood pressure measurements should be
considered before initiating drug treatment. If patient is hypotensive when standing
but has mild hypertension when seated, pharmacologic treatment may cause more
harm than good.

Hypertensive emergencies can be managed with oral antihypertensive drugs.

 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

1. Initial goal of therapy is to reduce BP to between 160-180/100-110 mmHg

within 2 hours and to <160 and <100 by 6 hours. Excessive fall of BP that
may precipitate coronary, cerebral, and renal ischemia should be avoided.
2. Diuretics, ACE inhibitor, beta-blocker, calcium-channel blocker, methyldopa
can be used or in combination
3. Sublingual administration of fast-acting nifedipine should be avoided as
degree of fall of BP may be too rapid.

Lifestyle Modifications

Weight management

The risk of serious health conditions such as diabetes, heart disease, arthritis, and
stoke, as well as high blood pressure increase with a body mass index (BMI) of 25 or
higher (BMI = weight in kilograms divided by height in meters squared [kg/m 2].) Over
weight is defined as a BMI of 25 to 29.9, obesity as a BMI of 30 or higher. While
most overweight or obese adults can lose weight by eating a healthy diet or
increasing physical activity, doing both is most effective.

Diet

Patients with hypertension should be advised to reduce their dietary sodium intake to
no more than 2,400n mg/day: dietary reduction to 1,500 mg/day is desirable as it
leads to even greater decreases in BP. If the desired sodium level is not achieved,
consider an alternative goal of reducing current sodium intake by 1,000 mg/day.
Discourage excessive consumption of coffee and other caffeine rich products.

Additionally, all patients should strive to:

 Make smart choices from every food group to meet their caloric needs.
 Get the most and best nutrition from the calories consumed. The DASH
eating plan provides the following key elements: Consume a diet rich in fruits
and vegetables (8-10 servings/day), and reduced in saturated fat and
cholesterol.

Physical activity

All sedentary older adults and persons with risk factors should undergo exercise
stress testing before initiation of a vigorous exercise program.

Tobacco cessation

Quitting smoking, a primary risk factor for cardiac disease, has immediate as well as
long-term benefits for patients with hypertension and the people with whom they live.
The AAFP recommended that clinicians ask all adults about tobacco use, advise
them to stop using tobacco, and provide behavioral interventions and U.S. Food and
Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who
use tobacco. (2015)
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

Moderation of alcohol consumption

Because alcohol use can raise blood pressure, patients with hypertension should
use alcohol in moderation. Moderate drinking is limiting alcohol to one drink daily for
a woman, two drinks daily for a man.

One drink is defined as a:

4- to 5-ounce glass of wine
12-ounce can of beer
1 1/2 –ounce shot of 80-proof liquor

Screen patients using the AUDIT-C Alcohol Questionnaire, and provide brief
guidance when appropriate.

Stress Management

Relaxation techniques, yoga, massage can reduce blood pressure and this can be a
part of their treatment.

Antihypertensive Initial dose Recommended

medication maximum dose1
Thiazide diuretics 12.5 mg daily 25 mg daily
Hydrochlorothiazide
(HCTZ)
ACE inhibitors Lisinopril 10 mg daily 40 mg daily
½
Combination 20/12.5 mg x tab daily 20/12.5 mg x 2 tabs daily
Lisinopril/HCTZ 50/12.5 mg daily 100/12.5 mg daily
Losartan/HCTZ
Angiotensin receptor 25 mg/day in 1-2 doses 100 mg/day in 1-2 doses
blockers
Losartan
Calcium-channel blockers 2.5 mg daily 10 mg daily
Amlodipine
Beta-blockers 25 mg twice daily 50 mg 100 mg twice daily
Metoprolol IR (tartrate) daily 200 mg daily
Metoprolol LA (succinate)
Atenolol2 100 mg/day in 1-2 doses
1
Frail elderly patients may require lower initial doses and slower titration schedules.
Frail elderly patients may require lower therapeutic doses as well.
2
Not preferred in frail elderly patients or those with CKD.

Drug timing strategies

 There is some evidence to support using BP medications in the evening

instead of the morning (except in patients with glaucoma or vascular ischemic
disorders)
 Consider twice daily (BID) dosing more strongly as the dose increases.
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

 When considering either of these strategies, decision making. For some

patients, compliance is more difficult if they have to take medications twice
per day instead of once. Also note that QHS (every bedtime) diuretic dosing
may result in poor tolerance/adherence in some patients. Be sure to discuss
this with patients and ask how compliant they feel they would be with a more
complicated medication regimen.

In patient is not meeting BP goal

Determine whether the patient is taking prescribed medications according to

instructions. Using open-ended questions, talk with the patient about any barriers to
adherence and check their understanding of their condition and the treatment(s) they
have been prescribed.

Special consideration

1. Sublingual antihypertensive medications should be avoided. The use of

centrally-acting antihypertensive medications such as clonidine should take
into consideration risk versus benefit.
2. With all drugs, orthostatic hypotension should be avoided because of the
increased risk of falling in older patients.
3. Thiazide diuretics reduces cardiovascular events in elderly although it can
exacerbate hyperuricemia, glucose intolerance and dyslipidemia.
4. Verapamil and diltiazem can precipitate heart block in elderly patients with
underlying conduction defects.
5. Short-acting rapid-release dihydropyridines must be avoided.

Follow up and monitoring

Medication Test(s) Frequency

ACE inhibitors or ARBs1 Potassium and Creatinine Before initiating therapy
Diuretics and/or Potassium and Creatinine and 2 weeks after initiating
aldosterone antagonist2 therapy and with each
increase in dose and
annually
Sodium3 Before initiating therapy
and consider at the time
periods listed above
Beta-blockers and/or No routine lab monitoring
Calcium channel blockers is required
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

1
For patients on ACE inhibitors or ARBs, renal function (creatinine) should be
checked because treatment may be associated with deterioration of renal function
and/or increases in serum creatinine, particularly in patients dependent on renin-
angiotensinaldosterone system; potassium should be checked because 2-5 % of
patients develop hyperkalemia.
2
For patients on diuretics or aldosterone antagonists, potassium should be checked
at least once a year, and perhaps twice a year and with any chance of dose because
excessive dosages can lead to profound diuresis with fluid and electrolyte loss; renal
function (creatinine) should be checked because use of diuretics may cause
oliguria , azotemia, and reversible increases im creatinine.
3
For patients who are >60 years, on multiple medications, or who have heart failure,
consider checking sodium levels as well.

Preventions

Primary prevention

1. Exercise
Two hours and 30 minutes (150 minutes) of moderate intensity aerobic
activity (e.g., brisk walking) a week, plus muscle-strengthening activities on at
least two days of the week

Or

One hour and 15 minutes (75 minutes) of vigorous intensity aerobic activity
(e.g., jogging, running) a week, plus muscle-strengthening activities on at
least two days of the week

Or

A combination of moderate and vigorous intensity aerobic activity equivalent

to the recommendations above, plus muscle strengthening activities on at
least two days of the week

2. Nutrition
Follow the Recommendation Energy Nutrient Intake (RENI) based on age and
weight (DOST-FNRI)

Secondary prevention
1. Annual BP screening
 SANTISSIMA TRINIDAD HOSPITAL
PINAGBAKAHAN CITY OF MALOLOS, BULACAN
TEL (044) 791 -7331

CLINICAL
PRACTICE
GUIDELINE
ON
HYPERTENSION