CLINICAL Hypertension in Older Adults

REVIEW
Indexing Metadata/Description
› Title/condition: Hypertension in Older Adults
› Synonyms: High blood pressure, older adults; hypertension, elderly persons; blood
pressure, high, older adults
› Anatomical location/body part affected: Cardiovascular system/heart and blood vessels,
brain, kidneys, optic fundi
› Area(s) of specialty: Cardiovascular Rehabilitation
› Description and overview
• Resting (seated) arterial blood pressure (BP) increases with advancing age, most rapidly
after age 60.(1) Both systolic and diastolic BP usually become elevated, although isolated
systolic hypertension (HTN) is not uncommon in older persons(2,3)
• Persons 55 to 65 years of age have a 90% lifetime risk of developing HTN,
defined as systolic/diastolic BP > 140/ > 90 mmHg.(2) HTN greatly increases
cardiovascular disease (CVD) risk.(3,4) The rate of hospital admissions due to
HTN-relatedconditions increased in the United States from 1980 to 2007, based on data
(N = 4,598,488hospitalized cases) from the National Hospital Discharge Surveys(42)
• Management of HTN in persons 60 to 80 years of age reduces risk of CVD such as
stroke, heart failure, myocardial infarction, all-cause mortality, cognitive impairment,
and dementia(4,5,6,7,43,44,54)
• There is some variance regarding the specific systolic and diastolic blood pressure range
recommendations for management of HTN in elderly populations
–According to the Eighth Joint National Committee (JNC8), current management
guidelines for persons with HTN recommend controlling resting BP values below
(<) 150 mmHg systolic and between 80 and 90 mmHg diastolic.(43)Therapeutic goals
of systolic BP < 130 mmHg and diastolic BP < 65 mmHg for the general population
should probably be avoided in older adults due to associated complications such as
falls possibly due to orthostatic hypotension(1,7,8)
Author
Rudy Dressendorfer, BScPT, PhD –The Working Group on Women’s Cardiovascular Health strongly disagrees with the
Cinahl Information Systems, Glendale, CA JNC 8 recommendations to raise the threshold of initiating treatment for older persons,
especially because of the effect on women, who are the majority of the older adult
Reviewers population with HTN. The working group notes that the new recommendations put
Amy Lombara, PT, DPT
women, especially Black women, at unnecessary excess risk and increase the existing
Cinahl Information Systems, Glendale, CA
Ellenore Palmer, BScPT, MSc sex and racial/ethnic cardiovascular disease disparities(58)
Cinahl Information Systems, Glendale, CA - This group suggests adhering to BP goal of < 140/90 for older women
Rehabilitation Operations Council –A scientific statement from the American Heart Association, American College of
Cardiology, and American Society of Hypertension recommends blood pressure in
Glendale Adventist Medical Center,
Glendale, CA
uncomplicated HTN should have a target of < 140 mmHg and < 90 mmHg diastolic in
Editor patients 65 to 79 years old(57)
Sharon Richman, MSPT • Antihypertensive drug therapy usually involves one or more of the following: diuretic,
Cinahl Information Systems, Glendale, CA
beta blocker, calcium channel blocker, or angiotensin converting-enzyme(ACE)
inhibitor, and angiotensin II receptor blockers (ARBS). Older adults often experience
adverse effects of these medications and might not or cannot comply fully with drug
January 5, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 therapy.(5,7,9) It remains unclear whether antihypertensive drug therapy per se improves
activities of daily living (ADLs) in older adults with HTN(45)
• Lifestyle intervention involving weight loss, diet, exercise training, and increased daily physical activity is especially
important in the initial medical management of HTN. Exercise training can help to manage HTN in older adults similar to
in young and middle-aged adults.(1,10,11) Clinicians should monitor BP during prescribed exercise in older adults with HTN
and control safe levels (seeClinical Review…Hypertension: An Overview; Topic ID Number: T709014)
› ICD-9 codes
• 401 Essential hypertension
–401.0 Malignant essential hypertension
–401.1 Benign essential hypertension
–401.9 Unspecified essential hypertension
• 402 Hypertensive heart disease
–402.0 Malignant hypertensive heart disease
- 402.00 malignant hypertensive heart disease without congestive heart failure
- 402.01 malignant hypertensive heart disease with congestive heart failure
–402.1 Benign hypertensive heart disease
- 402.10 benign hypertensive heart disease without congestive heart failure
- 402.11 benign hypertensive heart disease with congestive heart failure
–402.9 Unspecified hypertensive heart disease
- 402.90 unspecified hypertensive heart disease without congestive heart failure
- 402.91 unspecified hypertensive heart disease with congestive heart failure
• 403 Hypertensive renal disease
–403.0 Hypertensive kidney disease, malignant
- 403.00 hypertensive chronic kidney disease, malignant, without chronic kidney disease
- 403.01 hypertensive chronic kidney disease, malignant, with chronic kidney disease
–403.1 Hypertensive kidney disease, benign
- 403.10 hypertensive chronic kidney disease, benign, without chronic kidney disease
- 403.11 hypertensive chronic kidney disease, benign, with chronic kidney disease
–403.9 Hypertensive kidney disease, unspecified
- 403.90 hypertensive chronic kidney disease, unspecified, without chronic kidney disease
- 403.91 hypertensive chronic kidney disease, unspecified, with chronic kidney disease
• 404 Hypertensive heart and kidney disease
–404.0 Hypertensive heart and kidney disease, malignant
- 404.00 hypertensive heart and chronic kidney disease, malignant, without heart failure or chronic kidney disease
- 404.01 hypertensive heart and chronic kidney disease, malignant, with heart failure
- 404.02 hypertensive heart and chronic kidney disease, malignant, with chronic kidney disease
- 404.03 hypertensive heart and chronic kidney disease, malignant, with heart failure and chronic kidney disease
–404.1 Hypertensive heart and kidney disease, benign
- 404.10 hypertensive heart and chronic kidney disease, benign, without heart failure or chronic kidney disease
- 404.11 hypertensive heart and chronic kidney disease, benign, with heart failure
- 404.12 hypertensive heart and chronic kidney disease, benign, with chronic kidney disease
- 404.13 hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease
–404.9 Hypertensive heart and kidney disease, unspecified
- 404.90 hypertensive heart and chronic kidney disease, unspecified, without heart failure or chronic kidney disease
- 404.91 hypertensive heart and chronic kidney disease, unspecified, with heart failure
- 404.92 hypertensive heart and chronic kidney disease, unspecified, with chronic kidney disease
- 404.93 hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease
• 405 Secondary hypertension
–405.0 Malignant secondary hypertension
- 405.01 malignant renovascular hypertension
- 405.09 other malignant secondary hypertension
 –405.1 Benign secondary hypertension
- 405.11 benign renovascular hypertension
- 405.19 other benign secondary hypertension
–405.9 Unspecified secondary hypertension
- 405.91 unspecified renovascular hypertension
- 405.99 other unspecified secondary hypertension
• 796.2 Elevated blood pressure reading without diagnosis of hypertension
› ICD-10 codes
• I10 Essential (primary) hypertension
–I10.0 Benign hypertension
–I10.1 Malignant hypertension
• I11 Hypertensive heart disease
–I11.0 Hypertensive heart disease with (congestive) heart failure
–I11.9 Hypertensive heart disease without (congestive) heart failure
• I12 Hypertensive renal disease
–I12.0 Hypertensive renal disease with renal failure
–I12.9 Hypertensive renal disease without renal failure
• I13 Hypertensive heart and renal disease
–I13.0 Hypertensive heart and renal disease with (congestive) heart failure
–I13.1 Hypertensive heart and renal disease with renal failure
–I13.2 Hypertensive heart and renal disease with both (congestive) heart failure and renal failure
–I13.9 Hypertensive heart and renal disease, unspecified
• I15 Secondary hypertension
–I15.0 Renovascular hypertension
–I15.1 Hypertension secondary to other renal disorders
–I15.2 Hypertension secondary to endocrine disorders
–I15.8 Other secondary hypertension
–I15.9 Secondary hypertension, unspecified
• R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
_
(ICD codes are provided for reader’s reference and not for billing purposes)
› G-Codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end
reporting
›.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or
restricted
CJ At least 20 percent but less than 40 percent impaired, limited
or restricted
CK At least 40 percent but less than 60 percent impaired, limited
or restricted
CL At least 60 percent but less than 80 percent impaired, limited
or restricted
CM At least 80 percent but less than 100 percent impaired, limited
or restricted
CN 100 percent impaired, limited or restricted
Source: https://www.cms.gov/

.
› Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no specific special agencies are
applicable for this condition. No specific issues or information regarding reimbursement has been identified
› Presentation/signs and symptoms (1,5)
• Advanced age (i.e., age 65 and older)
• Elevated resting BP
–> 150 mmHg or > 140 mm Hg systolic and > 90 mmHg diastolic without compelling comorbidities(43,58)
–> 150 mmHg in cases of isolated systolic HTN
• Essential HTN is almost always asymptomatic. Patients who present with chest pain, shortness of breath, symptomatic
orthostatic hypotension, dizziness, nausea, or other acute symptoms that could be life-threatening require immediate
medical evaluation
–For detailed information on orthostatic hypotension, see Clinical Review…Orthostatic Hypotension; Topic ID Number:
T908170
• Common coexisting CVD risk factors include being overweight (body mass index [BMI] ≥ 25), type 2 diabetes, and a
sedentary lifestyle
–For detailed information, see Clinical Review…Hypertension, Essential, and Type 2 Diabetes; Topic ID Number:
T709013

Causes, Pathophysiology, & Risk Factors

› Causes
• 90% to 95% of cases do not have a specific cause, in which case the diagnosis is termed essential, primary, or idiopathic
HTN(3)
• 5–10% of cases are secondary HTN due to chronic diseases that underlie the etiology, including genetic syndromes, renal
failure, or endocrine disorders such as pheochromocytoma or Cushing’s syndrome(12)
• HTN is often associated with type 2 diabetes in older adults, but whether diabetes is a causal factor remains unclear
› Pathophysiology
• The hallmark of HTN in older adults is increased systemic vascular resistance, which in older adults is associated with
arterial stiffening and endothelial dysfunction.(57) In contrast, HTN in young and middle-aged adults is more often
associated with elevated cardiac output and increased sympathetic innervation(13)
• Isolated systolic HTN is often linked to arterial stiffening with age(13)
–The loss of arterial compliance is part of the aging process
–The aorta and large central arteries are involved
–Carotid-femoral pulse wave velocity is increased
–Systolic BP is increased because the reflected pulse waves return to the heart before the aortic valve closes(14)
• The effectiveness of interventions to lower systolic BP in older adults might depend on reducing arterial stiffness
–The pulsatile pressure-flow dynamics of BP are determined by vessel wall compliance, pulse wave velocity, and the
wave reflections (also called the augmentation index). Abnormal changes in these indices of arterial stiffness represent
independent CVD risk factors in persons with HTN(15)
–Age-related arterial stiffening might reduce the effectiveness of exercise training for reducing elevated BP in older
adults.(16) In addition, CVD risk factors might attenuate the effect of aerobic training on reducing and maintaining
improvements in arterial stiffness(17)
–Combined exercise and diet modification might be effective for reducing arterial stiffness in middle-aged adults at high
risk for HTN.(18) This might also apply to older adults(1)
–Authors of a 2015 systematic review examined the effect of various types of exercise on arterial stiffness in patients of all
ages with and without HTN and came to the following conclusions:(59)
 - Aerobic exercise tends to have a beneficial (reducing) effect on arterial stiffness in patients with and without HTN but
does not affect arterial stiffness in patients with isolated systolic HTN
- Vigorous resistance training is associated with increased arterial stiffness whereas low intensity, slow eccentric, or lower
limb resistance training in healthy subjects is not
- Combined training has either a neutral or beneficial effect on arterial stiffness
• Low-grade arterial inflammation contributed to increased arterial stiffness to a greater extent than endothelial dysfunction
in 858 Dutch older adults (mean, 67.5 years) with HTN and high CVD risk(19)
• Isolated systolic HTN (i.e., resting BP > 150/ < 90 mmHg) is a common form of HTN in persons over age 65 and occurs in
the majority of new cases in persons over age 80(12)
• Controlling systolic BP < 140 mmHg has been associated with reduced risk for heart failure.(7) However, researchers who
conducted a 10-year follow-up study (N = 4,408, mean age 72.8 years) in the United States found that 52% of incident
events of heart failure occurred in those with BP controlled below 140 mmHg at baseline(20)
• Whether BP should be much lower than 140/80 mmHg in older adults requires further confirmation of reduced CVD
mortality and risk-benefit analysis of adverse events, such as falls related to orthostatic hypotension (1,5,7,8)
• There is a target range for lowering systolic BP to improve or delay cognitive impairment(49)
–Researchers who conducted a longitudinal study in China investigated cognitive impairment in 294 older patients
(80 years of age) with HTN with an initial examination and a 4-year follow-up. The decline in Mini-Mental State
Examination (MMSE) scores as well as the increase of white matter hyperintensities (WMH) and WMH/total intracranial
volume (TIV) ratio was smaller in patients who maintained SBP between 140 and 160 mmHg. Additionally, greater
benefits were found when lowering SBP 15 to 35 mmHg compared to lowering systolic BP < 15 or > 35 mmHg
• The link between HTN and mortality might be related to age(44)
–Researchers of a study of adults taking antihypertensive medication (N = 9,787, ≥ 45 years of age) in the United States
found that systolic BP between 120 and 139 mmHg was significantly associated with reduced risk for cardiovascular and
all-cause mortality in those ≥ 55 years. In contrast, no association between systolic BP and all-cause mortality was found
for those ≥ 75 years. Also, no association was found between systolic BP and falls among participants in all age groups
• Randomized controlled trials (RCTs) are needed to investigate whether antihypertensive drug therapy exclusive of exercise
and functional training in older adults improves independence in ADLs(45)
• Researchers who studied U.S. male veterans (N = 2,153;mean age 75 years) with HTN found that exercise capacity was an
independent predictor of all-cause mortality outcomes at a mean of 9.0 years follow-up. The relationship was inverse and
graded;men with the highest exercise capacity had the most survival benefits(46)
› Risk factors (1,3,5)
• Age (over 45 for men and 55 for women). Prevalence exceeds 50% in Americans 60 years and older. Lifetime risk for men
and women aged 55 to 65 years by age 80 to 85 is > 90%(51)
• Overweight or high body mass index (BMI, 25 and higher). Excessive fat around the abdomen, or “centripetal” obesity
• Black (non-Hispanic) ethnicity
• Sedentary lifestyle (< 30 minutes of aerobic physical activity per day)
• High dietary salt intake (over 2,300 mg, or about 1 teaspoon per day)
• More than moderate alcohol consumption (i.e., averaging more than 2 drinks per day for men or more than 1 per day for
women)
• Mental stress/anxiety
• Certain chronic conditions (e.g., kidney disease, sleep apnea)
• Family history
• Smoking

Overall Contraindications/Precautions
› Notify physician immediately if patient presents with recent onset of nonspecific symptoms (e.g., headache, fatigue,
dizziness, nausea, blurred vision) that might indicate a hypertensive crisis or malignant HTN. Exercise is contraindicated in
these patients
› Observe the following contraindications to exercise established for individuals with known cardiovascular disease or
unstable medical conditions(21)
• Unstable angina
 • Resting systolic BP greater than 200 mmHg or resting diastolic BP greater than 110 mmHg
• Orthostatic fall in SBP with symptoms (postural hypotension)
• Critical aortic stenosis
• Acute systemic illness or fever
• Uncontrolled atrial or ventricular arrhythmias
• Uncontrolled sinus tachycardia greater than 120 beats/min
• Uncompensated congestive heart failure with symptoms
• 3rd-degree atrioventricular block without pacemaker
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Uncontrolled diabetes
• Severe orthopedic conditions that would restrict exercise
• Uncontrolled metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, and hypovolemia
• Acute stroke or myocardial infarction
› Postpone physical activity/exercise therapy and notify physician if:
• Systolic BP exceeds 200 mmHg before treatment(10,21)
• Diastolic BP exceeds 110 mmHg before treatment(10,21)
• Symptoms such as headache or dizziness develop during exercise
› Patients with HTN are at higher risk for exercise-related adverse cardiopulmonary events. Therefore, a medical evaluation
that includes submaximal exercise testing is highly recommended prior to initiating a vigorous exercise program, especially
for men over 45 and women over 55.(1,10,21) However, most patients with HTN can safely begin a low-to-moderateintensity
aerobic activity program such as walking prior to exercise testing(5)
› Antihypertensive medications should be taken at the prescribed usual time to control BP during physical activity(10)
› HTN should be controlled before initiating an exercise program, especially one involving resistance exercise
training(1,10,11,21)
› Avoid the Valsalva maneuver throughout examination and treatment
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/
Plan of Care

Examination
› Contraindications/precautions to examination
• Stop the exam and notify physician if patient reports chest pain, shortness of breath, or dizziness
• If an incremental aerobic exercise test on a treadmill or cycle ergometer is used to assess the patient’s BP response to
exertion, terminate the test if systolic BP exceeds 260 mmHg or diastolic BP exceeds 115 mmHg(10,21)
• Exercise testing should be “symptom limited” (i.e., terminate the test if the patient reports distress before the onset of
muscle fatigue)(22)
› History
• History of present illness/injury
–Onset and duration of HTN: Document date and level of BP when HTN was first discovered. Is this a chronic condition
or a recent diagnosis? If chronic, has client been able to control HTN with nonpharmacological and/or pharmacological
methods?
–Modifiable risk factors: What CVD risk factors are present? Have there been any recent changes in weight, physical
activity, diet, smoking, or use of caffeine or alcohol?
–Course of treatment
- Medical management
- Document comorbidities and current intervention
- Authors of a U.S. study concluded that HTN is associated with comorbid executive dysfunction in older adults but
not severity of depression(52)
 - Authors of a U.S. study found that older adults with HTN and the apolipoprotein E (APOE) gene, a genetic risk
factor for Alzheimer’s disease and other cognitive disorders, demonstrated poorer performance on executive function
and memory tests than those with neither or either alone(53)
- Ask patient about physician’s advice on:
- Physical activity/exercise program
- Diet (e.g., consumption of sodium, sweetened beverages, alcohol, and caffeinated products)
- Weight loss, as indicated
- Lifestyle management usually includes recommendations for(1)
- Weight loss in overweight/obese patients
- Dietary Approaches to Stop Hypertension (DASH) diet
- Regular exercise to improve cardiovascular (aerobic) fitness and muscular strength
- Smoking/tobacco cessation(54)
- Behavioral stress management that elicits the relaxation response might help older adults reduce their systolic BP and
dosage of antihypertensive medications(22)
- Medications
- Determine what medications have been prescribed. Confirm that they are being taken and whether they are effectively
controlling HTN. The following classes of drugs are commonly prescribed for older adults with HTN
- Thiazide diuretic (usually the first-line medication)
- Beta blocker
- Calcium channel blocker (including the vascular selective dihydropyridines)
- ACE inhibitor
- Angiotensin II receptor blocker (ARB)
- Therapeutic control of HTN in older adults reduces CVD mortality and morbidity; i.e., risks for stroke, heart failure,
myocardial infarction, all-cause mortality, cognitive impairment, and dementia(6)
- Based on a 2009 systematic review consisting of 15 RCTs, totaling 24,055 patients (the majority were 60 to 80 years
of age)
- Most trials evaluated the effectiveness of thiazide diuretic therapy (mean duration of treatment was 4.5 years)
- Similar risk reduction for cardiovascular events was found in older adult patients (over 80 years old) as for those 60
to 80; however, there was no reduction in all-cause mortality for the older adult patients
- Similar risk reductions were found in patients treated for isolated systolic HTN
- Antihypertensive medication reduces cardiovascular morbidity and mortality in older adults (i.e., risk for stroke, heart
failure, myocardial infarction, cognitive impairment, and dementia)(54)
- Based on a 2014 systematic review consisting of 31 published studies (15 trials and 16 studies involving a subgroup
analysis from a larger cohort), 95,874 participants, and an average age range of 65 to 105 years
- More than 24 agents were studied. All studies used an open-labeldesign or combination therapy to reach target blood
pressure. Thiazide and thiazide-like diuretics seem to provide the most consistent benefits
- Due to the large variety of antihypertensive agents, doses, and blood pressure targets used in RCTs or observational
studies, there is not enough evidence to recommend a preferred dose or agent for older patients
- Blood pressure reduction in older adult patients decreases risk of adverse cardiovascular outcomes(56)
- A 2014 systematic review included a total of 59,285 controls and 55,569 patients with HTN. Average follow-up was
3.44 years. Patients had a mean age of 71.04 years
- Average blood pressure of the first treatment group was 149.3 mmHg systolic, 77.4 mmHg diastolic compared to an
average of 162.8 mmHg systolic, 83.1 mmHg of the placebo group
- The second treatment group compared two-antihypertensive regimens with baseline BP (average systolic 157 mmHg,
average diastolic 86 mmHg) and BP reduction to an average < 140 mmHg systolic, < 80 mmHg diastolic
- Both treatment groups found similar significant decreases in all-cause mortality, cardiovascular mortality, and heart
failure compared to the non-drug placebo group
- The meta-regression analysis noted mean systolic blood pressure difference was linearly associated with all-cause
mortality, cardiovascular, stroke, and heart failure risk reduction in older adult individuals
- Due to similar benefits seen in both treatment groups, reducing BP to a level of 150 mmHg systolic, 80 mmHg
diastolic is recommended to lower cardiovascular risk factors
 - Orthostatic hypotension is a potential adverse effect of antihypertensive medications in older adults(1)
- Occurring in 7% men > 70 years old
- Increases age-adjusted mortality risk (i.e., premature death)
- Increases risks for falls and fractures
- Especially associated with alpha blockers and combination of alpha-beta blockers with diuretics and nitrates
- For detailed information on orthostatic hypotension, please see the Clinical Review referenced above
- Researchers who conducted a 2010 meta-analysis of RCTs (N = 6,701) concluded that thiazides and a maximum of
two drugs is the most reasonable medical strategy for reduction of all-cause mortality in persons over 80 years of
age(8,23)
- Researchers who conducted a study (N = 73) in China found that atorvastatin (Lipitor), a statin usually prescribed for
hypercholesterolemia, improved arterial stiffness, possibly by reducing oxidative stress damage, in older adult patients
with HTN(24)
- Adherence to prescribed antihypertensive drug therapy is reduced in older adults, probably because of side effects and
adverse events from
- drug interactions(5,7,9)
- increased drug sensitivity(5,7,9)
- decreased rate of drug metabolism(5,7,9)
- cognitive decline or dementia(25)
- Diagnostic tests completed: Recommended workup includes the following:(1)
- Electrocardiogram (ECG)
- Urinalysis
- Retinal exam
- Blood glucose
- Serum potassium, creatinine, and calcium
- Complete blood count
- Lipid profile – HDL cholesterol, LDL cholesterol, triglycerides
- Optional – urinary albumin/creatinine ratio or urinary albumin excretion
- Alternative therapies: Document any use of herbal, behavioral, or other therapies (e.g., massage) and whether or not
they help
- Previous therapy: Document whether patient has received physical therapy for this or other conditions and what
specific treatments were helpful or not helpful. Has the patient received education pertaining to conservative
management of HTN (e.g., exercise, diet, weight loss)?
–Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased):
Please see Risk factors for factors that could exacerbate or lead to HTN. Does stress and/or anxiety affect the patient’s
BP?
–Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document nature of symptoms. Pain is an unusual symptom of HTN and should be further
investigated
–Rating of symptoms: Essential HTN is almost always asymptomatic. However, a visual analog scale (VAS) or 0–10
scale can be used to assess symptoms the patient might report (e.g., at their best, at their worst, and at the moment)
–Pattern of symptoms: Document changes in any symptoms of coexisting conditions throughout the day and night, if any
(A.M., mid-day, P.M., night)
–Sleep disturbance: Does patient have difficulty getting restorative sleep? Document number of wakings/night
–Other symptoms: Document other symptoms the patient is experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician (e.g., dizziness, bowel/bladder issues, shortness of
breath)
–Respiratory status: Is there any pulmonary compromise related to the use of antihypertensive medications? Document
any use of supplemental oxygen
–Barriers to learning
- Are there any barriers to learning? Yes __ No __
- If Yes, describe _________________________
 • Medical history
–Past medical history
- Previous history: Any prior treatment for HTN?
- Comorbid diagnoses: Any history of heart disease, stroke, diabetes, renovascular disease, or osteoporosis?
- Medications previously prescribed: Obtain a comprehensive list of all prescribed medications as well as
over-the-counter medications and herbal remedies (some might raise BP)
- Other symptoms: Ask patient about other symptoms he or she is experiencing
• Social/occupational history
–Patient’s goals: Document what the patient hopes to accomplish with therapy (patient-oriented outcomes)
–Vocation/avocation and associated repetitive behaviors, if any: Does the patient regularly participate in physical
activities? Any hobbies and/or activities that the client enjoys that he or she is currently unable to do? Administer a brief
physical activity questionnaire
–Functional limitations/assistance with ADLs/adaptive equipment: If applicable, inquire about limitations and
equipment utilized
–Psychosocial and environmental factors: Ask about family situation, employment status, and working conditions that
might increase stress/anxiety
–Living environment
- With whom does the patient live (e.g., spouse/partner, children, siblings, caregivers)?
- Identify if there are barriers to independence in the home; are any modifications necessary?
- Inquire about the levels of the home, including stairs and numbers of floors
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Measure height and weight and determine BMI. Is weight reduction indicated?
–Researchers who conducted a study (N = 962 African American females > 65 years of age) in the United States found the
risk of HTN increased significantly at a BMI above 23 kg/m.(2)This finding indicates that control of HTN might require
weight reduction to a greater extent than currently recommended(26)
• Assistive and adaptive devices: Assess fit and use of prescribed devices, if applicable
• Balance: Assess static and dynamic balance reactions (might be altered by medications). Administer Berg Balance Scale,
as indicated
• Cardiorespiratory function and endurance
–Assess breath sounds (should be normal unless the patient has lung disease)
–Check pulse for rate and rhythm
–Use Borg Rating of Perceived Exertion (RPE) Scale to assess relative intensity of exercise(21)
–Assess systolic and diastolic BP (see Special tests specific to diagnosis, below)
–A treadmill or cycle ergometer submaximal graded exercise test can aid in the assessment of the patient’s HR, BP, and
RPE responses to exercise (both at baseline as well as after exercise training) and provide the basis for an individualized
prescription for aerobic exercise(21)
–The 6-minute walk for distance test (6MWT) provides an objective outcome measure of aerobic performance and can be
used as the basis for prescribing a walking exercise program(27)
• Circulation: Assess peripheral pulses in all limbs
• Functional mobility: Assess gross movement during transfers and functional tasks using the upper extremities (e.g.,
reaching, pulling, pushing, holding) and lower extremities (e.g., steps, squatting, kneeling, kicking). Administer FIM, if
indicated. Is mobility suitable for exercise program?
• Gait/locomotion: Assess ambulatory function, including synchrony of limb movements and gait speed, as well as posture.
Assess safety with dynamic gait index (DGI)
• Joint integrity and mobility: Passive accessory movement in the involved joints should be normal
• Motor control: Assess if patient has history of neurological impairment
• Muscle strength: Assess strength using standard manual muscle testing (MMT) and in functional tasks (e.g., handgrip,
pushing, pulling, sit-up, squatting), as indicated to target muscle groups in a resistance exercise program. Testing handgrip
strength might be useful for guiding the selection of free weights in a strengthening program. Testing of one-repetition
maximum (1-RM) strength of the extremities is not recommended on the initial physical exam, or considered necessary to
begin a resistive exercise program(28)
 • Observation/inspection/palpation: Assess for deformities and pain, discomfort, or tenderness in the extremities that might
restrict patient from participating in specific exercises. Assess for lower-extremity edema, as indicated
• Range of motion: Ensure that functional range of motion (ROM) and flexibility are present for the planned exercise
program
• Reflexes: Assess deep tendon reflexes
• Sensation: Assess sensation to light touch in the extremities
• Special tests specific to diagnosis
–Measure BP with a stethoscope and sphygmomanometer (the bladder of the cuff should cover at least two thirds of the
circumference of the arm) in good working order. Patient should be relaxed in the sitting position with the cuffed arm
supported and at the level of the heart. Take the BP reading 2 times, with 2 minutes between readings, in both arms. The
highest reading might be accepted as the reference value
–Assess for orthostatic (postural) hypotension in standing position, as indicated by the patient’s history

Assessment/Plan of Care
› Contraindications/precautions
• Clinicians should follow the exercise guidelines of their clinic/hospital and the physician’s order
• Individually prescribed and supervised submaximal exercise training generally is safe and well tolerated when the exercise
program is tailored to accommodate each patient’s functional capacity and subjective response to exertion(10,11,21)
• HTN should be controlled before initiating an exercise program, especially one involving resistance exercise
training(1,10,11,21)
• Resting BP higher than 180/110 mmHg is an absolute contraindication and higher than 160/100 mmHg is a relative
contraindication to performing resistance exercise(28)
• Monitor BP on a regular basis during exercise. According to standard guidelines, terminate exercise and consult the
physician if:(10,21,28)
–Systolic BP exceeds 250 mmHg or diastolic BP exceeds 115 mmHg
–Systolic BP fails to rise more than 20 mmHg
–Systolic BP falls unexpectedly more than 10 mmHg
–Exercise-related symptoms such as chest discomfort, palpitations, lightheadedness, or shortness of breath are reported, as
they indicate exercise-related distress
• To prevent exaggerated increases in BP during therapeutic exercise due to anxiety or lack of warm-up, provide the patient
with a thorough orientation to using the prescribed exercise equipment and at least 5 to 10 min of light aerobic exercise
before increasing intensity
• Reduce exercise training intensity if patient reports unusual fatigue or “hard” RPE
• Avoid heavy resistance exercise for most older patients, especially those with known osteoporosis
• Instruct patients not to perform Valsalva maneuver during exertion. This precaution is especially important for patients with
a history of orthostatic hypotension
• Extend the cooling-down period and avoid having the patient stop suddenly after exercise because this might cause
orthostatic hypotension (i.e., a precipitous fall in systolic BP due to venous pooling) and possibly falling due to syncope
• Electrotherapeutic modalities are not indicated for treating HTN. Use cryotherapy with caution in patients with HTN as
cold can cause a transient increase in BP; discontinue treatment if there is an elevation in BP
• Rehabilitation professionals should always use their clinical judgment regarding the use of modalities for coexisting
conditions
› Diagnosis/need for treatment: Essential HTN/sedentary lifestyle, functional decline in ADLs, poor physical fitness,
overweight, increased CVD risk
› Rule out: These conditions should be ruled out: Resistant HTN (inadequate BP control despite 3 or more antihypertensive
medications), renal HTN, pulmonary artery HTN, symptomatic coronary artery disease, endocrine disorders (e.g.,
pheochromocytoma, Cushing’s syndrome, metabolic syndrome)(29)
› Prognosis
• In most cases, proper pharmacologic and/or lifestyle intervention can control essential HTN, although long-term
monitoring with periodic adjustments in treatment usually is required(1,5,6,10,11,29)
 • Researchers who conducted a 2005 meta-analysis of 72 RCTs (N = 3,936 participants) found that aerobic endurance
training (≥ 4 weeks) produced significant reductions in resting and daytime ambulatory systolic/diastolic BP of 3.0/2.4
mmHg and 3.3/3.5 mmHg(47)
• HTN might accelerate the age-related decline in gait speed, even in well-functioning older adults
–Based on a longitudinal cohort study (N = 643;mean age 72 years) of men and women in the United States(30)
–Participants with HTN (n = 293) had a faster rate of gait speed decline over 18years follow-up than those (n = 350) with
BP < 140/ < 90 at baseline
–Neither health and fitness measurements nor brain scans explained this association between HTN and the decline in gait
speed
› Referral to other disciplines
• Primary care physician for questions regarding medical release for exercise program
• Internist for uncontrolled HTN
• Nutritionist for dietary evaluation and weight loss
• Psychiatrist/psychologist for stress management
› Other considerations
• Lifestyle interventions recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure(1)
–Weight loss to manage obesity
–DASH diet
–Regular aerobic exercise (30 minutes per day)
• Additional management of HTN(50,55)
–Smoking/tobacco cessation (with pharmacological intervention as warranted by physician)
–Limiting alcohol consumption (no more than 2 drinks per day for men and 1 drink per day for women)
–Self-measured blood pressure monitoring with or without additional support (e.g., education, home visits); at-home
self-monitoring decreases likelihood of “white coat HTN”
• A protein-enriched diet (higher whey protein intake) over 2 years did not significantly affect BP in a randomized trial (N =
219 women, aged 70 to 80) in Australia(31)
• Olmesartan medoxomil might provide a more effective and sustained 24-hour control of BP than ramipril, based on
pooled individual data on 1,453 older adult patients with HTN entered in 2 RCTs in Italy.(32) This finding has implications
especially for older adult patients who choose to exercise in the morning or some hours after their last intake of medicine
• Health literacy needs to be considered when working with older adults with HTN(60)
–Authors of a systematic literature review of the various instruments used to assess health literacy in older adults with
HTN found that older adults had limitations, especially in management of care and knowledge about the disease
–Fewer years of schooling, old age, and greater number of years living with HTN have been associated with inadequate
health literacy in patients with HTN(61)
› Treatment summary: Recommended goal values for management of HTN in adults aged 60 years and older in the United
States are < 150 mmHg or < 140 mmHg systolic and below 90 mmHg diastolic BP.(43,58)Most types of individualized and
supervised exercise training programs seem effective for complementing pharmacologic control of HTN in older adults
• Aerobic exercise training
–General guidelines for low-risk individuals in a supervised program(1,10,11,21)
- Type of activity: Aerobic (e.g., walking, dance, or stationary cycling)
- Intensity: “Light” to “somewhat hard” RPE, corresponding to 11 to 13 on Borg’s 15-point (6 to 20) scale. Lower
intensity appears as effective as higher intensity in sedentary adults aged 55 years and older(21)
- Duration: Totaling 30 to 60 minutes of continuous or intermittent physical activity per day. Preferably, more than 5
hours per week for overweight individuals in a weight-loss regimen
- Frequency: Most, preferably all, days of the week
–Studies involving aerobic training of older adults with HTN
- Authors of a study in Brazil found that a moderate jogging program (30 minutes at 50% to 60% of peak aerobic
intensity, 2 times per week for 12 weeks) was associated with significant reductions in resting systolic and diastolic BP
in 12 previously sedentary older women with HTN.(33) This study did not include a control group
 - Researchers who conducted an RCT in the United States with 52 sedentary residents ≥ 75 years of age in community
living facilities found that a variety of aerobic activities (40 minutes at 85% to 90% of age-predictedmaximum HR, 3
days per week for 10 weeks) significantly lowered systolic BP (–7.8 mmHg) and diastolic BP (–9.6 mmHg) versus no
exercise(34)
- Authors of an RCT(N = 39 older adults with mean age = 71.5 years with HTN and type 2 diabetes)in Canada found that
vigorous aerobic exercise training (40 minutes at 80% to 85% of maximum HR, 3 times/week) lowered systolic BP 11
mmHg on follow-up at 12 weeks whereas systolic BP decreased only2 mmHg in the control group(35)
- Researchers of an RCT (N = 40;mean age 71 years) conducted in South Korea found that an integrated health education
plus individually tailored exercise program for 12 weeks significantly reduced systolic BP in community-dwelling adults
with prehypertension (mean resting BP 135/80 mmHg), versus no exercise program. The exercise group also improved
their health-related quality of life (Medical Outcomes Study Short-Form [SF-36])compared to controls(36)
• Resistance exercise training
–The American Heart Association position statement on resistance training states that lifting weights at a moderate
intensity (40–60% of 1-RM) is safe and effective for persons with controlled HTN(28)
–General guidelines recommend moderate-intensity dynamic weight lifting, preferably on machines, 2 or more
nonconsecutive days per week(10,18,28)
–Resistance training should probably be initially combined with aerobic training to offset the increased arterial stiffness
(pulse wave velocity) that has been reported after resistance exercise alone(37)
–Authors of a study (20 women, mean age = 66.8 who were normotensive on BP medication) in Brazil found that
progressive weight-lifting (9 exercises, 3 times per week, 12 weeks) at 60% of 1-RM (4 weeks), 70% of 1-RM (4 weeks),
and 80% of 1-RM (4 weeks) was associated with significantly decreased systolic BP (–10.5 mm Hg)(38)
–Researchers of an RCT (N = 104) in the United States found that a 6-monthprogram of combined aerobic (45 minutes at
60% to 90% of maximum HR) and resistance training (2 sets of 7 exercises, 10–15 repetitions at 50% of 1-RM for 3 days/
week) did not lower systolic BP more in the exercise group than in the controls(16)
–Researchers who conducted an RCT (N = 48 men, 65-75 years of age) in Portugal found that both aerobic training
and combined aerobic-resistance training programs (moderate-to-vigorous intensity, 3 days/week for 9 months) were
associated with significant reductions in systolic BP and diastolic BP(48)
–Caveats related to resistance exercise
- The intensity of resistance training in older adults should perhaps be low to moderate or “light” to prevent an increase in
arterial stiffness(37)
- Moderate resistance training performed on the same day as aerobic exercise might attenuate in older adults the reduction
in systolic BP associated with aerobic training (16)
- Resting systolic BP might fall up to 10 mmHg in the first hour after a resistance exercise session compared to the
pre-exercise value, based on a study of 30 older adult women with HTN in Brazil(39)
• Static handgrip exercise training: Isometric handgrip training (four 2 minute static contractions at 30% maximal voluntary
contraction, 3 days per week for 10 weeks) significantly decreased systolic BP (–19 mmHg) in hypertensive older adults on
medication in a study conducted in Canada.(40) Diastolic BP did not change significantly (7 mmHg)
• Breathing training: In a small study conducted in Thailand researchers compared the effects of loaded breathing exercises
(six breaths per minute with 18 cm H2O in a threshold breathing device) and unloaded breathing exercises (six breaths per
minute with no load) on blood pressure in older adult subjects (aged 62 to 70 years) with isolated systolic HTN to a control
group that did no breathing exercises. The subjects were trained to do the breathing exercises for 8 weeks at home. At the
end of this time period, researchers found that systolic BP was significantly reduced compared to pre-treatment readings
(and compared to the control group) for both loaded and unloaded breathing groups. The reduction in systolic BP was
significantly greater for the loaded group as compared to the unloaded group. At follow-ups, the BP of those in the loaded
group remained below preintervention levels for 6 weeks; 2 weeks for the unloaded group(62)
• Independent exercise/recreational activity: Authors of a prospective study of 3,193 adults conducted in France, (mean
age = 74 years)with HTN and coronary heart disease who were followed for 6 months found that regular unsupervised
recreational physical activity (self-paced, > 20 min, > 3 times per week) was associated with significantly fewer new major
cardiovascular events compared to those who did not engage in regular exercise(41)
.
Problem Goal Intervention Expected Progression Home Program
Elevated resting Reduce systolic Exercise therapy Start with intermittent, Provide the patient with
BP associated with and diastolic BP; _ low-intensity exercises a home program to
reduced physical improve aerobic See program and gradually progress perform independently
fitness; increased fitness, strength, and components in the intensity and throughout treatment
cardiovascular physical capacity; Treatment Summary duration of exercises to and after discharge
risk secondary to increase daily physical above for: the maintenance phase _
insufficient physical activity, decrease risk _ _
activity of cardiovascular Aerobic exercise
disease _
_
Resistance exercise
_
_
Static handgrip exercise
_
_
Recreational activity

Desired Outcomes/Outcome Measures

› Desired outcomes with outcome measures
• Reduced severity of existing HTN
–Resting systolic and diastolic BP measurements
• Increased aerobic fitness
–Symptom-limited graded cycle-ergometer exercise test, 6MWT
• Increased strength
–MMT, weight-lifting, static handgrip
• Increased daily physical activity
–Physical activity questionnaire
• Improved health-related quality of life
–SF-36

Maintenance or Prevention
› Continue prescribed exercise training
› Weight reduction and control, as prescribed
› Dietary program, as prescribed

Patient Education
› Information from the National Institute of Aging at the National Institutes of Health (NIH) on HTN can be found at
https://www.nia.nih.gov/health/high-blood-pressure
› Specific information for older adults with hypertension can be found at the Health in Aging website at
http://www.healthinaging.org/aging-and-health-a-to-z/topic:high-blood-pressure/info:unique-to-older-adults/
› For general information about the prevention and treatment of hypertension, see the American Society of Hypertension
website at http://www.ash-us.org/ASH-Foundation-Overview.aspx
 Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
1. US Department of Health and Human Services. National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Published August 2004. Accessed September 27, 2017. (G)
2. 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(8):1003-1010. (R)
3. Carretero OA, Oparil S. Essential hypertension. Part I: definition and etiology. Circulation. 2000;101(3):329-335. (R)
4. Lewington S, Clarke R, Qizilbash N, 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(9349):1903-1913. (M)
5. Acelajado MC, Oparil S. Hypertension in the elderly. Clin Geriatr Med. 2009;25(3):391-412. (R)
6. Musini VM, Tejani AM, Bassett K, Wright JM. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev. 2009;4:CD000028.
doi:10.1002/14651858.CD000028. (SR)
7. Aronow WS. Treatment of hypertension in the elderly. Geriatrics. 2008;63(10):21-25. (R)
8. Mazza A, Ramazzina E, Cuppini S, et al. Antihypertensive treatment in the elderly and very elderly: always “the lower, the better?”. Int J Hypertens. 2012;2012.
doi:10.1155/2012/590683. (RV)
9. Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA. 2005;294(4):466-472. (R)
10. Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray CA; American College of Sports Medicine. American College of Sports Medicine position stand. Exercise
and hypertension. Med Sci Sports Exerc. 2004;36(3):533-553. (G)
11. Sharman JE, Stowasser M; Australian Association for Exercise and Sports Science. Australian Association for Exercise and Sports Science position statement on exercise and
hypertension. J Sci Med Sport. 2009;12(2):252-257. (PP)
12. Elliott WJ. Systemic hypertension. Curr Probl Cardiol. 2007;32(4):201-259. (RV)
13. Cheitlin MD. Cardiovascular physiology: changes with aging. Am J Geriatr Cardiol. 2003;12(1):9-13. (RV)
14. Lim MA, Townsend RR. Arterial compliance in the elderly: its effect on blood pressure measurement and cardiovascular outcomes. Clin Geriatr Med. 2009;25(2):191-205. (RV)
15. Wang X, Keith JC, Jr, Struthers AD, Feuerstein GZ. Assessment of arterial stiffness, a translational biomedical marker system for the evaluation of vascular risk. Cardiovasc
Ther. 2008;26(3):214-223. (RV)
16. Stewart KJ, Bacher AC, Turner KL. Effect of exercise on blood pressure in older persons: a randomized controlled trial. Arch Intern Med. 2005;165(7):756-762. (RCT)
17. Madden KM, Lockhart C, Cuff D, Potter TF, Meneilly GS. Aerobic training-induced improvements in arterial stiffness are not sustained in older adults with multiple
cardiovascular risk factors. J Hum Hypertens. 2013;27(5):335-339. doi:10.1038/jhh.2012.38. (RCT)
18. Aizawa K, Shoemaker JK, Overend TJ, Petrella RJ. Effects of lifestyle modification on central artery stiffness in metabolic syndrome subjects with pre-hypertension and/or
pre-diabetes. Diabetes Res Clin Pract. 2009;83(2):249-256. (R)
19. van Bussel BCT, Henry RMA, Schalkwijk CG, Dekker JM, Nijpels G, Stehouwer CDA. Low-grade inflammation, but not endothelial dysfunction, is associated with greater
carotid stiffness in the elderly: the Hoorn Study. J Hypertens. 2012;30(4):744-752. doi:10.1097/HJH.0b013e328350a487. (R)
20. Butler J, Kalogeropoulos AP, Georgiopoulou VV, et al. Systolic blood pressure and incident heart failure in the elderly. The Cardiovascular Health Study and the Health, Ageing
and Body Composition Study. Heart. 2011;97(16):1304-1311. (R)
21. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and
Wilkins; 2010. (GI)
22. Dusek JA, Hibberd PL, Buczynski B, et al. Stress management versus lifestyle modification on systolic hypertension and medication elimination: a randomized trial. J Altern
Compliment Med. 2008;14(2):129-138. (RCT)
23. Bejan-Angoulvant T, Saadatian-Elahi M, Wright JM, et al. Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized
controlled trials. J Hypertens. 2010;28(7):1366-1372. (M)
24. Wang J, Xu J, Zhou C, et al. Improvement of arterial stiffness by reducing oxidative stress damage in elderly hypertensive patients after 6 months of atorvastatin therapy. J Clin
Hypertens. 2012;14(4):245-249. doi:10.1111/j.1751-7176.2012.00600.x. (R)
25. Igase M, Kohara K, Miki T. The association between hypertension and dementia in the elderly. Int J Hypertens. 2012;2012. doi:10.1155/2012/320648. (RV)
26. Javed F, Aziz EF, Sabharwal MS, et al. Association of BMI and cardiovascular risk stratification in the elderly African-American females. Obesity. 2011;19(6):1182-1186. (R)
27. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE. The six-minute walk test: a useful metric for the cardiopulmonary patient. Intern Med J. 2009;39(8):495-501.
doi:10.1111/j.1445-5994.2008.01880.x. (RV)
28. Williams MA, Haskell WL, Ades PA, et al; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Nutrition, Physical Activity, and
Metabolism. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on
Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(5):572-584. (PP)
29. Acelajado MC, Calhoun DA. Resistant hypertension: who and how to evaluate. Curr Opin Cardiol. 2009;24(4):340-344. (RV)
30. Rosano C, Longstreth WT, Jr, Boudreau R, et al. High blood pressure accelerates gait slowing in well-functioning older adults over 18-years of follow-up. J Am Geriatr Soc.
2011;59(3):390-397. (R)
31. Hodgson JM, Zhu K, Lewis JR, et al. Long-term effects of a protein-enriched diet on blood pressure in older women. Br J Nutr. 2012;107(11):1664-1672. doi:10.1017/
S0007114511004740. (RCT)
32. Omboni S, Malacco E, Mallion J-M, Volpe M, Zanchetti A; Study Group. Twenty-four hour and early morning blood pressure control of olmesartan vs. ramipril in elderly
hypertensive patients: pooled individual data analysis of two randomized, double-blind, parallel-group studies. J Hypertens. 2012;30(7):1468-1477. doi:10.1097/
HJH.0b013e32835466ac. (RCT)
33. Rodriguez D, Fernandes da Costa R, Vieira AS, et al. Efficiency of two sessions of jogging per week for the reduction of the blood pressure in previously sedentary
hypertensive women. Fit Perf J. 2008;7(3):169-174. (R)
34. Huang G, Thompson CJ, Osness WH. Influence of a 10-week controlled exercise program on resting blood pressure in sedentary older adults. J Appl Res. 2006;6(3):189-195.
(RCT)
35. Madden KM, Lockhart C, Potter TF, Cuff D. Aerobic training restores arterial baroreflex sensitivity in older adults with type 2 diabetes, hypertension, and hypercholesterolemia.
Clin J Sport Med. 2010;20(4):312-317. (RCT)
36. Park YH, Song M, Cho BL, Lim JY, Song W, Kim SH. The effects of an integrated health education and exercise program in community-dwelling older adults with hypertension:
a randomized controlled trial. Patient Educ Couns. 2011;82(1):133-137. (RCT)
37. Collier SR, Kanaley JA, Carhart R. Effect of 4 weeks of aerobic or resistance exercise training on arterial stiffness, blood flow and blood pressure in pre- and stage-1
hypertensives. J Hum Hypertens. 2008;22(10):678-686. (R)
38. Terra DF, Mota MR, Rabelo HT, et al. Reduction of arterial pressure and double product at rest after resistance exercise training in elderly hypertensive women. Arq Bras
Cardiol. 2008;91(5):274-279. (R)
39. Cunha RM, Jardim PC. Subacute blood pressure behavior in elderly hypertensive women after resistance exercise session. J Sports Med Phys Fitness. 2012;52(2):175-180.
(R)
40. Taylor AC, McCartney N, Kamath MV, Wiley RL. Isometric training lowers resting blood pressure and modulates autonomic control. Med Sci Sports Exerc. 2003;35(2):251-256.
(R)
41. Mourad J-J, Danchin N, Puel J, et al. Cardiovascular impact of exercise and drug therapy in older hypertensives with coronary heart disease: PREHACOR study. Heart
Vessels. 2008;23(1):20-25. (R)
42. Liu L, An Y, Chen M, et al. Trends in the prevalence of hospitalization attributable to hypertensive diseases among United States adults aged 35 and older from 1980 to 2007.
Am J Cardiol. 2013;112(5):694-9. doi:10.1016/j.amjcard.2013.04.050. (R)
43. 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 (JNC8). JAMA. 2014;311(5):507-20. doi:10.1001/jama.2013.284427. (G)
44. Banach M, Bromfield S, Howard G, et al. Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking
antihypertensive medication. Int J Cardiol. 2014;176(1):219-26. doi:10.1016/j.ijcard.2014.07.067. (R)
45. Canavan M, Smyth A, Bosch J, et al. Does lowering blood pressure with antihypertensive therapy preserve independence in activities of daily living? A systematic review. Am J
Hypertens. Advance online publication. August 25, 2014;(pii):hpu131. (SR)
46. 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(1):30-5.
doi:10.1161/HYPERTENSIONAHA.114.03510. (R)
47. Cornelissen VA, Fagard RH. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension.
2005;46(4):667-75. (M)
48. Sousa N, Mendes R, Abrantes C, Sampaio J, Oliveira J. A randomized 9-month study of blood pressure and body fat responses to aerobic training versus combined aerobic
and resistance training in older men. Exp Gerontol. August 2013;48(8):727-33. doi:10.1016/j.exger.2013.04.008. (RCT)
49. Peng J, Lu F, Wang Z, et al. Excessive lowering of blood pressure is not beneficial for progression of brain white matter hyperintensive and cognitive impairment in elderly
hyperintensive patients: 4-year follow-up study. J Am Med Dir Assoc. 2014;15(12):904-910. doi:10.1016/j.jamda.2014.07.005. (R)
50. Oza R, Garcellano M. Nonpharmacologic management of hypertension: What works?. Am Fam Physician. 2015;91(11):772-776. (RV)
51. Schroeder LM, Patel R. Hypertension, essential. In: Domino FJ, ed. The 5-Minute Clinical Consult Standard 2016. 24th ed. Philadelphia, PA: Wolters Kluwer Health;
2015:546-547. (GI)
52. Brown PJ, Sneed JR, Rutherford BR, Devanand DP, Roose SP. The nuances of cognition and depression in older adults: The need for a comprehensive assessment. Int J
Geriatr Psychiatry. 2014;29(5):506-514. doi:10.1002/gps.4033. (R)
53. Hajjar I, Sorond F, Lipsitz LA. Apolipoprotein E, carbon dioxide vasoreactivity, and cognition in older adults: Effect of hypertension. J Am Geriatr Soc. 2015;63(2):276-281.
doi:10.1111/jgs.13235. (R)
54. Goeres LM, Williams CD, Eckstrom E, Lee DS. Pharmacotherapy for hypertension in older adults: A systematic review. Drugs Aging. 2014;31(12):897-910.
doi:10.1007/s40266-014-0219-8. (SR)
55. Daskalopoulou SS, Rabi DM, Zarnke KB, et al. The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis,
assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2015;31(5):549-568. doi:10.1016/j.cjca.2015.02.016. (G)
56. Briasoulis A, Agarwal V, Tousoulis D, Stefanadis C. Effects of antihypertensive treatment in patients over 65 years of age: A meta-analysis of randomised controlled studies.
Heart. 2014;100(4):317-323. doi:10.1136/heartjnl-2013-304111. (M)
57. Rosendorff C, Lackland DT, Allison M, et al; American Heart Association; American College of Cardiology; American Society of Hypertension. Treatment of hypertension in
patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension.
Hypertension. 2015;65(6):1372-1407. doi:10.1161/HYP.0000000000000018. (G)
58. Ferdinand KC, Walsh MN, Merz NB, Pepine CJ. 2014 hypertension recommendations from the Eighth Joint National Committee Panel Members raise concerns for elderly
black and female population. J Am Coll Cardiol. 2014;64(4):394-402. doi:10.1016/jacc.2014.06.014. (G)
59. Li Y, Hanssen H, Cordes M, Rossmeissl A, Endes S, Schmidt-Trucksass A. Aerobic, resistance and combined exercise training on arterial stiffness in normotensive and
hypertensive adults: a review. Eur J Sport Sci. 2015;15(5):443-457. doi:10.1080/17461391.2014.955129. (SR)
60. Machado ALG, Lima FET, Cavalcante TF, de Araujo TL, Vieira NFC. Instruments of health literacy used in nursing studies with hypertensive elderly. Revista Gaucha de
Enfermagem. 2015;35(4):101-107. doi:10.1590/1983-1447.2014.04.45139. (SR)
61. Osborn CY, Paasche-Orlow MK, Bailey SC, Wolf MS. The mechanisms linking health literacy to behavior and health status. Am J Health Behav. 2011;35(1):118-28. (R)
62. Sangthong B, Ubolsakka-Jones C, Pachiarat O, Jones DA. Breathing training for older patients with controlled isolated systolic hypertension. Med Sci Sports Exerc. September
2016;48(9):1641-1647. doi:10.1249/MSS.0000000000000967. (R)