Hypertension management in the elderly and the very elderly

Hypertension increases with age, with a very high prevalence in older patients. Since hypertension is a major contributor of cardiovascular diseases, this condition accounts for the majority of stroke and a relevant number of coronary artery disease cases in the older adults. Ageing is associated with frailty and multimorbidity, often associated with polypharmacy, which may complicate the management of hypertension. Specific diseases like diabetes and Parkinson disease associated with autonomic dysfunctions, and the frail condition, should be carefully considered in order to avoid orthostatic hypotension. Aortic stenosis, cardiac hypertrophy, heart failure, reduced glomerular filtration rate, arrhythmias such as atrial fibrillation, obstructive coronaropathies and cerebral vascular lesions constitute hemodynamic challenges and may be associated with increased adverse effects during anti-hypertensive treatments. Moreover, specific drugs and drug-drug interactions are associated with sides effects particularly deleterious in the older patients. The worsening of the state of health and the increase in the degree of frailty can result either as a consequence of target-organ-damage related to hypertension or caused by antihypertensive drugs. Therefore, in the older adults, a careful assessment of the individual risk/benefit profile and a personalized view of the patient is necessary to establish the appropriate blood pressure targets and the appropriate treatments.