General Approach to Therapy and Monitoring

As is the case in the approach to treatment of other chronic diseases in an older patient, it is important to define goals of antihypertensive therapy that are individualized to a given patient. In this context, the benefits as well as the potential risks of any therapeutic intervention need to be balanced to achieve, on the one hand, an overall goal of preventing the morbidity and mortality associated with high blood pressure without adversely affecting the patient's functional performance or quality of life on the other. A therapeutic approach directed toward reduction of systolic blood pressure to below 135 to 140 mmHg and diastolic blood pressure to less than 85 to 90 mmHg should be developed utilizing treatments least likely to produce adverse effects. For individuals with markedly elevated systolic blood pressure, an intermediate target, such as 160 mmHg, may be appropriate.

The major focus of treatment should be on the systolic blood pressure and pulse pressure because, among older hypertensive individuals, these are stronger predictors of adverse outcomes than is the diastolic blood pressure. In view of the concerns about the J-shaped curve, it is important not to overtreat with an intervention that produces an excessive reduction in diastolic blood pressure. With the exception of hypertensive urgencies and emergencies (discussed next), it is unnecessary and perhaps deleterious to attempt rapid reductions in blood pressure to achieve this target level of control.

In light of the age-associated pathophysiologic changes that result in impaired blood pressure homeostasis, too rapid a reduction in blood pressure may be associated with the development of symptomatic hypotension in some situations (e.g., postural or postprandial hypotension). Likewise, it is advisable to not make dosage adjustments or additions of other therapies too rapidly to avoid overtreatment. Once the patient's blood pressure has been controlled to an optimal level, it is appropriate to reevaluate the need for continued therapy. A reduction in dose or in some cases a trial period without antihypertensive medication (with close monitoring of the patient's home and office blood pressure) will help to minimize the possibility of overtreatment of blood pressure.

Another general approach to therapy is to continuously assess not only the response to therapy, but also the development of adverse effects of treatment. The development of orthostatic hypotension is an adverse effect that may occur with any antihypertensive medication, although central-acting agents and vasodilators are more commonly implicated in this regard. The symptoms of orthostatic hypotension may be atypical; rather than providing a history of postural unsteadiness, the older patient may cite generalized weakness or fatigue. Because orthostatic hypotension is common in hypertensive patients (its frequency increasing in parallel with the supine systolic blood pressure level), and given the often occult nature of its presenting symptoms, it is essential to determine supine and upright blood pressure measurements as part of routine monitoring of all older hypertensive patients.