Medical professionals are re-evaluating how aggressively to treat high blood pressure in older adults, according to a Mar. 20 report. The discussion comes as new guidelines and recent studies suggest tighter control of systolic blood pressure may benefit both heart and brain health.
The issue is important because high blood pressure, or hypertension, is common among older adults and has been linked to increased risk of cardiovascular disease and cognitive decline. Recent changes in medical guidelines have lowered the threshold for what is considered normal blood pressure, prompting questions about how low patients should aim.
Mark Supiano, a geriatrician at the University of Utah, described treating a 78-year-old patient whose initial blood pressure was above recommended levels despite medication. After lifestyle changes and additional medication, her readings improved. Supiano said that recent studies showing cognitive benefits from lower blood pressure "have tipped the scales" for older adults. "What's good for the heart is good for the brain," he said.
The American Heart Association and American College of Cardiology updated their guidelines in 2017 based on findings from the SPRINT trial, which showed that intensive treatment to bring systolic numbers below 120 reduced risks of heart attacks, strokes, and mortality so significantly that the study was stopped early. The most recent revisions now encourage even tighter control for those at cardiovascular risk and consider it reasonable for others as well.
Erica Spatz from Yale School of Medicine noted that blood pressure naturally rises with age due to arterial stiffening. She emphasized the importance of home monitoring since readings can vary throughout the day and are often higher in clinical settings due to anxiety or other factors. John Dodson of NYU Langone Health said he now treats his older patients more aggressively after evidence showed benefits even among frail individuals.
However, some experts remain cautious about overtreatment. Rita Redberg from University of California-San Francisco advises her patients on lifestyle modifications but does not always recommend medication for moderately elevated readings. She encourages patients to focus on enjoying life rather than frequent monitoring if their risk is not high.
While tighter control may offer population-level benefits such as reducing dementia rates, tools like the PREVENT calculator do not account for cognitive outcomes or apply well to those over 79 years old. For some patients with serious illnesses or advanced age, aggressive treatment may not be appropriate given potential side effects and limited benefit over time.
Supiano reflected on his patient's experience: "Maybe it gave her another couple of good years... Maybe it delayed the progression." He also wondered whether starting intensive treatment earlier would have made a difference.
