High blood pressure in older adults: targets, treatment and safety

The NHS says high blood pressure puts extra strain on blood vessels, the heart, brain, kidneys and eyes, and untreated it raises the risk of heart disease, heart attacks, strokes, heart failure, kidney disease and vascular dementia. Lowering it even by a small amount helps reduce these risks. Age itself is a risk factor: you are more likely to develop high blood pressure as you get older.

High blood pressure usually causes no symptoms, so it is found by measurement. The NHS suggests anyone aged 40 or over who has not had a check for more than 5 years should have one, and many pharmacies offer free checks for those over 40.

NICE guideline NG136 says that if clinic pressure is 140/90 or higher, a second reading is taken, and a third if they differ substantially, recording the lower of the last two. If the clinic reading is between 140/90 and 180/120, ambulatory monitoring is offered to confirm the diagnosis, or home monitoring if ambulatory monitoring is unsuitable or not tolerated. Home or ambulatory results are about 5 mmHg lower than clinic readings.

NICE adds that in people with symptoms of postural hypotension, including falls or postural dizziness, blood pressure should be measured lying down (or seated if lying is inconvenient) and again after standing for at least 1 minute. A fall of 20 mmHg or more in systolic, or 10 mmHg or more in diastolic, prompts a look at likely causes including current medicines.

NICE gives separate clinic targets by age. For people under 80 with hypertension it is below 140/90. For people aged 80 and over it is below 150/90, with lower targets where chronic kidney disease with significant protein in the urine is present. These are general targets; individual decisions consider frailty, other conditions and preferences.

For people over 80 with stage 1 hypertension (clinic 140/90 to 159/99), NICE says to consider drug treatment alongside lifestyle advice if clinic pressure is over 150/90, using clinical judgement for people with frailty or multimorbidity. Individual cardiovascular risk and preferences for treatment, including no treatment, should be discussed.

The NHS says there are many types of blood pressure medicine, and the one recommended depends on how high your blood pressure is, your age and your ethnicity; most are taken as tablets once a day and some people need more than one. NICE says for step 1 treatment a calcium-channel blocker is offered to adults aged 55 or over without type 2 diabetes, or of Black African or African-Caribbean origin without type 2 diabetes; if it is not tolerated, for example because of ankle swelling, a thiazide-like diuretic is offered. If there is evidence of heart failure a thiazide-like diuretic is offered. For older people, NICE notes that salt substitutes containing potassium chloride should not be used, particularly with some blood pressure medicines or kidney disease.

Medicine reviews matter in later life: some medicines can lower blood pressure on standing, so any new dizziness or fall after a dose change should be reported rather than doses being changed alone.

The NHS lists a healthy balanced diet, regular exercise (at least 150 minutes a week), losing weight if overweight, not eating too much salt, no more than 14 alcohol units a week on a regular basis, less caffeine and not smoking. NICE adds that calcium, magnesium or potassium supplements should not be used to lower blood pressure. Exercise is adapted to ability, and walking, chair-based exercise or balance classes can all contribute.

Call 999 for sudden chest pain that does not go away or spreads to the arm, neck, jaw or back, or for sudden weakness, facial droop or slurred speech. The NHS advises NHS 111 if you often have headaches or blurred vision or have chest pain that comes and goes. A fall, faint or sudden dizziness on standing should be raised with a GP, since it may mean medicines or blood pressure need adjusting.