Page 8 - hypertension_newsletter8

REFLECTIONS
Hypertension
Hypertension Global Newsletter #8 2025

of timely initiation of antihypertensive treatment when indicated. Polypharmacy is a key consideration; in particular, cholinesterase
inhibitors, which are frequently prescribed in patients with Alzheimer’s disease, are associated with an increased risk of adverse drug
Hypertension
reactions when used concomitantly with diuretics or beta-blockers or non-dihydropyridine CCB. The overarching recommendation for
pharmacological treatment in this age group is to consider monotherapy initially, start with low doses, and uptitrate slowly to minimise
adverse drug events.

Twelve hot questions in the management of hypertension in patients aged 80+ years identified by ESH
WG on hypertension in older adults (high-level summaries)

1. How can one outline the mechanisms and consequences of systolic, diastolic, and pulse pressure evolution
with age?
The relationship between BP levels and CV risk in older adults is not linear and follows a U-shaped curve. This U-shaped
curve (i.e., high morbidity and mortality for very low BP levels) is explained by two different age-related processes: a
decrease in DBP levels which reflects high arterial stiffness that many individuals develop after the age of 65 years, and a
decrease in SBP levels occurs generally very late in life due to multimorbidity and marked frailty.
2. Is it useful to evaluate global cardiovascular risk in very old adults?
Evaluating CV risk in very old adults is useful, particularly for guiding primary prevention in those without established CVD.
In addition, a comprehensive geriatric-based evaluation is essential to guide management decisions in these older adults
since individualised decisions are often needed.

3. What is the impact of neurocognitive disorders in the management of hypertension?
Neurocognitive disorders significantly impact hypertension management by necessitating early cognitive screening, careful
drug selection, and individualised treatment strategies that balance the risks and benefits, especially in frail, older adults
with dementia, where treatment decisions must consider functional status, potential adverse effects, and may benefit from
the involvement of caregivers.
4. What is the impact of non-cardiovascular drugs on blood pressure variations?
In older adults being treated for hypertension, management decisions should take into account accurate information on use
of non-cardiovascular drugs/supplements to check a possible interference on BP management related to their use, focusing
on both the potential hypertensive and hypotensive effects.
5. What are the considerations for 24-h ambulatory blood pressure monitoring and self-monitoring of BP in
older adults?
In adults aged 80 and over, ambulatory and home BP monitoring can offer valuable insights beyond office measurements but
must be used cautiously due to practical and cognitive challenges, and should be used to complement office BP readings.
6. How to deal with the high blood pressure variability (postural variations, postprandial, etc.)?
In older adults, high BP variability (often driven by age-related changes and comorbidities) should be managed through
routine standing BP checks, careful medication use, and lifestyle strategies to prevent hypotensive episodes and guide
individualised treatment.
7. How to assess frailty in patients with hypertension? From the concept to the everyday clinical practice
Frailty in hypertensive patients (especially those 80+ or with multimorbidity) should be routinely assessed using simple
validated tools like the Clinical Frailty Scale, with treatment tailored accordingly and referral to geriatrician considered for
high frailty levels.
8. Are there differences in the management of hypertension between men and women in older age?

In older adults, especially women who make up most hypertensive octogenarians, BP control is often poorer than in men.
While no sex-specific antihypertensive treatment guidelines exist, older women may benefit from tailored therapy due to
differences in drug responses, comorbidities, and a higher risk of adverse effects.

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