Gerontocardiology: Focusing on hypertensive elderly patients

The current European guidelines (from 2018) recommend a mild reduction of blood pressure in older patients. But other studies advocate alternatives.

Key issues about older patients with hypertension:

Old age is not homogeneous: every patient is different

Arterial hypertension affects more than one in two people over the age of 65, and the trend is rising. Both women and men are affected, although men seem to suffer from the disease more frequently. Especially in old age, the treatment of hypertension is often complicated by comorbidities such as diabetes, heart failure or wear and tear diseases. In addition, the elderly react differently to antihypertensive medication than younger patients. This is also associated with long-term complications such as kidney damage or falls.

Nevertheless, it is particularly important in old age to find individualised therapies, because not every elderly patient is the same. For example, biological age in particular must be taken into account. There are 80-year-olds who still participate very actively in life, while others of the same age are in need of care.

Hypertension increases risk of dementia

Every physician knows that untreated hypertension leads to organ damage in the long term, with the cardiovascular system being particularly affected. Heart attacks, strokes and increased mortality are the result. But not only that: a recent study from March 2023 has proven that hypertensive patients suffer from vascular dementia significantly more often than healthy people.

Current therapy recommendations are being reviewed

Therefore, it is important to treat hypertension also in older people. The current European guidelines will be revised in June 2023. Currently, it is recommended that systolic pressure should not be lowered until 140 mmHg in people between 65 and 79 years of age. For patients aged 80 and older, this is even higher at 160 mmHg. Diastolic blood pressure should not exceed 90 mmHg in either group.

The target values for the systolic R-R are between 130 and 139 mmHg - if this is tolerated by the affected person.

There is little data on elderly patients

Unfortunately, the data on outcomes for older people is rather limited. However, a study from 2008 argues clearly that those with the disease benefit significantly from therapy - with a significantly reduced risk of stroke, heart failure, and death.

Older people also benefit from lower R-R values

The most recent data available come from China. In one study, standard therapy, as recommended in the European guidelines, was compared with intensified blood pressure reduction. Here, the target blood pressure was between 110 and 130 mmHg. The result: people whose blood pressure was set lower had a risk of cardiovascular events or mortality that was reduced by about 25 %.

Although hypotension occurred more frequently in the group, it was not significantly more often associated with secondary complications such as kidney damage or falls.

Conclusion for medical practice: Therapy is important

Older people also benefit from treatment of hypertension. Intensified treatment seems to be possibly associated with better outcomes. However, an individualised approach is important for this patient group to achieve the best possible results.

Experts estimate that about 30 % to 40 % of hypertensives are not treated. Of those who take antihypertensive medication, about 40 % to 60 % are not sufficiently well controlled. This makes it more important to find an adequate, targeted treatment that is tailored to the patient.


Weil, Joachim, Prof. Dr., Sana (Kliniken Lübeck GmbH, Lübeck, Germany). Session: "Challenges in cardiological therapy: The old patient in hypertension therapy." (Original German title: Herausforderungen in der kardiologischen Therapie: Der alte der Hochdrucktherapie). 89th Annual Conference of the German Society of Cardiology (German acronym: DGK). Mannheim,  Germany. 14 April 2023