As we age, our bodies undergo numerous changes, and one of the most significant is the impact on our cardiovascular system. Blood pressure, a crucial indicator of heart health, tends to increase with age, making it essential to understand the relationship between aging and hypertension. This article will explore the expected changes in blood pressure as we grow older, the reasons behind these changes, and how to manage blood pressure effectively in later life.
The Aging Cardiovascular System
Changes in Blood Pressure with Age
As we age, our blood pressure typically follows a predictable pattern:
- Systolic blood pressure (SBP) shows a continuous increase between the ages of 30 and 84 years or over.
- Diastolic blood pressure (DBP) increases until the fifth decade and then slowly decreases from the age of 60 to at least 84 years of age.
- This leads to a steep rise in pulse pressure (PP) with aging.
These changes result in a high prevalence of hypertension among older adults. In fact, over 70 percent of people age 60 and older have high blood pressure.
Physiological Reasons for Increased Blood Pressure
The increase in blood pressure with age is primarily associated with structural changes in the arteries, particularly large artery stiffness. This stiffening is mainly due to arteriosclerotic structural alterations and calcification, leading to:
- Earlier reflected pressure waves from the arterioles towards the heart during blood pressure wave propagation.
- These pressure waves arriving back during systole, increasing central SBP and widening PP.
Defining Hypertension in Older Adults
The definition and treatment thresholds for hypertension in older adults have evolved over time. Different guidelines provide varying recommendations:
| Guideline | Definition of Older Patients | BP Threshold for Treatment | Blood Pressure Target |
|---|---|---|---|
| ACC/AHA 2017 | ≥65 years | ≥130/80 mmHg | <130/80 mmHg |
| ACP/AAFP 2017 | ≥60 years | SBP ≥150 mmHg | SBP <150 mmHg |
| ESC/ESH 2018 | Elderly 65-79 years, Very Old ≥80 years | Elderly ≥140/90 mmHg, Very Old ≥160/90 mmHg | SBP 130-139 mmHg, DBP 70-79mmHg |
It’s important to note that these guidelines acknowledge the importance of blood pressure treatment in older adults to lower atherosclerotic cardiovascular disease (ASCVD) risk, but recommend a cautious approach and close monitoring of these patients.
Health Impacts of Hypertension in Older Adults
Uncontrolled hypertension in older adults can lead to several serious health complications:
- Increased risk of cardiovascular events and mortality
- Higher incidence of stroke
- Development of heart failure
- Kidney disease
- Cognitive decline and dementia
Managing Hypertension in Older Adults
Lifestyle Modifications
Non-pharmacological interventions can be highly effective in managing blood pressure in older adults:
- Dietary sodium reduction: Reduce intake to ≤2.4 g sodium or ≤6 g sodium chloride per day.
- Physical activity: Engage in ≤30 minutes of aerobic activity per day, most days of the week.
- Moderate alcohol intake: Limit to ≤2 drinks per day for men and ≤1 drink per day for women.
- Weight management: For obese adults, aim for weight loss to ideal body weight, which may reduce blood pressure by 5 mmHg.
- DASH diet: Consider a diet rich in fruits, vegetables, whole grains, and low-fat dairy.
Pharmacological Treatment
When lifestyle modifications are insufficient, medication may be necessary. The choice of antihypertensive drugs should be based on individual patient factors:
- Thiazide diuretics: Often recommended as first-line therapy due to their effectiveness and generally good tolerability.
- Angiotensin-converting enzyme (ACE) inhibitors: Effective in lowering BP and reducing cardiovascular outcomes.
- Angiotensin receptor blockers (ARBs): Considered an alternative first-line treatment when a diuretic is contraindicated.
- Calcium channel blockers (CCBs): Effective in lowering BP and reducing cardiovascular outcomes.
Beta-blockers are generally not recommended as first-line treatment in older adults due to inferior benefits compared to other drug classes.
Special Considerations for Older Adults
Orthostatic Hypotension
Orthostatic hypotension (OH) is a common concern in older adults, defined as a sustained reduction of SBP >20 mmHg or DBP >10 mmHg within 3 minutes of standing. Management strategies include:
- Avoidance of alcoholic beverages
- Slowly rising from sitting to standing
- Slow deep breathing
- Eating small, frequent meals
Frailty and Comorbidities
For elderly adults with a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach are crucial in deciding the intensity of BP lowering and the choice of antihypertensive drugs.
Conclusion
As we age, changes in our cardiovascular system lead to an increased likelihood of developing hypertension. However, with proper management through lifestyle modifications and, when necessary, appropriate medication, older adults can effectively control their blood pressure and reduce their risk of cardiovascular complications.
