August 4, 2026
Management of Hypertension in Older Adults
By Sumathi Devarajan, MD, and Molly McCulloch
Background
A 94-year-old living in an assisted living facility with a history of pulmonary embolism, osteoarthritis, atrial fibrillation, history of hypotension, and now with new onset hypertension diagnosed at age 91, has been treated with an angiotensin converting enzyme inhibitor initially (lisinopril 15 mg), to which 12.5 mg of hydrochlorothiazide was added for optimal blood pressure control.
This inspired us to review the evidence for blood pressure management in older adults and so I had my 4th year medical student do a clinical inquiry on the geriatric elective rotation.
These are her findings.
Clinical question: For adults 65 years and older with late-onset hypertension, what blood pressure (BP) targets and treatments reduce the risk of cardiovascular events while minimizing harm?
Evidence suggests that intensive control of systolic BP to less than 130 mmHg significantly reduces cardiovascular (CV) events in older adults.1-3,6 The definition of CV events varies in the literature, but includes stroke, acute coronary syndrome, heart failure, myocardial infarction, and cardiovascular death.1,3,6 In a selected population of healthy adults, the benefit of systolic BP control to less than 120 mmHg is, overall, greater than the harm.3,7 However, in frail/very old patients (typically 80 years or older, functionally impaired, multimorbidity, polypharmacy), individualized targets and deprescribing (discontinuing or reducing one or more medications when risks outweigh benefits) are indicated,5,10 as tight systolic BP control modestly increases the risk of adverse events (hypotension, syncope, acute kidney injury [AKI]).3,5
BP targets in older adults
The STEP (Strategy of Blood pressure Intervention in the Elderly Hypertensive Patients), STEP follow-up, and SPRINT (Systolic Blood Pressure Intervention Trial) follow-up studies highlighted optimal systolic BP targets for older adults.
In the original STEP trial, systolic BP targets of 110-129 mmHg (intensive control) were compared to targets of 130-149 mmHg. In STEP, 8,511 adults, ages 60 to 80 years with hypertension were enrolled and CV events were defined as stroke, acute coronary syndrome, heart failure, revascularization, and CV death. Results showed a 26% decrease in CV events in the intensive control group, with no major increase in serious adverse events. Overall, authors concluded that targeting a systolic BP of 120-130 mmHg safely reduces CV events in older adults.1 Furthermore, the STEP Long-Term Follow-up study, which followed patients for 6.1 years after intervention, compared sustained intensive control versus delayed intensive control and showed that starting intensive control earlier produced greater long-term cardiovascular benefit, with an 18% reduction in CV events when intensive control was started early.2
In the SPRINT trial, systolic BP targets below 120 mmHg were compared to targets below 140 mmHg. The population included 9,361 adults aged 50 years and older with high CV risk (defined as hypertension and high-risk criteria, including advanced age or comorbidities). There was a 25% decrease in CV events and 27% decrease in mortality, but adverse effects in the form of hypotension, syncope, and AKI increased. Overall, authors reported that treating to a target systolic BP of less than 120 mmHg reduces mortality, but treatment-related harms are increased, indicating that selection and monitoring of older patients for intensive BP control should be undertaken judiciously.3
Harms and treatment safety
The SPRINT, post hoc analysis of the SPRINT trial (frailty analysis), and Syst-Eur (Systolic Hypertension in Europe) Trials highlighted the harm, risk, and treatment safety aspects of antihypertensive therapy in older adults.5 In the SPRINT trial, higher rates of adverse events, noted above, were seen in the intensive treatment group (systolic BP goal <120 mmHg). For patients in this group, medications were adjusted to achieve this target, often with multiple antihypertensive medications.3
The frailty analysis demonstrated that CV events and mortality were reduced with intensive BP control, in the frailty group, even if serious adverse events did occur.5 The Syst-Eur trial demonstrated that when older adults are treated for hypertension, orthostatic hypotension did not increase, indicating that fall concerns may be overestimated in older adults with frailty receiving hypertension control.9
However, the decision to target intensive systolic BP treatment goals should be undertaken carefully following a thorough evaluation of the possible risks and benefits and an assessment of what matters to the patient, and should be made through shared decision-making with the patient and their family or caregivers.
Late-onset/aging implications
Specifically focusing on health implications of late-onset hypertension and the aging population were a SPRINT substudy examining cognitive outcomes, another SPRINT substudy focused on subclinical brain infarcts, and a SPRINT secondary analysis. Reboussin showed that intensive BP control overall reduces cognitive decline risk in older adults with hypertension, with a decrease in mild cognitive impairment (HR 0.87) and a decrease in composite cognitive impairment, but no statistically significant difference in the incidence of dementia alone.4 Kern concluded that the risk of cerebral ischemic injury in patients with subclinical brain infarcts was reduced with intensive BP control.8 Sun showed that older adults gain significant absolute benefit from achieving systolic BP goals of less than 130 mmHg, which reduces CV events without adverse renal consequences.6
Clinical Implications
Based on the summarized evidence, there are benefits of intensive blood pressure control (systolic BP goal <120 mmHg), but also risks and harms that can result. In some populations, this leads to benefits that outweigh the risks. In practice, BP control should be tailored to each patient, their clinical situation, underlying comorbidities, and preferences.
In otherwise healthy patients 65 years of age and older targeting systolic BP <130 mmHg is reasonable. For patients with high CV risk, clinicians should evaluate the risks and benefits of intensive treatment (systolic BP <120 mmHg). High CV risk is defined in the SPRINT studies as systolic BP 130-180 mmHg with clinical/subclinical CV disease, chronic kidney disease, Framingham risk 15% or greater, or age 75 years or greater.3,4,5,8 SPRINT did not include patients with diabetes, prior stroke, or symptomatic heart failure, suggesting that the results of the SPRINT studies should not be extrapolated to patients with these comorbidities.
For frail patients aged 80 years and older, relaxed hypertensive control and/or deprescribing of antihypertensive medications may be indicated to reduce the risk of hypotension, falls, and acute kidney injury. Frailty was defined in the SPRINT trial by the “frailty index” that included multiple health variables, comorbidities, cognitive status, and clinical symptoms. The OPTiMISE (Optimising Treatment for Mild Systolic Hypertension in the Elderly) Trial, defined frailty based on characteristics such as age 80 years or above, use of 2 or more antihypertensive medications, and multimorbidity. Patients should be monitored for the appearance of orthostasis and deterioration of renal function and these adverse consequences prevented during hypertensive treatment.10
Sumathi Devarajan is a faculty member in family medicine at OHSU and the course lead for the geriatric elective, helping guide students to explore clinical inquiry through patient encounters in ambulatory care.
Molly McCulloch is a 3rd-year medical student at Oregon Health and Science University and used her clinical experience with a patient in the geriatric elective rotation to look at HTN in older adults.
References for this article are available here.