High Blood Pressure and the Elderly
Medical opinion is currently a bit mixed about high blood pressure and the elderly. Most agree that most of the elderly have high blood pressure. However, many doctors and clinicians don’t agree about what to do about this, if anything.
High blood pressure and the elderly – what’s the issue?
You might wonder what the issue is here. Surely high blood pressure is high blood pressure whatever your age? Well, actually it turns out that it’s not quite that straightforward.
The fact is, having high blood pressure when you’re older can be different to having it when you’re younger in several ways. Firstly, elderly people actually tend to have a different kind of high blood pressure to younger people. Secondly, the effects of high blood pressure can be different in the elderly (whatever type of high blood pressure they have). As a result, what’s considered to be a healthy or ‘normal’ blood pressure for an elderly person may be different to what’s healthy for younger folk.
What’s a suitable treatment for high blood pressure also varies depending on the age of the person. Blood pressure-lowering medications (in fact, most medications) can have different or stronger effects on the elderly. Which means that different types or amounts of medications may be best. Or none at all.
Some of this might sound surprising. It was to me anyway, when I started researching this article! So here are more details.
Types of high blood pressure (and how they can vary with age)
The medical profession are increasingly realising that high blood pressure in older folks can be quite different than in younger folks. They’re finding that older people tend to experience increases mostly in systolic blood pressure. (The systolic blood pressure is the pressure against the walls of the blood vessels as the heart pumps blood out. It’s indicated in the first number in a blood pressure reading.) This is probably because as you get older your arteries are likely to stiffen to some extent, which pushes up systolic blood pressure.
However, in middle-aged folk, it’s diastolic blood pressure which tends to creep up. (Diastolic blood pressure is when the heart’s at rest, between pumps, and is indicated by the second number in a blood pressure reading.) As such, diastolic hypertension is potentially more dangerous for younger people and systolic hypertension for older folk.
As one hypertension expert puts it (Dr Logan from Mount Sinai hospital, Toronto, Canada),
“In a sense, you have almost two forms of hypertension. Up until about 10 years ago, doctors only paid attention to diastolic hypertension. Now we know it’s really systolic hypertension that matters in older people.”
What’s more, older folk can find their diastolic blood pressure drops, even as their systolic blood pressure rises! This condition’s called “wide pulse pressure”. Having this condition makes taking blood pressure medications particularly tricky. Most drugs bring down both aspects of your blood pressure, so any drug that brings down your systolic blood pressure will also bring down your diastolic blood pressure. Which means, if someone has wide pulse pressure, then their diastolic pressure can be pushed too low by medication.
Very low blood pressure can be dangerous. It can mean not enough blood is flowing back to the heart, which can deprive it of oxygen. This results in less blood being delivered to the brain, which can make you dizzy, putting you more at risk of falling. And of course having a fall can be very serious for an elderly person.
The effects of high blood pressure in the elderly – they’re not all bad!
First of all, for some elderly people, high blood pressure may not be particularly bad for them. It depends a lot on the person – their general state of health, other medical conditions they have, etc. Secondly, in some instances, having high blood pressure can actually be good for an older person.
High blood pressure may help some elderly people live longer
For example, whether high blood pressure puts you at higher risk of dying (sooner than you would otherwise) can depend on how physically well and active you are, or aren’t. Researchers at Oregon State University in the US found that high blood pressure is associated with increased mortality risk for older people who’re fairly physically robust. However, this is not the case for those who’re quite frail. In fact, in the very frail, high blood pressure appears even to be associated with a lower mortality risk! (The researchers measured frailty in terms of how fast the people in their study were able to walk, and the strength with which they were able to grip something.)*
One of the lead researchers, Professor Odden, suggests why this could be.
“As we age, our blood vessels lose elasticity and become stiff. Higher blood pressure could be a compensatory mechanism to overcome this loss of vascular elasticity and keep fresh blood pumping to the brain and heart.
And everyone ages differently – there is a profound difference between the physiological age of an 80-year-old man who golfs every day and someone who needs a walker to get around. So with [fitter older people such as] fast walkers, high blood pressure may be more indicative of underlying disease and not just a symptom of the aging process.”
High blood pressure in the elderly may help prevent dementia
Another interesting finding is that developing high blood pressure when you’re older may help prevent you from developing dementia.
Researchers at the University of California followed 559 people in their 90s for almost three years. Although none had dementia at the start of the study, some developed it during the three years. The researchers found that those who had normal blood pressure were more likely to develop dementia than those with high blood pressure. Specifically, they found that those who’d developed high blood pressure in their 80s were 42% less likely to develop dementia in their 90s compared to those with normal blood pressure. And those who developed high blood pressure in their 90s were 63% less likely to develop dementia than those with normal blood pressure.
Note that the key factor is when you develop high blood pressure. Having high blood pressure when you’re young or middle-aged actually makes you more likely to develop dementia later in life. It’s only developing high blood pressure very late in life which may protect you from dementia. And even then, the research currently indicates only an association between very late-onset high blood pressure and lower risk of dementia. In other words, it’s not yet clear if there’s a direct causal relationship between the two.
Nevertheless, these findings are intriguing. Especially since research from scientists in Israel suggests that blood pressure can affect one’s mental abilities in old age quite significantly.
High blood pressure in the elderly may aid mental clarity
Another possible benefit of high blood pressure for the elderly is that it may help mental clarity be maintained.
Israeli researchers, at Ben-Gurion University of the Negev, studied almost 500 elderly folk aged 70 – 85 to investigate links between blood pressure and mental abilities. They found that those with moderate high blood pressure performed better on tests of various mental tests (of memory, concentration, and visual retention) than those with normal blood pressure.
You can interpret this in different ways. Some would argue that the higher blood pressure is helping these folk maintain mental capacity. Others wouldn’t go that far but acknowledge that certainly these effects need to be taken into account when prescribing medications to the elderly.
Dr Michael A Weber (editor of the American Journal of Hypertension in which the paper was published) states,
“The important lessons from Israel is that when clinicians treat blood pressure in older people, they should be sensitive to the possibility that there could be subtle but important changes in how people react to that treatment. Doctors should be on the lookout and either ease back a little on the treatment or try different medications.”
Dr Weber points out that treating elderly people with strong medications could reduce their ability to think clearly, either due to the drugs themselves or the simple fact of their blood pressure being lowered too quickly.
He and Professor Corrada, of the Californian study, both postulate that high blood pressure may help ensure an adequate supply of blood to the brain for elderly people, thereby ensuring their brain gets enough oxygen. We are all experiencing changes in our blood pressure throughout the day, however older people’s brains can’t adapt as well to this, and high blood pressure may compensate for this.
No ‘one size fits all’ solution to high blood pressure in the elderly
There are a couple of things to be aware of here.
The effects of high blood pressure on a person’s health can change
One is that the effects of blood pressure on other aspects of our physical and mental functioning is highly dynamic. In other words, it changes – with age, with circumstances, with other health conditions that arise.
A good demonstration of this is the Israeli study mentioned above which found a positive association between high blood pressure and performance on mental tests. The Israeli researchers conducted a second follow-up study six years later with the same people. Or at least, with the three-quarters of them who were still alive.
In this case they found that generally mental performance was best in those whose systolic blood pressure had either significantly increased over the six years or significantly decreased (due to treatment), compared to those whose systolic blood pressure had remained fairly constant. The researchers thus suggest that both increase and decrease of systolic blood pressure can in some way beneficially affect mental functioning in the elderly. They also note that much more research needs to be done to understand this whole issue more clearly.
High blood pressure can still be very risky for the elderly
The other thing to note is that fact that high blood pressure is still considered to be generally risky for the health of elderly people. So discussing these possible helpful effects of high blood pressure in the elderly is not to suggest that high blood pressure isn’t potentially harmful. Nor to suggest that high blood pressure in the elderly shouldn’t be treated. Studies show that, in general, treating high blood pressure in the elderly can substantially reduce their risk of stroke and coronary heart disease, and their risk of dying sooner than later. (In the Israeli follow-up study, those who had died since the original study had, on average, higher systolic blood pressure than the surviving participants.)
The point here is that medical staff are increasingly recognising that high blood pressure, and high blood pressure medications, can have unexpected effects in some elderly people. And as such, these kinds of factors need to be taken into account when deciding what to do about high blood pressure and the elderly.
What is ‘normal’ blood pressure for an elderly person?
Partly in recognition of these issues, several health bodies in America have now changed their guidelines for treating blood pressure in the over 60s.** Rather than trying to get people’s blood pressure down to under 140/90, they recommend a slightly easier goal of 150/90.
(See our article here for a discussion on how ‘normal’ blood pressure is defined, and the implications of this: Normal vs Ideal Blood Pressure )
But should this goal be applied to all elderly people? Here the jury is still out.
What should be done about high blood pressure in the elderly?
The main point raised by the researchers in the studies discussed is that, when it comes to high blood pressure and the elderly, there’s no “one size fits all” approach. And when it comes to giving medications, we should be very careful.
Blood pressure-lowering medications – the pros and cons
The benefits of taking medicine to lower your blood pressure are surely obvious: lower blood pressure, and in turn, lower risk of heart disease, stroke, etc. Some have even suggested that the benefits are so good that blood pressure-lowering meds should be given to all the elderly. Even those who don’t have high blood pressure. Hard to believe? Read about it here: Study recommends high blood pressure drugs for the elderly
Everything is not quite as it may appear though. For starters, there’s some research suggesting taking blood pressure medications doesn’t actually increase your life. (There’s a discussion of this here: High blood pressure control – medication or natural methods? )
Some negative effects of blood pressure medications for the elderly
And then there’s the fact that blood pressure medications can have very different costs and benefits for the elderly. This has been made very clear by quite a few recent studies.
For example, a study by researchers at the Yale School of Medicine in the US found that older people who were taking blood pressure-lowering medications were more likely to have falls than those who weren’t on such medications, even though they also had high blood pressure.
High blood pressure drugs may increase the risk of falling
The study followed almost five thousand people over 70 who’d been diagnosed with high blood pressure for three years. They took note of those who suffered falls in those three years. There wasn’t a huge difference, mind you. About 8.5% of those on blood pressure meds had falls compared to 7.1% of those who weren’t on those meds. However, those falls were serious falls, that resulted in broken bones and emergency hospital visits. Which can have further serious knock-on consequences when you’re older.
One reason for this is that blood pressure-lowering medications can lower blood pressure too much and make you dizzy, especially if you’re elderly. Now, an observational study like this can’t prove cause and effect. However, researchers urged medics to take into account the possible harmful effects of high blood pressure medications when treating old people with high blood pressure.
Commenting on this study, geriatrician Dr Lisa Kernisan, says,
“Note that often the expected chance of benefit (e.g. avoiding a stroke or heart attack) is about the same as the risk of harm that was found in this research study.”
The importance of treating high blood pressure in the elderly on a case-by-base basis
The upshot is that it’s vital to treat every person’s blood pressure individually, rather than sticking slavishly to generic guidelines and goals.
Dr Howard LeWine, from Harvard Medical School, emphasises this,
“No matter what the guidelines say, your blood pressure treatment and goals should be tailored to you personally. For example, a very old and frail person is more likely to feel better and have less fall risk with fewer medications and a blood pressure higher than 150 or even 160.”
The researchers involved in the Oregon University studies of frailty and high blood pressure and the elderly made a similar point. They noted that very frail older folk don’t respond well to blood pressure-lowering medications. Nor do they appear to benefit from having their blood pressure lowered in this way.
And as Dr Weber pointed out (in discussing the Israeli research, above), bringing elderly people’s blood pressure down too quickly or “aggressively” with medications can create other problems, such as impairing their ability to think clearly.
As lead researcher in the Oregon studies, Chenkai Wu, notes,
“The research is basically saying older adults are not one single group, they’re very different in terms of their health status, and drugs may not have the same benefits for everyone.”
Or as geriatrician Dr Kernisan points out, “Less (medication) is often more (safety and well-being).”
(Actually, I’d recommend reading her article about high blood pressure and the elderly here:
The risks of treating high blood pressure in the elderly)
Then of course there’s the possibilities, discussed above that high blood pressure can even have some benefits for some elderly people.
Non-drug treatments for high blood pressure – a better solution?
A good solution in many cases may be to treat high blood pressure but not with medications. Or at least, to balance drug treatments with non-drug methods of lowering blood pressure too.
The expert panels who reviewed the blood pressure guidelines for elderly people (discussed above) actually recommend this. They advise that everyone with high blood pressure – or even close to high blood pressure – should make the kind of lifestyle changes that are known to help lower blood pressure. These include eating a healthier diet, losing weight if you’re overweight, and being more physically active. Obviously, as you get older, you might find you’re less mobile than in your younger years. However, there are many forms of exercise out there. As long as you’re careful, you can still improve your physical fitness and health. (For good advice, check out this article on how to exercise safely with hypertension.)
Lower your blood pressure naturally and safely
Reducing your blood pressure naturally really is a good option. You won’t be forcing your blood pressure down, possibly too much, with drugs, with all the risks that entails. You’ll just be taking out the unhealthy elements of your life which could be pushing your blood pressure up too much.
So how do you do this? What does it involve?
It’s pretty simple really. Making some adjustments to what you habitually eat and drink can make a big difference. Being active regularly can go a long way to reducing blood pressure. Stress, or just general tension, can also push up blood pressure. So making time for relaxing practices or activities can be very helpful. Or just simply making a wee bit of time to properly mentally unwind each day.
You can browse this website for more details on what kinds of things to eat and drink – or avoid eating and drinking – for lower blood pressure. (Quick tip – stop eating processed or ready-made foods and you’ll be doing yourself a huge favour.)
We’ve also got some tips on how to keep yourself active for a healthier heart and blood pressure. (Quick tip – even a daily short walk can be very beneficial for your blood pressure.)
And, if stress is a problem, you can read more about how to take the edge off it and develop habits of relaxing more. Even if stress isn’t a problem, most of us could benefit from doing some simple relaxation techniques most days. (Quick tip – breathing slowly is the quickest way to lower your blood pressure and everyone can do it.)
There’s a good introductory article here: How to lower blood pressure naturally
However, if you want clear and detailed guidance on how to lower your blood pressure naturally, have a look at our guide:
As the title suggests, it’s an easy-to-follow step-by-step guide to lowering your blood pressure naturally through changes in your daily diet and habitual activities. The fact is there are many many tasty things you can eat and drink that’ll help bring blood pressure down. There are also a lot of activities that can help keep you active, without requiring you to jog down to the gym. And there are myriad enjoyable ways to live a more relaxing, satisfying life… all while lowering your blood pressure 🙂 All of which are covered by this guide.
And don’t be put off by the thought that you’re going to have to live a saintly life. By the time you’re in your senior years you should be enjoying yourself. You can still drink a nice glass of wine. (That’s assuming you don’t have other medical conditions that make this dangerous!) You can eat dark chocolate. And you can take pleasure in the fact that these can actually be helping lower your blood pressure. It’s never too late to be living a good life. And by the time you’re “elderly”, you can be forgiven for being smug 🙂
Post by Alison.
* I say ‘mortality risk’ as this is the medical term usually used in such studies. Yet it’s always struck me as quite an absurd term, given that the only certainty is that we’re all going to die. You could say that the ‘mortality risk’ of life itself is 100%. I spent some time online looking up the exact medical definition of ‘mortality risk’ and couldn’t find it. So presumably what’s meant by ‘mortality risk’ here is the risk of dying sooner than you would otherwise due to causes related to high blood pressure.
* * These organisations include the Eighth Joint National Committee (JNC8), who revised their blood pressure treatment guidelines in 2013, and the American College of Physicians and American Academy of Family Practice, who altered theirs in 2017.
High blood pressure and the elderly: References and further information:
The risks of treating high blood pressure in the elderly -http://www.kevinmd.com/blog/2014/03/risks-treating-high-blood-pressure-elderly.html
Do you really have high blood pressure? – http://www.aarp.org/health/conditions-treatments/info-05-2011/high-blood-pressure-older-adults.html
New blood pressure guidelines for elderly – http://betterhealthwhileaging.net/new-blood-pressure-guidelines-mean-older-adults/
High blood pressure medications and risk of falling – http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1832197
High blood pressure medications and risk of falling – http://betterhealthwhileaging.net/falls-blood-pressure-medications-elderly/
Israeli research on high blood pressure, elderly, and mental abilities – http://www.webmd.com/hypertension-high-blood-pressure/news/20031030/high-blood-pressure-elderly-mind
Israeli follow-up research on high blood pressure, elderly, and mental abilities – http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7176.2011.00525.x/full
Oregon studies into high blood pressure and frailty – https://www.sciencedaily.com/releases/2017/03/170328145331.htm
High blood pressure and dementia – http://www.webmd.com/hypertension-high-blood-pressure/news/20170117/high-blood-pressure-elderly-dementia
‘Normal’ blood pressure and age – https://link.springer.com/article/10.1007/s11606-011-1660-6
Exercising safely with hypertension – https://www.acls.net/2015/03/02/can-i-safely-exercise-with-hypertension/index.html