Hypertension in the elderly: Change of, or new implications within the existing, paradigm?

Hypertension is the leading cause of morbidity and mortality among the older adults worldwide. Pathophysiology of hypertension in old age has been linked to the large arterial remodelling and stiffness. This is followed by concentric hypertrophy of the arterioles and baroreceptor dysfunction. The process leads to increase of systolic (SBP) and, after 5th decade, decrease of diastolic (DBP) blood pressure, with the bulk of the hypertension-related risk associated with SBP rather than DBP. However, the exact SBP value that should constitute the threshold for the diagnosis of isolated systolic hypertension has been debated. On one hand, a constant and linear relationship between systolic blood pressure and risk of complications has been implied. On the other hand, some experts point to the possibility of age-stratified cut-off values. When assessing the results of outcome trials in especially the oldest old, the absolute benefit is of paramount importance, when a greater relative benefit does not necessarily translate into less patients who need to be treated for a given period of time to avoid one event, and remaining life expectancy may be less than ten years. The latter issue is also of importance when generalisability of the clinical trial results is concerned. Further, especially in patients aging without success, burdened with multiple chronic diseases and poorly functioning, we need to take into account the average remaining life expectancy, their cognitive and functional capacity, comorbidities, polypharmacy together with patients' preferences. Whenever possible, a “de-prescribing” model of hypertension management in old adults may have some merit.