Guidance to help upskill primary and secondary care clinicians in decision making when managing hypertension in frail older people


Ensure you are familiar with the principles outlined in Managing cardiovascular disease in frail older people.

Hypertension in older people

Hypertension is one of the most important preventable causes of premature morbidity and mortality and it is estimated that at least 25% of adults (increasing with age) will have high blood pressure.

It is a cause of premature mortality and uncontrolled hypertension is a major risk factor for:

  • ischaemic and haemorrhagic strokes
  • myocardial infarction
  • heart failure
  • chronic kidney disease
  • cognitive decline

Target blood pressure

In the recently updated NICE guidelines for hypertension, stated blood pressure (BP) targets are dependent on age and co-morbidities. Blood pressure targets and choice of drug therapy are not given for frailty but there is advice to ‘use clinical judgement for people with frailty or multimorbidity’.

For those over 60 years and frail, hypertension should be managed using an individualised approach that takes into consideration their functional and cognitive impairment.

NICE give slightly higher targets for BP measurements in the clinic setting compared to ambulatory or home measurements.

Clinic targets

  • below 140/90 mmHg for adults aged under 80 years
  • below 150/90 mmHg for adults aged 80 years and over

Ambulatory or home targets

  • below 135/85 mmHg for adults aged under 80 years
  • below 145/85 mmHg for adults aged 80 years and over

There is debate over the optimal blood pressure (BP) target in different patient groups with international guidelines producing differing recommendations.

Further information

The European Society of Cardiology/European Society of Hypertension guidelines for the Management of Arterial Hypertension (section 8.8) outlines the data available from clinical trials to date whilst acknowledging the gaps in the evidence around the value of lowering blood pressure in the very frail population.

Managing risk of falls

One of the main adverse drug effects of managing hypertension in older people is the increased risk of falls.

Medicines that increase the risks of falls are those that can cause:

  • hypotension
  • postural hypotension
  • vasovagal syncope
  • bradycardia
  • postural orthostatic tachycardia syncope (POTS)

Older people with BP <110mmHg are at risk of falling but even those with normal BP could be at risk of syncope. The risk of falls and fractures are further worsened by impaired balance, polypharmacy and visual impairment in frailty.

The BEGIN algorithm may be used  to initiate antihypertensives and provide suggestions for deprescribing.


Guidance from the Tasmanian Deprescribing Network on deprescribing antihypertensive agents recommend tapering doses slowly at a rate of 25% per month over 3 to 4 months.

Safety of deprescribing

Antihypertensives can be deprescribed safely in frail older people without increase in mortality or adverse outcomes:

  • the DANTE study found that stopping antihypertensives in older people with mild cognitive impairment and postural hypotension increased SBP by 7.4mmHg and DBP by 2.6mmHg with higher recovery from postural hypotension
  • Potter et al found no increase in mortality as a result of stopping antihypertensives
  • older people who were normotensive with therapy and on monotherapy were more likely to remain normotensive after stopping
  • the risk of an elevated blood pressure was highest in the first month and within 12 months

Risks of deprescribing

Medicines with an antihypertensive effect may have other benefits in patients with other comorbidities, for which they may have been prescribed.  Therefore, discontinuation of these medicines may worsen the underlying condition and should be considered during the process of deprescribing.

When to refer

Consider referral to specialist care if symptoms persist or for further advice.

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