6 Steps to Better High Blood Pressure Treatment for Older Adults

Have you been concerned about high blood pressure (hypertension)? Or are you worried about an older relative having a stroke or heart attacks?

You’re not alone. After all, hypertension is the most common chronic condition among older adults, and medications for blood pressure (BP) are among the most commonly taken drugs in the US.

Even more important: poorly controlled hypertension is a major contributor to the most common causes of death and disability in older adults: strokes, heart attacks, and heart failure.

So it’s certainly sensible for older adults – and for those helping aging parents – to think about blood pressure.

And once you start thinking about high blood pressure, you’ll probably start to wonder.

Are the blood pressure medications you’re taking enough? Is your blood pressure at the “right” level or should you and your doctors work on changing things?

And what about that major research – the SPRINT trial — that made the news in 2015? (In this study, older adults randomized to aim for a lower BP did better than those who got “standard” BP treatment.)

These are excellent questions to ask, so I’d like to help you answer them.

Now, I can’t provide exact answers on the Internet. But what I can do is provide a sensible process that will help you successfully address these questions.

In this article, I’ll share with you the process that I use to:

1. Assess an older person’s blood pressure management plan, and
2. Determine whether we should attempt changes.

If you’re an older adult, you can use this approach to get started assessing your own BP management plan. This will help you to better work with your doctors on assessing and managing your blood pressure.

If you are helping an older relative manage health, you can follow these steps on behalf of your relative.

But first, let’s review a few key terms related to blood pressure.

Key terms about blood pressure and hypertension:

• Systolic blood pressure (SBP): the “top number” when BP is checked. This reflects the pressure in the arteries when the heart squeezes. It’s by far the most important number to consider when it comes to older adults.
• Diastolic blood pressure (DBP): the “lower number” when BP is checked. This reflects the pressure in the arteries when the heart relaxes.
• Pulse: the heart rate. Automatic BP monitors report pulse along with BP. Doctors must evaluate a person’s heart rate when considering a change in BP medication.
• Hypertension: Usually defined as BP> 140/90, assuming the readings are taken in a doctor’s office. (There is a slightly lower cut-off if the readings are taken at home.) If only the systolic BP is high, this is called “isolated systolic hypertension.” This type of hypertension is very common in older adults, as aging is associated with both increases in systolic BP and decreases in diastolic BP.

How to better measure blood pressure

As you can imagine, a key component of optimizing BP management is to measure an older person’s BP and pulse.

Measuring BP allows us to:

• Diagnose people with hypertension,
• Determine how severe it is (which helps us all decide how important it is to intervene),
• Evaluate how well people are responding to a treatment plan, whether that plan involves lifestyle changes or medication or both.

Measuring BP usually sounds straightforward.

People assume it’s just a matter of finding out what the BP was at the doctor’s office, or getting a reading from a home monitor, or maybe even a reading from a health fair or drugstore.

But in fact, research has shown that a single office-based BP reading often does not represent a person’s usual BP. One study even found that the “usual” way of measuring BP misdiagnosed 24-32% of volunteers!

This is because people are often anxious when at the doctor’s office, which can temporarily raise BP. Studies estimate this “white-coat hypertension” affects 10-20% of people.

Furthermore, BP is constantly changing a bit, moment to moment. So experts agree that it’s much better to obtain several readings and average them, in order to properly assess a person’s usual BP.

For instance, in the ground-breaking SPRINT trial of intensive BP lowering in older adults, the researchers checked BP by having participants first rest quietly in a room for five minutes. Then an automatic monitor checked BP three times in a row, with a one-minute interval between each check. The average of these three readings was then used to assess BP and make changes to hypertension medications, if necessary.

As you can imagine, this is not the way most people’s blood pressure is measured by their doctors.

So what’s better?

Currently, the “gold standard” for evaluating blood pressure is called “ambulatory blood pressure monitoring” (ABPM). It involves wearing a special monitor that checks BP every 15-60 minutes over 24 hours. The doctors then receive a report showing the average daytime BP and average nighttime BP.

Such monitoring provides excellent information for patients and doctors. In fact, research shows that ABPM is a better predictor of future cardiovascular events (e.g. heart attacks, strokes) than conventional office-based BP measurements are. However, ABPM is not yet widely available, since it requires special equipment and may not be covered by insurance.

So what is considered next best? Research shows that home BP measurements are better than “usual-care” office BP measurements. Meaning, home BP measurements correlate better to the BP that is measured if one uses the fancy 24-hour ambulatory monitoring approach.

Based on these facts, in 2008 the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association issued a joint scientific statement calling for home BP measurements to become a routine component of BP measurement in people with known or suspected hypertension.

They also suggested that clinicians review a week’s worth of home BP readings before making a clinical decision or changing a person’s medications.

(You can read the whole scientific statement, titled Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring for free! I especially recommend reading the abstract at the beginning, which summarizes the proven benefits of home blood pressure monitoring. You can also read the American Heart Association’s 2019 guidelines on measuring blood pressure at home here, in section 4.)

Now that I’ve made the case for checking BP carefully at home, let me share the six-step process you can use to assess your blood pressure management plan.

A 6 step process for assessing a blood pressure management plan

1.Obtain a high-quality home blood pressure monitor.

Why: Studies have found that home-based measurements are better than office-based BP measurements. They better reflect a person’s BP over 24 hours.

Notes: See “Choosing & Using a Home Blood Pressure Monitor” for more details on choosing a monitor. Be sure to get one that measures BP at the upper arm (those wrist ones are not accurate enough!). Ask your doctor for help validating that your home monitor is getting accurate readings.

2. Check blood pressure twice a day, every day for one week.

Why: Since blood pressure is constantly changing a bit — or sometimes a lot — in the body, checking several days in a row means that you’ll have several readings that can be averaged.

Aim to check at the same times every day. An average of several daily readings provides a more accurate picture of a person’s BP.

Checking in the morning and evening is recommended by many experts. This is because BP can vary during the day, especially in people who are taking BP medications. But if checking twice a day seems too hard, just check once a day.

Experts also often say to check BP in the morning before any medications are taken. However, if there have been any concerns about falls, I like to review readings taken about an hour after medication. This is because I want to make sure the BP isn’t falling too low when a person takes their medication.

Optional but helpful: Use a “three measurements in a row” technique if possible. The SPRINT trial measured BP by letting participants rest quietly for five minutes, and then having the monitor check the BP three times in a row, with a one-minute pause between each check. Those three readings were then averaged into a reading for the day.

Some home blood pressure monitors have a feature that makes this easy to do.

3. Make an up-to-date list of all current medications.

Why: Your doctors will need to know exactly what medications you are taking, in order to evaluate your blood pressure treatment plan.

Notes:

• Start by listing those for heart or BP.
• But list all others, because some medications that are not prescribed for BP can still affect BP (such as Flomax, which can be used to improve urination when a man has an enlarged prostate).
• Also list all supplements, vitamins, herbs, and over-the-counter medications.
• Be sure to note if any medication is not being taken exactly as prescribed. It’s especially important for the doctors to know if an older person has been skipping any of the medications that affect BP.
• Note any concerns about side-effects, cost, or other concerns related to continuing the medication.

4. List the lifestyle approaches to lowering BP that you are following (or interested in).

Why: Although prescription medications are the main way doctors often try to treat hypertension, many lifestyle changes have been shown to help lower BP as well.

You’ll want to let your doctor know which of these you are using. Also, let your doctor know if you’d be interested in incorporating any of these into your BP management plan.

Many of these lifestyle changes are great for older adults, because they benefit health in many ways but have fewer risks than taking prescription medication.

Note: Proven approaches to lower high blood pressure include:

• Weight loss
• Exercise
• The DASH (Dietary Approaches to Stop Hypertension) diet
• Reducing sodium (salt) intake, especially in people who seem to be salt-sensitive
• Not smoking
• Meditation

5. Make an appointment to discuss blood pressure management with your usual doctor.

Why: Your doctor can help you identify a good target blood pressure goal, and can help you develop a plan to reach that goal. Be sure to bring up any concerns regarding falls, or other potential side-effects of treatment.

Notes:

• Bring in your home BP readings and your up-to-date medication list.
• Consider asking the doctor to check BP sitting and standing, especially if you’ve had any concerns about falls
• Ask your doctor what target BP goal they recommend for you, given your health history.
  • Research indicates that the biggest benefit is in getting systolic BP down to the 140s. A systolic BP target goal of <150 is a good starting place for most older adults, as recommended by major guidelines in 2013 and also by more recent high blood pressure guidelines issued in 2017.
  • Results from SPRINT suggest that if you’re similar to the SPRINT participants, you may experience additional benefits by aiming for a systolic BP close to 120. If you’re considering this, be sure to read my article explaining SPRINT and related research, so that you’ll have a clear understanding of how likely you are to benefit (at best, an estimated 1 in 27 chance based on the research) and what are the risks and burdens.
• Ask your doctor about taking most (or maybe even all) of your BP medications at night.
  • A randomized trial published in 2019 found that taking BP medications at bedtime (rather than in the morning) resulted in lower ambulatory blood pressure readings and fewer cardiovascular events!
  • Taking BP medications at night is likely to be a simple way to help them be more effective. For more on taking blood pressure medication at night, see this Harvard Heart Letter: Is nighttime the right time for blood pressure drugs?

6. Plan to follow up to see how your BP plan is working, and to make adjustments if needed.

Why: Whatever you and your doctors decide to do, you’ll want to make a plan for seeing how your blood pressure responds to the changes.

Note: Remember that experts say a week’s worth of home BP monitoring is more accurate than a follow-up BP check in the office.

Be sure to ask your doctor to specify:

• When should you undertake this home monitoring? (Most BP medications will take their full effect within 1 week. Lifestyle changes will take weeks to months to have an effect.)
• When will you be meeting — by phone or in-person — to discuss the results of the follow-up BP monitoring?
• What level of high (or low) BP should trigger a call to the office?

And that’s it!

Make the effort

Now, this approach is more work than usual. It takes a little more time and effort than just going to your doctor and having them check your blood pressure.

But the benefits make this time well spent. Think about it.

You and your doctor get a more accurate picture of what is going on inside your body.

You get to help create a blood pressure management plan that is just right for you.

You may even help prevent some serious health problems. Like a heart attack or stroke, or a serious fall due to incorrect medication.

No one likes the thought of letting a chronic condition get dangerously out of control. And no one likes to take more medication than they need to.

You can help keep this from happening.

Just follow this process for assessing a blood pressure management plan, and you’ll be on your way to confirming that you’re following a blood pressure management plan that’s right for you, or for your older parent.

This article was last reviewed and updated on 8/26/21. (Don’t miss the recommendation to try BP medications at bedtime!)