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:
- Assess an older person’s blood pressure management plan, and
- 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.)
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, and why I recommend a monitor such as the Omron 786N.
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 (such as the Omron 786N) have a feature that makes this easy to do; Omron calls this feature “TruRead.”
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
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.
6. Plan to follow-up on any changes to the plan.
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.
I found this very helpful for high blood pressure.
What is considered as low.
regards
Dawn
What is considered low depends a bit on the person, their medical history, and the particular circumstances. It is also important to compare a person’s blood pressure to his or her “usual blood pressure.” A SBP of 102 is different in a young woman who usually has SBP 100-105, compared to an older person who has historically registered SBPs of 130-150.
In other words, context is very important when it comes to low blood pressure.
A systolic number less than 90 is almost always considered low. For older adults on BP medication, I don’t like to see their SBP less than 120, especially if there have been concerns about falls.
Certain chronic health conditions, such as Parkinson’s disease, are associated with low blood pressure.
You can learn more from the Mayo Clinic here: Low Blood Pressure.
I’m really finding the information helpful. I am almost 64. Does this make me an “older adult”? Thx
Good question! At 64 you are certainly older than when you were 50, and your healthcare should probably be a little different.
Although geriatricians almost never care for people in their 60s, much of our knowledge base on modifying healthcare as people age is relevant from the sixties onwards.
For instance, when people are in their sixties, it’s usually reasonable to be careful about medications that can affect thinking and memory. It also becomes more important to be careful about medications that can affect the kidneys, and the body becomes more vulnerable to side-effects in general.
Glad you are finding the info helpful!
one of the best reviews of handling hypertension in the older population I tend to interact with as a patient advocate in San Miguel de Allende Mexico
I love your blog…use it a lot in postings where it gets a lot of views.
thanks for your hard work.
Thank you, I’m glad you find this useful.
I’m concerned about my mother who is 96 1/2. her blood pressure was 120/72, yet I think it should be higher because she has had a fractured hip and then fell again–I don’t think en ought blood is getting to the brain, consequently her thinking is not very good–they dropped her Losartan and upped her Amlodipine to 5mg
And I am 67 and am on HCTZ25mg (I retain a lot of water) and Losartan 75mg which causes leg cramps but I think I am experiencing angina – not always; it goes away after the initial pain – now I’m worried – yes I could lose weight but do not smoke(17yrs ago) or drink(used to then stopped now for a number of years). What’s are next move. Iam adopted so I can’t look to my Mom for any genetics…Thank you, Laurie
Your mother’s situation does sound worrisome, as you are describing falls and also some concerns with thinking. Her age of 96 is pretty old, so clinical research studies don’t provide much guidance on what is optimal blood pressure. Unless she has compelling medical reasons to aim for a SBP of 120, most geriatricians would probably reduce her BP meds and try to aim for a SBP in the 130s or 140s. So you may want to ask your mother’s doctor to discuss with you what is a suitable BP goal for her, and whether a reduction in BP meds might be reasonable.
Also, if your mother has been falling, then it is really important to pursue a comprehensive evaluation for fall prevention. There may be other factors causing her to fall, such as risky medications or low leg strength. See these articles for more:
Why Older People Fall & How to Reduce Fall Risk
10 Types of Medication to Review if You’re Concerned About Falling
Similarly, if you are concerned about her thinking, then she should be evaluated and checked for the many things that can diminish brain function. These include medication side-effects and more. See How to Diagnose & Treat Mild Cognitive Impairment.
Lastly, regarding your own health concerns, if you are concerned about possible angina or any type of chest pain, I strongly urge you to bring this up with your usual doctor as soon as possible. This is the only next move that can be recommended. A health care provider needs to evaluate you in person in order to determine whether additional testing of your heart is necessary. Heart disease in women your age is not uncommon and can be very serious, so don’t delay.
You didn’t mention that almost all blood pressure meds cause blood sugar to rise which is a real problem if you are pre-diabetic and trying hard to keep your numbers down so that you won’t have to take diabetic meds. My husband’s BP meds make him feel bad and make his blood sugar rise. If he stops the BP meds he feels great but his BP goes up. Happens on each BP med he’s taken.
Hm. It’s actually not very common — as far as I know — for blood pressure medications to cause a rise in glucose. I just reviewed the UpToDate topic on treating hypertension in people with diabetes. In the ALLHAT trial there was a small increase in glucose with chlorthalidone (a thiazide-type diuretic), but that’s the only glucose side-effect that is mentioned.
That’s not to say that BP medications might not have this effect on your husband; every person’s physiology is a little different, and some people will have unusual reactions to certain medications.
But worsening blood sugar is not something that most people on BP meds should worry about. Overall, clinical research finds that treating people with diabetes and prediabetes for their high blood pressure improves health outcomes.
I would recommend that you and your husband keep discussing with his doctors these concerns about the effect of his BP meds on his sugar, and more importantly, on his wellbeing. Perhaps with some additional effort, you’ll be able to find a BP management plan that helps keep his BP in a reasonable range without causing too many side-effects.
It’s also important to remember that several lifestyle approaches can improve BP and blood sugar. Good luck!
Could it ever be appropriate for a physician to prescribe slightly higher-than-routine dosing of a well-tolerated blood pressure medication, when other types of BP meds are not tolerated or would be problematical because of interactions with all the other drugs one might be on? I would assume fall risk should be evaluated in conjunction with such a consideration, and that it also might depend on how the particular tolerated BP med actually works in the body.
Well, it’s almost always possible for a prescription to be appropriate given certain circumstances…
For the situation you have in mind, it sounds like the person is on the usual maximum dose of a certain BP medication, is tolerating it, but might need more BP medication because the BP is not yet at goal?
Clinicians do sometimes prescribe still higher doses of a BP medication, especially if adding another agent doesn’t seem to be a good option. However, the BP may not improve much in response, although the risk of side-effects (such as electrolyte disturbances) usually does go up. You can ask your usual healthcare provider or a pharmacist to review potential side-effects with you, so that you’ll know what to monitor for.
The risk of falls due to BP meds is mainly a consideration when the SBP is lower than 120, or if the BP drops with standing. So it can be a good idea to check that BP sitting and standing. If the SBP is less than 130, then the clinician should be able to explain why he/she is proposing an increase in BP med dosing.
Be sure to discuss with the clinician what the target BP is, and why.
My BP since in my 30’s has been 135/75. I am 72 and last June it was averaging 160/70. I joined WW and lost 35 lbs but my home readings (BP monitor checked with doctor’s) 150-160/65-70. However, at doctors office it went from 170-145/75. I am planning to home monitor twice per day this next week. Another concern, my doctor is not concerned enough to put me on a hypertension pill. Isn’t 140 and above alarming? Health wise, my other health readings are all normal or below…..cholesterol, diabetes, plaque in arteries, etc.
Congratulations on losing all that weight, that is a wonderful achievement.
Re BP: as noted in the article above, several expert groups recommend treating adults aged 60+ to a goal of SBP less than 150. So if you find that your SBP is often in the 150s or higher, then it would be reasonable to consider a medication to lower BP, especially since it sounds like you’ve been trying lifestyle treatments but your BP is still not low enough.
A SBP above 140 is not “alarming” per se, but historically this has been the cutoff separating “high” blood pressure from normal or “bordeline” blood pressure. Many doctors do still believe that older adults should be encouraged to get their SBP below 140, and in the SPRINT blood pressure trial, one group of participants actually aimed to get their SBP below 120.
I would encourage you to read our two articles explaining the SPRINT blood pressure trial. This will help you understand whether it’s worthwhile for you to ask your doctor to help you reach a lower BP goal, such as less than SBP 140.
New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research
What the New Blood Pressure Guidelines — & Research — Mean For Older Adults
In general, people get the most benefit from lowering BP from above 160 to the 140s. After that, many benefit from still lower BP, but the likelihood of benefit gets smaller and smaller…it’s diminishing returns, if you will.
Re your doctor, if after home monitoring you find your SBP is still in the 150s, then you can remind your doctor that guidelines do recommend treating adults your age to SBP less than 150. Good luck!
How can we treat hi pulse rate ?
To treat an abnormally high pulse rate, it’s essential to start with a careful evaluation to figure out what is causing the high pulse rate. It’s also important to determine whether the high pulse rate is a very new problem, versus a chronic problem.
Many things can cause a high pulse rate, including atrial fibrillation, other heart rhythm disorders, anemia, infection, substance withdrawal, medication side-effects, and more.
To treat an elevated pulse rate, you have to treat the underlying cause.
My mother had a massive cardiac event 19years ago. She is currently 79y and has 25% function of her heart. Up until 6 months ago was doing great. Then she started getting very tired and could hardly get out of bed.turns out her bp medication was making her hypotensive. The cardiologist put her on a new medication but took her off all bp mendications for 2 days. I had her take her bp twice a day for those two days and her bp was 111/62or less in am and evening. She also on day two felt great and was able to be back to normal ADL. She took the new medication in the evening before bedtime and woke up with a be of 83/54. Scared me to death. She felt terrible all day. I told her to not take it again. I have been since monitoring her bp twice daily and she is averaging 110/64. She had one morning at 154/83 when she was scared about some thing with a family member but later that evening it was again at 112/68. She has an apt. With cardiologist in 9 days. Should i have her cont. to stay off if we monitor daily and we do not see a spike in bp. I called her dr. After first week and the message from nurse, since doctor would not talk to me, was to take half of her enalipril. I said ok and still am afraid to let her take it. Am i wrong is there another reason for her to take this medication that causes the hyopensiveness?
Sounds like your mother has had some significant heart failure in the past. Such people can be very sensitive to high blood pressure, because heart failure can get much worse when the heart has high blood pressure to push against.
That said, it’s still important to not lower BP too much, even in heart failure.
It sounds to me like the cardiologist is in the process of trying to figure out what is the right dose of BP meds for her at this time, given the current state of her heart. Re the nurse’s recommendation, you may want to call back and make sure they realize that your mother’s SBP is only around 110, even off all BP meds. Ask them what they think her goal BP should be.
You can also try the half dose they suggest, and if it seems to make your mom tired and hypotensive again, call them right away and ask for revised advice.
Generally, you are doing exactly the right thing, which is to monitor and record her BP and what happens in relation to her medications. This will help her doctors figure out the right combination of medications she should be on. Good luck!
Thank you very much.
Here I found very insightful and also helpful information. My mom is 65 years old and she is facing high blood pressure (BP). This management plan will help me to assessing her BP.
Thank you so much. Keep coming with such more informative.
What about honey? I have heard, honey helps in controlling the blood flow in arteries. Also, taking honey regularly makes the heart stronger. Is it true?
Mihika
I’m not aware of any high-quality scientific research finding that honey improves cardiovascular outcomes.
hello;
i have read recently (from a very credible source) that the idea of limiting salt to reduce high blood pressure has no scientific evidence and has some how become a fact that has no supporting evidence. can you comment?
My understanding about salt and blood pressure is this:
– several credible studies have found that reducing salt intake in randomized trials is associated with a fall in blood pressure
– the reduction in blood pressure is often modest, but still significant from a public health perspective
– some evidence suggests that some individuals are more salt-sensitive than others, when it comes to BP. It’s even possible that the same individual may have BP that is more or less salt-sensitive, depending on what else is going in that person’s body and health.
Here is a recent meta-analysis addressing this issue:
Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials (2013)
Potassium has also been found, in some studies, to decrease blood pressure, see here.
(Note: potassium is cleared by the kidneys, so never try to significantly increase potassium intake without first discussing with your health provider.)
For individuals trying to reduce their blood pressure, I recommend considering a “trial of one”: make a dietary change to sodium (or potassium, but perhaps not both at the same time), and follow your blood pressure daily or weekly for several weeks. See what happens.
Hope this helps.
I enjoyed your information. I’m printing it so I can share it with my family and friends.
Thank you, glad to know it!
Iam an Indian 83 yrs old. My normal b p used to be120 l80. Today I was feeling different so checked It . is 150 by 100 .iam given some mild medicine. By chance I came across your blog . It gave me so much support. It is very informative. Iam very clear what I have to do. Thank you very much.
Glad you found this helpful!
I am having high blood pressure measuring 140/110. I was watching some yoga video and reading lots of articles. So I am thinking of trying the nature cure way for about 1 month or two and if doesn’t work I am thinking of visiting a doctor. Your advice, please. Thank You
You don’t say how old you are, but a diastolic BP of 110 is quite high and would be unusual in an older adult. For that level of diastolic high blood pressure, I would recommend seeking medical advice sooner rather than later.
Hello ! mam I am a 19 year old guy weigh around 233 pounds having high blood pressure problem from last 9 to 12 months just recently started taking medication as adviced I don’t smoke neither drink but I am not getting the cure as this problem is effecting my daily life and overall health on a daily basis once my highest ever hbp reading was 180/100 that time I was completely shocked second time 4 days later it came 160/100 means this thing is not in a mood to leave me I am complete feared about my life and want a permanent cure to get rid of this problem permanently plz do help me out not able to find any kind of help as I’m too young for such problem just wanting a permanent cure so it may never ever effect me in future if possible
Sorry that you are having high blood pressure problems. You are young whereas I am an expert in aging health, so I’m not even sure what are the most likely causes of such high BP in someone your age.
You will need to see a health provider in person for further evaluation. Your BP is quite high so I would encourage you to go as soon as possible. For most people high blood pressure is a chronic problem, but sometimes there is an underlying cause that can be treated. It can also be greatly improved with the right lifestyle measures. Good luck.