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.
You didn’t mention alcohol consumption and bp. Is moderate use a problem for bp?
Alcohol can be tricky, with some observational studies linking moderate alcohol use to improved health outcomes and other studies questioning this.
(Moderate alcohol use is often defined as one drink/day for women and up to 2 drinks/day for men.)
Studies have also found that high alcohol intake is associated with higher BP. In terms of moderate intake, a recent systematic review found that reducing alcohol improved BP in those with higher intake of alcohol but not in people who drank two or fewer drinks per day.
The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis
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.
I have been doing a search to find information I can trust about my high BP, and I am so glad I found you! Your information and links to more have answered my questions, hardly addressed by my doctors and pharmacists. I am an 87-year-old female in generally excellent health, eating properly and on the move. I get moderate exercise and have just now started a program with a trainer–paid for by my Medicare provider! I don’t want to lose strength or the ability to teach, write, and get around.
Glad you’ve found the information here helpful. Sounds like you are being very thoughtful and proactive about maintaining your health. Wonderful that your Medicare plan is covering an exercise program with a trainer! It’s true that as one gets older, being more deliberate and purposeful about exercise and strength work becomes more important. good luck and take care!
I just found this site while reading the Washington Post article, and I so hope there is some help for me. I will be 71 in a couple of weeks. I am a congenital heart survivor, having surgical repair by Dr. Cooley in 1960 at the age of 12. I learned a few years ago that I have a “showering” of micro hemorrhages in my brain from the heart lung machine not being “neuroprotective”… That news was shocking and traumatizing. As a child I expected to die. Both my young brothers died of other congenital illnesses. At any rate that apparently puts me at higher than normal stroke risk.
Some years ago I was put on medication for elevated blood pressure, as my mother before me. I took my medication and checked my values “religiously”… All of a sudden last October I developed malignant hypertension. I was hospitalized 3 times in 3 days with values over 220, then the hospital sent me to a nephrologist. He started running tests which were all normal. The hospital put me on Clonidine but the nephrologist did not add anything while running tests. In November I had to be hospitalized again. That time the ER doctor said they were not going to release me back to the same situation and added Amlodipine Besylate. My blood pressure has been normal with one brief spike since. Problem now are medication side effects: edema of feet and legs, hearing loss from fluid retention, bloating and constipation and generally not feeling well. I had always worked full time but finally retired this March. I am very disappointed to think that after working so hard for so may years I am going to feel like this in retirement due to side effects. I have talked to my nephrologist, especially a few weeks ago when I developed hearing loss from fluid retention and found that all the side effects are cumulative. He sent me an email saying we will stop the Clonidine and Amlodipine with no adjustments or anything in their place!! My pharmacist has tried to be helpful but can’t change anything. He says Amlodipine is one of the worst meds for side effects and many patients have to stop it for something else. The nephrologist does not seem to have done any research on side effects in order to suggest alternative medications, or to offer adjustments. He seems kind and listens, but offers nothing. In fact all of my medications for this condition were prescribed at the hospital. We have few geriatric doctors in this area, and no geriatric cardiologists. My regular cardiologist who just prescribed my standard meds cancelled my appointment when I developed the spikes. I already knew he was not up to challenges…I see an adult congenital cardiologist every so often even though he tells me I don’t need him as my congenital repair and heart are fine. There are not a lot of nephrologists here, but I think there is a better one in the same group so I doubt he will see me. I am really in a dilemma because I certainly cannot risk spikes, but would hope to feel better and not risk side effects such as fluid retention causing worse problems. It has also elevated my blood glucose which I watch and control through diet and exercise. The medication had my blood pressure running as low as the low 80s over low 50s, obviously too low, which is when the edema developed and I was lethargic. Now values are good. I have found little information on malignant hypertension and had never heard of it. I will greatly appreciate any suggestions. Thank you! PS I do not have a primary care doctor because so many here will not take Medicare and the “good” ones are not taking new patients or retiring. I have been looking for some time. My neurologist even had me send records to his good friend, an internal medicine specialist and they called and said he couldn’t help me….I had endocarditis at age 5 and have some medical PTSD. Sorry to write a novel, but I am thrilled there may be some help for me!
Sorry to hear of all your challenges related to blood pressure. Your situation sounds particularly complicated and so it’s probably appropriate for you to be seeing a specialist. High blood pressure can be treated by either cardiology or nephrology; nephrology might be better if you are also experiencing edema, but it also depends on what they think caused your hypertensive emergency in the first place and whether you seem to have anything going on with your kidneys.
Edema is a known side-effect of certain calcium channel blockers; doesn’t affect everyone but certainly can be an issue, especially with higher doses of this type of BP medication.
I took a brief look in the medical literature, and apparently combining a calcium channel blocker with an ACE (angiotensin-converting enzyme) inhibitor BP medication can improve edema:
Effect of renin-angiotensin system blockade on calcium channel blocker-associated peripheral edema
You may want to ask your nephrologist if that might be an option for you to try. You could also consider asking more questions about what they think may have caused your hypertensive emergency in the first place.
There are many different classes of BP meds that they could try, but it’s impossible for me to say which would be appropriate to try next for your particular situation.
If you are dissatisfied with your current nephrologist, you need to either persistently and politely keep asking for more help and more of what you need (e.g. more explanations), or you need to try a different nephrologist. I’m sorry as doing this is a lot of work, but unfortunately, it does sound like you need to work closely with a health professional.
You could also try looking for an online community of people with similar health problems, as this can be a good source of moral support. Good luck!
Dear Dr. Kernisan, you don’t know how thrilled I am to hear back from you!! There seems to be so little kindness these days that I so appreciate your caring response. I have had little success finding information about malignant hypertension. You mentioned following up was a lot of work, but it has been so consuming for me due to my fear, but also trying for a decent quality of life with as few side effects as possible, that my daughter says I need to find something else to do. (I have no other family left)…Besides a very stressful job, and caregiving for my mother who lived to be 97, I have always done volunteer work, so am really ready to get back to being productive…As far as my malignant spikes, I have asked every doctor and no one has an answer as to why it suddenly developed. That is one reason it is so scary. The nephrologist says he guesses it was from years of chronic stress. All the tests (kidney and carotid artery) were negative. I do a ton of research and am so glad to have found your site!! I found you through a link in a Washington Post article by Janice Neumann on August 17 “New Blood Pressure Guidelines Can Cause Problems for the Elderly”… I did not find a way to contact her. I have had no luck finding similar patients but need to learn social media skills. Thank you again so much!!!! I will be a faithful follower from now on!!! Best Regards, Kathy
Glad to be helpful. If the nephrologist says all the tests were negative, that sounds reassuring and might mean your doctors could try different types of BP medication with you. Generally, three types of medication are considered equally acceptable for first-line treatment of high blood pressure: thiazide-type diuretics, ACE inhibitors or angiotensin receptor blockers (these two are related), or calcium channel blockers such as amlodipine.
Honestly I find that the best information is on Uptodate.com, there is a topic on treating high blood pressure in older adults. It’s written for professionals but summarizes all the important info, you can subscribe for 7 days for $20.
If stress is an issue for you, you might want to consider working on relaxation therapies, mindfulness, and other non-drug methods to reduce stress.
To find others online with similar health concerns, you could try SmartPatients or PatientsLikeMe.
Good luck and thank you for joining our community!
I am a 55 year old woman who was diagnosed with hbp about 5 years ago. I also have degenerative arthritis in my hips, in particular,and have had to keep up with strength training exercises over the past 20 years to ward off the pain. When first diagnosed with hpb, my doctor put me on Benicar. It helped immediately but I also began to experience some severe muscle and joint pain in my hips and legs. She switched me to Valsartan and the pain abided for about 2 months. Then came back again. Fast forward to last fall when I had a left hip replacement. Recovery was slow, especially for my age. I kept stumping the PT as to why my muscle tension was so tight. Finally, after I started working out at the gym, my pain resided. Counter intuitive, I know. Now I am scheduled to have a right hip replacement in November 2018 and am experiencing intermittent excruciating pain in my quads and tibia. I’ve been reading about an uncommon side effect of bp meds being muscle and joint pain. I’m wondering how much the bp meds are contributing to my pain. Would it be unreasonable to try switching bp meds every 3/4 months? Thank you for any advice you can provide.
Well, it sounds like you started with one BP med in the angiotensin II receptor blocker (ARB) class, and then your doctor switched you to another drug in that same class. These drugs do affect potassium, which can affect muscle function but otherwise, I haven’t heard of them being particularly associated with joint pain, and I didn’t see much mention of this when I looked just now in my clinical reference (Uptodate.com).
There are several other classes of BP med you could try. If you think you are having side-effects from your ARB, then it might make sense to try a different class, such as a calcium channel blocker. (You could also try a thiazide diuretic, but that would be more likely to affect blood electrolytes.)
I would not recommend changing BP medications every 3-4 months just to prevent the onset of potential side-effects, but it certainly makes sense to reassess how you are doing on a BP med after a certain interval (usually after a few weeks, and then every few months or more often if the dose still needs to be refined or if there is concern about potential side-effects).
Re your pain, I’m not surprised that PT or exercise helped! They often do help if one is able to get there, gets a good therapist, and is able to stick with the exercises (no small feat when one is hurting in the first place). good luck!
Speaking of BP meds that effect potassium, my potassium is usually around 3.3 which is below the threshold. My doctor thinks this is due to the diuretic chlorthalidone and recommends a supplement like KLOR. I also take lisinopril and amlodipine. I have no symptoms of hypoglycemia and have put off taking the supplement. Perhaps switching to a potassium sparing diuretic would be the way to go, but I tolerate my current meds very well. I am a very active 75 year old man. Thank you so much for your good work with this blog.
Thank you for your feedback, I’m very glad if you find this site useful.
Hypoglycemia refers to low blood sugar, not low potassium. I am guessing that you meant to write you have no symptoms of hypokalemia (low potassium)?
In general, symptoms are uncommon when the potassium level is over 3.0. However, some observational studies, such as this one, have found that mild hypokalemia is associated with an increased risk of poor health outcomes.
The main thing that strikes me about your comment is that you are taking three different BP medications. This is necessary for some people, but in other cases, with a little tinkering we are able to provide adequate control with just two medications. The combination of an ACE inhibitor (such as lisinopril) and a calcium channel blocker (such as amlodipine) was shown to be particularly favorable in the ACCOMPLISH trial, so this combination is now recommended by many experts.
So, you may want to discuss your BP medications further with your doctor. In particular, you may want to discuss the potential risks of mild hypokalemia, and you may also want to ask whether it might be possible for you to manage your BP adequately with two medications instead of three. Good luck!
Dear Dr. kirnisan,
I am an active 79 years old male of very slight build and weigh about 100 lbs.Till age 71,I ran and walked 40- 50 miles per week.
About 4 years ago ,my doctor told me that he was concerned with systolic blood
pressure which was averaging 157 in doctors office.I bought Amron blood pressure monitor and check my readings in the morning within 30 minutes of getting up at 4.45 a.m. and the I go for my walk and run or just walk and weight training 5 days a week. My home readings average about 115/67 with heart rate averaging 55.Pl. note that I have been on Amlodopine 2.5 mg. taking it about an hour before going to bed.I also take Flowmax and Avodart for enlarged prostate.
I am a light sleeper.
Recently, I started checking my blood pressure at about 5.0 p.m at home the readings can average as high as 142/67 with heart rate of about 58.
At my annual exam in late July, my blood pressure was again 157/65/54 as checked by doctor with 6 consecutive readings and on my own BPmonitor. My doctor reviewed about 100 readings on home BP monitor and came to the conclusion that he was not concerned.
I am known to be somewhat of an anxious person and somewhat high strung.Recently, I have started meditation with the hope of calming my mind.
I would appreciate your comments and any recommendations about bringing my BP to normal level in the evening as well.
Pl. note that I am a terrible typist and thus make spelling errors.
Thank you. Look forward to your response.
Sincerely,
Rai Batra
Congratulations on being proactive about your health.
Well, it is common for people’s BP to be higher in the office, but if it’s higher in the evenings at well, you could certainly discuss changing your BP management with your doctor. I would recommend that you discuss further with your doctor. Specifically, you may want to ask your doctor why your BP seems to be higher in the evening, and what your goal should be for your home BP readings. You could also try changing the time of day you take your amlodipine, to see if that changes your daily BP pattern.
If you are in good health and prefer to minimize your cardiovascular risk, it could be reasonable to aim for a lower BP goal, such as that in the SPRINT study. I would just encourage caution about bringing that morning reading down further. You could discuss whether diet or other lifestyle changes might help you bring down BP, and then you could also talk to your doctor about adjusting your BP medications.
I am glad you are trying to address anxiety and being wound up. It certainly might help bring down your blood pressure, esp if you learn exercises related to deep breathing and other ways of inducing the body to physiologically relax. good luck!
Hello Dr. Kernisan, I’m glad I found this website, I’ve got a couple of questions, I would be very grateful for your input.
I just turned 45, a few weeks before that I suffered from a constant bad headache for a few days, I have one of those digital BP readers and it was 150/96, was quite shocked since my BP was very low 110/58 but I last took more than a year ago. My blood pressure was so low that I was denied donating blood several times when my mum had an accident.
Next day I went to a doctor, my reading was 145/94, he ordered a blood test, renal functions and other things and cholesterol level; he put me on a mild ACE inhibitor-10mg. He told me I have essential hypertension and didn’t advise any dietary/lifestyle changes except for lower sodium intake. I’m fit, workout every other day and I’m vegetarian for more than 20 years.
The tests came back all normal except for the cholesterol which is at 245- which is considered high risk according to the lab. The doctor gave me crestor medicine to combat the cholesterol and an additional aspirin 100 mg- I’m guessing as a blood thinner.
My questions are (which the doctor dodged):
Can we predict when was the hypertension triggered based on the cholesterol level test, in other words how long did I have it, when I asked him he dodged and said I might have always had high cholesterol, even though I only consume no fat dairy and rarely if ever eggs. I’m trying to establish a time frame of certain events.
It’s been almost 3 weeks since my diagnosis, my BP fluctuates badly from 125/75 early mornings to as high as 140/90 midday, my average would be around 130/85. Is that normal? and what are my chances of developing drug-resistance on the long run that’d require more/different medications.
Regarding the aspirin, the doctor said that it’s likely I’ll have to take it indefinitely. Wouldn’t that put me at a ver high risk of brain haemorrhage?
With medication, what is my risk of developing complications(blindness, cardiovascular etc) and death from stroke/heart attack. I’m asking for euthanasia preparations and at what age?
I can’t answer anyone’s health questions in detail over the Internet, but I can provide a few comments in response to your questions and concerns.
It is indeed normal for BP to fluctuate throughout the day; the body’s control of blood pressure is a very dynamic process and so it can fairly quickly go up or down. We generally recommend that people check their home BP at about the same time every day; you may want to ask your doctor what time he or she would recommend for you.
I address aspirin and other methods of cardiovascular risk reduction in this article:
How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do
At age 45, there is still lots of time for lifestyle changes and other health management efforts to make a big difference in your outcomes. I believe the article above links to a cardiovascular risk calculator online; you could use that or something similar to get a ballpark estimate of your CV risk. Your doctor can also advise you. Good luck!
Thank you so much.
Dear Dr. Leslie Kernisan, MD MPH:
Thank you so much for your highly informative article on hypertension for seniors–the best one that I have read. Presently, my wife, age 78, weight 98 lbs., height 4′ 11″, has been on a 4 m Atacand (brand name) per day for close to ten years now. Healthwise, I was concerned about its side effects on her. Pricewise, it is a very, very costly drug and our plan now requires her to pay a newly required deductible of $350 before reaching a new copay that has also become more expensive as well. She does not smoke or drink. Her family doctor has suggested that she switches to a generic brand Atacand but she prefers not to risk with its poorer bioavailability. Is such a preference valid? Are there any benefits in a generic that would outweigh its bioavailability constraint? Is there any alternative brand name drug that would offer her a good transition? Thank you kindly again for sharing the above highly informative, useful, and rare article regarding hypertension for seniors. I’d look forward to your reply with great appreciation–if I may.
Sincerely,
Don Y.
I’m glad you found the article helpful.
Your question would probably be better addressed to a pharmacist or pharmacologist. I hadn’t attempted you describe, but it seems to me fairly low risk to try the switch. You will find out fairly quickly whether it works as well for her BP or not, and even if it’s slightly less effective, her provider could increase the dose a bit.
For most garden-variety hypertension, research suggests that which BP medication to use is less important than reaching a certain goal lower BP. So we usually try to find a medication that is affordable and has minimal side-effects. Hope this helps!
i am currently 63 years old and was on a higher daily dose of zestoretic from about 1992-2010 for 140/90 BP and slowly reduced my need (lower mg) for zestoretic by paying more attention to my health (diet, weight, exercise, etc), eventually (about 2014) i got down to 10mg of lisinopril (no more hctz) about once per week or as needed since i was monitoring BP at home. in late 2016, a new doctor recommended that i stop taking 10mg lisinopril, and my blood pressure was usually low about 100/60 after breakfast or exercise and would go up to about 130/90 in the evening. in 2017, my BP was 150/90 the morning before hernia surgery. anyway, long story short my BP seems to fluctuate a lot during the day, low (100/60) after exercise, low after breakfast, high (130/90) before going to bed. the low BP periods get shorter and shorter so i went back to taking 10mg lisinopril as needed, about once every 2 or 3 weeks and the low BP periods get long again. also my pulse seems to get higher (80) when my BP gets lower 100/60 and my pulse gets lower (70) when my BP gets higher (130/90). anyway, i recently moved so probably need to see another new doctor, but thought i would just let you know what is going on.
Fluctuations in BP throughout the day are pretty common; what you describe doesn’t sound exceptional or very worrisome, but of course it’s best to check on that with your doctor or someone who can examine you and review your health history.
Also common for the pulse to increase when the systolic blood pressure goes down, that is the heart compensating for low BP. In your case, it may or may not be an indication that your body is finding a systolic BP of 100 to be on the low side. I would consider a systolic BP of 100 to be low for someone on BP medications; there are a few medical conditions that warrant a lower BP but for garden-variety essential hypertension, I’m not aware of any randomized studies that have demonstrated better outcomes at such a lower SBP.
As you get established with your new doctor, you may want to discuss what your goal BP should be, and the likely benefits/risks of continuing on your current regimen. Good luck!
I find the information and the comments of your readers very helpful. Am not taking any BP medications but it is good to know how to maintain an acceptable BP especially for the elderly.
Thank you!
My blood pressure is usually between 180 – 190 systolic and 86 – 110 diastolic. I am 71 years old and have mitochondrial dysfunction. The symptoms are muscle weakness, chronic fatigue, rapid heartbeat when walking more than a few yards; hence I am extremely sedentary. I take 75g Losartan (UK brand?) plus 75g aspirin a day. My last blood pressure tests at the surgery and at the hospital didn’t seem to raise an eyebrow which really surprised me since they were very high as usual. Do you think this is due to my health condition? My feet and ankles are always swollen at the end of each day.
NB: before my mitochondrial condition (12 years ago) I was pretty fit and active and enjoying my life immensely and my blood pressure was lower but still not within a healthy range.
I am not very familiar with mitochondrial disorders, they are relatively uncommon. As far as I know, the symptoms usually relate to muscle problems. My guess would be that your high blood pressure is not particularly related. And even if it were related, that doesn’t explain why it shouldn’t be treated with anti-hypertensive medication or other approaches.
I would recommend asking your health providers to discuss your high BP with you. If you would like to reduce your cardiovascular risk, you should perhaps tell them this is important to you, and then ask for their help addressing your high BP. Good luck!