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. 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.
- 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
- 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.
- 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!)
Car DGP says
Hi, thank you for this article, very informative and easy to understand. So positive and encouraging!
I am 43 years old, female and usually have average BP of 136-145/85-95 for the last 3 years. However, lately, I was shocked when I got a reading as high as 165/100 a month ago. I am using Omron which I bought more than 7 years ago. My pulse rate is not more than 90 bpm. I had Annual Physical Exam – with slightly higher cholesterol, moderate fatty liver, within normal limit ECG finding, other internal organs with normal findings, as well. I have no other underlying illness, thanks God. My health provider constantly suggested lifestyle modification but not blood pressure medications yet. I gained 3 kgs within this month, and now weighed 76 kgs which falls under the Obese 1 category.
My office work requires me to sit long time for 8 hours and sometimes encountered stressful works. I rarely do exercise, if I can, I do yoga and walking but that is very RARE. Most of the time I feel tired due to work to even do simple exercises at home.
I have apprehensions on taking the BP maintenance because my health provider said it will be a lifetime maintenance. To keep my BP lower or at least maintain a 140/90 BP, I am taking herbal medicines, like cat’s claw capsule, potassium capsule, magnesium, garlic capsule, COQ10 and lowered my salt in-take. Still giving myself a chance to try to lose weight for 3 months, which according to my health provider might help to lower BP. Then if I fail to maintain such reading, will suggest that I go on medications. Our family history includes mother and some siblings with high BP.
At my age, and in this situation, can I maintain a BP of 140/90 for 6 months then aim a lower reading after that? Or having a reading of more than that on some occasions suggest BP medications already? I sometimes fear stoke or heart failures because of my elevated BP. Could that reading (165/100) give stroke or heart failure?
I hope you could enlighten me if my plan is correct. More as I have apprehensions to start lifetime medication at my age.
Thank you very much and Kudos to your very helpful article and responsiveness.
Nicole Didyk, MD says
I’m glad you like the articles!
I usually see older patients, but I can share the American Heart Association hypertension treatment guidelines:https://www.ahajournals.org/doi/pdf/10.1161/HYPERTENSIONAHA.120.15026?msclkid=c8e68e6ec67f11ec96c62d8c9aaa4bc7
I can understand being worried about having high blood pressure , and also worrying about being on medication, although blood pressure meds are not necessarily a lifelong commitment, and if a person makes a lot of progress with lifestyle changes, they may not require meds at all. For a low-risk person (no heart or kidney disease, diabetes, etc.), then trying for lifestyle change for 3-6 months is totally reasonable before starting medication.
Car DGP says
Thank you Very much for your response and help.
May I also ask what cause/s for a left arm SBP to be 20 mm HG higher than that of the right arm? Also, a 30 mm HG higher when in lying position that when in sitting position. This is my case.
Thank you again and more power!
Nicole Didyk, MD says
A higher blood pressure in one arm can be a sign of stiffening of the arteries, which can be serious. Of course, there are many things that can affect blood pressure measurement, so it’s important to make sure the readings are taken correctly. If this difference is persistent, it calls for a visit to the doctor.
Blood pressure is usually lower when sitting than lying down, but a big difference, accompanied by lightheadedness when the person stands up is called “postural hypotension”. Postural hypotension can be a risk factor for falls, so it’s worth talking to a doctor about that as well.
Car DGP says
Thank you for the very helpful information.
Robert Kelly says
My BP is borderline/elevated (130/80) but I am trying to address it with exercise, diet, mindfulness, rather than medication. Is there a timeline I should give myself, in terms of letting the behavior modifications have their effects? 6 months? A year? I don’t want to hurt myself in the process, by delaying medication, but I also don’t want to get on medication if these behavior changes are actually working to bring the BP into a good range.
A related, follow-up question about home BP monitoring: I am a generally anxious person, and more so about taking my BP (I can really work myself up into a tizzy when a reading comes back higher than average…catastrophic thinking, etc. etc.). Is there a cadence for checking BP that is adequate, but not so frequent that it raises anxiety/obsessiveness? Once a week? Once a month?
Nicole Didyk, MD says
Hello and it’s great that you’re being so engaged in managing your health!
Depending on your risk factors, the guidelines may vary, but for most, a trial of lifestyle change for 3 to 6 months is what’s recommended. After that, medication might be needed. You can look at the American Heart Association guidelines here.
Many people get anxious about BP measurement and that can increase the readings! It’s probably OK to check BP once every 3 months if you’re on a stable regimen. If you just can’t get a proper reading at home, consider gong to your health provider for a check, or ask for a 24 hour blood pressure assessment for greater accuracy.
Best of luck!
Robert Kelly says
thank you for your informative reply! you are providing help to a lot of people with your site.
Samuel Igbawua says
Your explanations are straight and easy to understand. I am 66 and have the problem of high BP as well, sometimes with pains in my neck. My question is, are there any natural ways of treating HP or are any herbal remedies to ailment?
Nicole Didyk, MD says
I’m glad you found the article easy to understand!
Many compounds have been studied in the treatment of hypertension: Vitamin D, calcium, magnesium, cacao, omega 3, garlic and coenzyme Q10 are just a few. As this article mentions, some of these therapies are promising but there isn’t a high level of evidence to recommend their use.
We always recommend non-medication lifestyle modifications to manage hypertension, such as a healthy diet high in vegetables and fruit, exercise, stress management and smoking cessation. Doing these things well can reduce the need for medication.
Steve C says
thanks so much for this article. It reinforces my faith in my GP of 40 years. I’m slightly shy of 69.
Every time he measures my BP it’s mid/high 140s/70, at odds with my home readings.
He suggested this method of home testing and to write down the results over a 2 week period.
My resting morning BP is consistently mid/high 120s/70, my evenings closer to mid 130s but never in the range he measures at his surgery (and he does have my arm slightly below my heart level when he does it?).
He did also mention that it is not so much what it reaches on occasion (within limits of course) but that the arterial pressure of my heart pumping can relax considerably – which he considers important
Nicole Didyk, MD says
I’m so glad you enjoyed the article and I’m happy to hear that you have a good relationship with your family doctor.
Many family doctors in Canada use an automated BP measurement device called BPTru, which takes several readings over 5-10 minutes (with the nurse or doctor out of the room) and then averages the readings. I notice BPTru has gone out of business, but hopefully a new manufacturer has stepped into the breach.
In any case, keep up the good work with monitoring your BP!
Hi, my mom is 67 and about two months back we found her bp was in range of 165-180/95-98. We got in touch with a doc and she diagnosed a couple of tests. RFT revealed she was high on uric acid (9) and creatine was 1.40. So she prescribed amlodipine 2.5mg morning (11am) and telma 40 night (9:30 pm) for BP and one medicine for uric acid. Things were under control for last 1.5 months as bp range was 122-135/75-82 range but now again been 4 days her bp has started shooting up to 147-157/82-84 range. Please if you can suggest what or where are we going wrong. She is on low sodium diet and exercises daily for 30 minutes. It’s really worrying us. Thanks!
Nicole Didyk, MD says
It’s great that you’re involved in your mom’s health care and helping her keep track of her blood pressure!
First of all, make sure you have a reliable monitor so that your readings are accurate. You can read more about choosing a blood pressure measurement device here.
Blood pressure can vary from day to day, and even depending on how much salt you’ve recently consumed, or what position your body is in when you take the reading. This article gives a good review of how to take a blood pressure reading at home: https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home
I would suggest keeping a good blood pressure journal and talking it over with your doctor to see if a medication adjustment is needed.
Dan Norris says
Approximately how long should one wait to see blood pressure lowering by making lifestyle changes such as eating according to the DASH diet, avoiding smoking, avoiding alcohol, and getting recommended amounts of aerobic and strength exercise, proper amounts of sleep, etc?
Nicole Didyk, MD says
It’s tough to answer your question, Dan.
Of course, there are immediate health benefits to quitting smoking and doing vigorous exercise, and those benefits only increase with sustained commitment to those new behaviours!
Most studies of the effect of “lifestyle” changes on blood pressure looked at results at 3 – 6 month intervals, and current guidelines recommend re-evaluating blood pressure after 3-6 months of behaviour change.
It’s helpful to look at the lifestyle changes you mention as a long-term journey towards better health. The American Heart Association has excellent resources about how to reduce the risk of a heart attack or stroke through behaviour change.
Dan Norris says
Thank you Doctor, I am making those changes I mentioned now and will evaluate in 3 to 6 months. I was asking to know if the life style changes didn’t work so well when to “throw in the towel” so to speak and seek medication as well.
Priscilla Martin says
I take many drugs for many comorbidities including hypertension. I have Parkinson’s. Morning BP medications taken one hour before BP check which includes BP meds.
Morning BPs since June ’21 range from 96/49 to 182/93. Evening BPs range from 102/76 to 179/97. Cardiologist attributes fluctuations to Parkinson’s and recent incidence on CHF to fluctuating BPs.
I have had many attacks of hypotension over the last 20 years with one recent incidence of 30/20. I have a previous diagnosis of MS 20 years ago. Neurologist put me on Midodrine in May.
Nicole Didyk, MD says
Postural hypotension, or a drop in blood pressure when a person stands up, can be a common symptom in Parkinson’s disease and other conditions. It can be severe enough to cause lightheadedness and even falls. Certain medications can make postural hypotension worse, and blood pressure pills are a common culprit.
The treatment of postural hypotension includes increasing intake of salt and fluid, and stopping any medications that might be making things worse, if possible. Midodrine tightens up the blood vessels, and can increase blood pressure, and can help alleviate symptoms in those with sever postural BP drop. I also use fludrocortisone, which is a corticosteroid (similar to prednisone) that promotes retention of fluid and salt.
Both of those medications can cause high blood pressure and other side effects, so their use usually requires a doctor’s supervision.
I hope the Midodrine works for you and thanks or taking the time to chare your experience.
Norma D Linn says
Could you PLEASE make these articles print friendly. They’re very long and would be far more useful to me if I could print them, read them and continue to refer to them as needed. I would only like to have the articles print friendly. The comments do not need to be.
Nicole Didyk, MD says
I’m glad to hear that the articles are worth printing out for you!
When printing from computer, it’s usually possible to choose which pages you would like printed in the printer dialog box that opens. This might be one strategy to only print the pages you need and save a few trees.
Hello mam, my grandfather age is 70 yrs and his bp is still at 160/100 after medication with telmisartan…. he is on hypertension medication for around 10 year…And when i visit to consultant who had strted this medication …he jst says no need to worry continue with medication…ot is okk…
But i am confused and worried is it really ok to have bp 160/100 with medication.
Nicole Didyk, MD says
I can understand being concerned about blood pressure readings like those. I can’t give specific medical advice over the internet, but I often suggest that my patients have a look at the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, which you can download here.
There may be some reason that the consultant didn’t want to make a medication change, related to the patient’s other medical issues or medications. Hypertension treatment is always individualized and guidelines are just an overview of what might be best for most people.
My father in law has high bp 180/100, he also had a bypass surgery few years ago.
What can we do to lower the bp.
Nicole Didyk, MD says
I can’t give medical advice over the internet, but your father in law is lucky to have such a concerned child! Blood pressure targets can vary depending on a person’s age and other medical issues. Check out the American Heart Association Guidelines, here.