[Treatment of hypertension in the elderly]

Although an increase in the systolic pressure is a physiological phenomenon of the ageing process, the beneficial effect of treatment in the elderly, in terms of reducing risk of cerebral vascular events, heart failure and coronary artery disease, leads to a common definition of hypertension in adults. A subject is considered to have hypertension if the systolic pressure is greater than 160 mmHg or the diastolic pressure is greater than 95 mmHg. A subject whose blood pressure is less than 140/90 mmHg is considered to be normotensive. The rules and strategy for the prescription of antihypertensive drugs remain the same whatever the age of the patient. But, despite the large number of drugs available, it is often difficult to obtain normal levels in the elderly. Treatment should thus be based on a pragmatic strategy, setting the target level as a function of the initial blood pressure. A decrease of 20 to 30 mmHg in the systolic pressure should be considered as a satisfactory result. In the elderly patient, the rule should be to limit prescription to two drugs since these patients risk exposure to interactions with other pharmaceutical classes because of the multiple disease situations encountered. In case of "non-response" to a two-drug regimen, the physician should carefully question patient compliance, search for an unrecognized primary cause, and reconsider the validity of pressure assessment at consultation. A third drug cannot be justified unless non-response has been confirmed with ambulatory or self-measurement of blood pressure levels.