I’m pleased to see this in detail exploration of the topic of blood pressure control in the elderly, since I’ve wondered about it for quite awhile. The take home message is slightly nuanced in that the investigators find that tighter control in vigorous elderly (85 and older-people still playing tennis, hiking etc…) is warranted. But looser control in the more frail elderly who are more prone to falling and dizziness. All medications are more dangerous in the elderly because of slower metabolism, so dosage is very tricky. They say 140/90 is a decent blood pressure to shoot for.

The medical guidelines for treating hypertension, set by a Joint National Committee in 2003 (and about to be updated) established a goal of 140/90; the systolic reading, the first of the two numbers, is the more important measure in people over age 50. The guidelines recommend medication for people who have higher blood pressure (as more than two-thirds of those over age 65 do) because of the well-established risk of heart attack and stroke. The recommendations don’t differ for the very old, but perhaps they should.

“The paradigm in medicine is, high blood pressure is bad, treating it is good,” Dr. Odden said. “We’re saying, maybe we need to look more closely at the guidelines and tailor them more to older adults.” Her study shows that “it’s not just age, it’s your physiology, your functional status, frailty” that matters…

It’s a conversation worth having with a doctor, though hypertension treatment has become so reflexive that it could be a tough discussion. “Few physicians are aware of these findings, and they’re going to be suspicious,” Dr. Goodwin said.

But give it a try anyway, he said: “We have to bring the complexity of decision making in the elderly into the light of day.”