geriatrics
Drug Categories of Concern in Older Adults
Antihypertensives
In many older adults, lower starting doses of antihypertensives may be necessary to reduce risk of adverse effects; however, for most older adults with hypertension, achieving blood pressure goals requires standard doses and multidrug therapy. Initial treatment of hypertension in older adults typically involves a thiazide-type diuretic, angiotensin-converting enzyme (ACE) inhibitor,angiotensin IIreceptor blocker, or dihydropyridine calcium channel blocker, depending on comorbidities. Beta-blockers should be reserved for those with heart disease or for rate control of atrial fibrillation. Short-actingnifedipinemay increase mortality risk and should not be used. Sitting and standing blood pressure should be monitored, particularly when multiple antihypertensives are used, to check for orthostatic hypotension, which may increase risk of falls and fractures. Ambulatory or home blood pressure monitoring may also be more accurate in older adults than in-clinic blood pressures because many older adults suffer from white-coat syndrome (an increase in blood pressure while at a doctor's office) or masked hypertension (a decrease in blood pressure while at a doctor's office). Clinicians must balance the goals for blood pressure targets and risk of adverse effects in older adults (such as inducing orthostatic hypotension or increasing the risk for falls). 