Hypertension is the most prevalent cardiovascular disease in the world. The greatest burden of hypertensive related cardiovascular disease occurs in the elderly, in whom the predominant form of hypertension is isolated systolic hypertension.

        Data from the third National Health and Nutrition Examination Survey (NHANES III) have shown that isolated systolic hypertension is the single most frequent subtype of hypertension by middle age and that isolated systolic hypertension becomes the overwhelmingly dominant form of hypertension after age 60.

        The population of India aged 60 years and above is estimated to increase from 55.3 million in 1991 to 75.9 million in 2001. The prevalence of hypertension is age related, being the highest in the age group of 50 - 59 years in male and 60 - 64 years in females in Urban areas. In rural areas an age related increase in seen with both series in the age group of 60 -64 years. A community based study in Mumbai in 1980 showed increase in BP with age, with prevalence in 15% of total population surveyed 34.5% in those over 55 yrs and 38.5% in those over 65 yrs and 44.4% in those over 70 yrs. A community based study carried out in Vellore showed the prevalence of hypertension at 30% in 50 - 54 age group and 40% in those above 55 yrs.

        In elderly population, Systolic Blood Pressure (SBP) is a better predictor of cardiovascular / cerebro vascular events, end stage renal disease and all cause mortality as compared to diastolic blood pressure. Data from the Framingham Heart study and Multiple Risk factor Intervention Trial (MRFIT) have provided evidences of the benefits of aggressively lowering SBP. This is particularly relevant to older individuals who frequently have an isolated elevation of SBP (140 mm of Hg or greater with a DBP below 90).

        In May 2000, the Coordinating committee of National Blood Pressure Education Programme issued a clinical advisory statement intended to advance and clarify the recommendations of sixth report of JNC (1997). The committee specifically recommended that SBP should become the principle clinical end point for the detection, evaluation and treatment of hypertension.

        Primary hypertension is by far the most common form of hypertension in elderly. However clinicians must recognize that certain identifiable causes of hypertension (e.g. atherosclerotic renovascular hypertension, primary aldosteronism) may occur more frequently in older persons especially in those whose hypertension first represented after age 60 or is resistant to treatment.

        Blood pressure must be measured in elderly with special care because some older persons have psuedohypertension (falsely high sphygmomanometer reading) due to excessive vascular stiffness. In addition more elder persons with hypertension especially women have white-coat hypertension and excessive variability of SBP. Older patients are more likely to exhibit an orthostatic fall in blood pressure and hypotension, thus in older patients, blood pressure should always be measured in the standing as well as seated or supine position.

    Treatment of hypertension in older persons have demonstrated major benefits. The systolic hypertension in the elderly programme (SHEP) in United States, the systolic hypertension in Europe (Syst-Eur) trial and systolic hypertension in China (Syst-China) trial published their main findings in 1991, 1997 and 1998 respectively. Overall active treatment compared with Placebo reduced all cause mortality by 17%, Cardiovascular mortality by 25% all cardiovascular end points by 32%, total stroke by 37% and myocardial infarction including sudden death by 25%.

    Hypertension therapy in elderly as in younger persons should begin with life style modification. Older patients will respond to modest salt reduction and weight loss. If goal blood pressure is not achieved, (140/90 in a person with no associated risk factors) then pharmacologic treatment is indicated. The starting dose in older patients should be about half of that used in younger patients.

        The sixth JVC report identified diuretics as initial therapy of choice with long acting dihydropyridine calcium channel blockers as an alternate if diuretics are ineffective or not well tolerated. Benefits of treatment were also noted with ACE inhibitore in the recent trials. The drugs regimen should be simple, starting with a low dose of a single drug that is titrated slowly. The selection of the first line antihypertensive agent should be based on a careful assessment of pathophysiological and clinical parameters in each individual geriatric patent.

   Although two guidelines (WHO/ISH and JNC VI th ) have recommended treating SBP to goal, there seems to be a reluctance in the medical community to embrace this paradigram shift and revise treatment plans. We must disseminate the new information and motivate physicians and other providers to include elderly hypertensives n their treatment plans.

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