Irene had a blood pressure with the upper number over 190. This type of blood pressure, isolated systolic hypertension, is the strongest predictor of stroke. We helped verify she had a problem and then worked to get a blood pressure medication started.


Stroke is a leading cause of death among all American’s and the most disabling event for an older adult. Of those that have a stroke, 10% make a full recovery with rehabilitation, 40% have some mild to moderate loss of function, another 40% have significant functional loss and the remaining 10% are likely to need long term care in a nursing home. But if you modify certain risk factors for stroke then perhaps you can significantly reduce your risk of having a stroke. Important to understand is that high blood pressure is the single most significant risk factor for stroke in older adults.

About 2/3 of first strokes are attributable to hypertension so treating hypertension significantly reduces your risk of a stroke. But many older adults may be traveling with the assumption that the lower number, called diastolic blood pressure, is the most important. However, when we age that number usually stabilizes and then the higher number, the systolic blood pressure, tends to rise. The elevation of systolic blood pressure in the absence of high diastolic blood pressure is called “isolated systolic hypertension”. OK, I know that’s a lot, but if you can appreciate that the upper number is just as important as we age, if not more important, then you can monitor your blood pressure and manage your risk. Risk factors for hypertension are: smoking, high salt intake, lack of exercise, high body weight, diabetes, high cholesterol and aging itself.

Below is a table that classifies blood pressure in terms of severity by stage. The higher the numbers the greater the risk.

Class Systolic # (upper)
 Diastolic # (lower)
Normal <120 And <80
Prehypertension 120-139 Or 80-89
Stage I Hypertension 140-159 Or 90-99
Stage II Hypertension > or = 160 Or > = 100

Appreciate the following: In a wellness group I helped design, I found it revealing that in about 12% of participants, they had previously undetected and untreated isolated systolic hypertension.

Reducing Your Risk

What is encouraging is that you can greatly reduce your risk of a disabling stroke by first finding out your blood pressure and then treating it with medication to lower that upper number. When the upper number is high, medication is usually needed. There are many medications that can be used to treat high blood pressure and the use of these medications should be individualized. Not everybody should use the same medication but selection should be driven by several factors such as co-morbid conditions, like diabetes, which may warrant an antihypertensive agent that also protects the kidneys. Or perhaps you are allergic to thiazide diuretics and use a different medication. Regardless, if you know your blood pressure is high, work with your physician to get it down!

Drugs to be Cautious of

Some medications in older adults are associated with significant side-effects that can affect function or increase risk in other areas, such as causing sedation and low blood pressure thereby increasing fall risk. Drug selection is important as we age since we don’t want to add another complicating factor into our lives. Drugs used for hypertension can generally be well tolerated in older adults but some drugs, such as clonidine and some beta blockers, like atenolol and metoprolol, can cause drowsiness, fatigue and dry mouth which affects function and quality of life. Alpha blockers, drugs like doxazosin and terazosin are notorious for causing dizziness upon standing and may be a significant risk factor for falling in older adults. We generally recommend staying away from this class of drugs, if at all possible.

One drug that is a useful first-line agent in treating hypertension is hydrochlorothiazide (HCTZ). But the dose of HCTZ in most older adults should be no more than 25mg daily and most will respond to a dose of 12.5mg daily. The concern with higher doses is that dehydration can occur or, the loss of potassium which has other implications. HCTZ at higher doses can also have lingering effects on bladder function since diuresis can continue into the nighttime hours thereby making managing incontinence a challenge.

There are other ways to modify risk such as aerobic exercise, moderate weight loss, quitting smoking, and coping with stress. These approaches can work but many people do not find it easy to incorporate change into their daily routines, nor do people see the benefit in changing if they are over 70 years old thinking it’s too late. However, there are many older adults that do make changes in their lives, well into their 80′s, that benefit from those changes. By learning more about how you can improve your likelihood of successful aging through small changes in lifestyle, you are then more likely to make a beneficial change.