This is a consensus guideline for the pharmacological management of hypertension with frailty. This information was developed by the Dalhousie University Academic Detailing Service and the Palliative and Therapeutic Harmonization (PATH) Program.

This guideline is unique in that it focuses equally on when to stop and when to start medications.  We recommend stopping antihypertensive medications that are used for the sole purpose of keeping the systolic blood pressure (SBP) below 140 mmHg, although we are unable to make treatment recommendations for frail older adults with previous stroke (see below).


  • Carefully review the risks and potential, but unproven, benefits of treatment.

Methods for measuring blood pressure

  • Decisions about treatment should be based on blood pressure measurements in the seated (not supine) position, while also considering the presence of orthostasis.
  • To evaluate orthostasis, measure BP lying, then immediately on standing and after 2 minutes.  Ask the patient if they feel lightheaded or dizzy when standing.

Stopping treatment

  • If sitting SBP is <140mmHg, medications can be tapered and discontinued to achieve the targets described in the guideline.
  • Before discontinuation, consider if the medications are treating additional conditions, such as rate control for atrial fibrillation or symptomatic management of heart failure.

We are unable to make treatment recommendations for frail older adults at high risk for cardiovascular events.  In particular, whether or not to discontinue treatment for individuals with a history of previous stroke is uncertain (see rationale: High Risk due to Previous Stroke)

Starting treatment

  • Consider starting treatment when SBP is ≥160mmHg.
  • Target SBP should be 140 to 160 mmHg while sitting as long as:
    • There is no orthostatic drop to <140 mmHg using the technique described above.
    • There are no adverse effects from treatment that affect quality of life.
    • See above recommendation regarding treatment of high risk individuals with previous stroke.
  • In the very frail with short life expectancy, a target SBP of 160 to 190 mmHg may be reasonable.
  • The blood pressure target does not need to change when there is a history of diabetes.
  • In general, use no more than 2 medications.

Click here for a pdf version of the information above.