Skip Navigation
Skip to contents

CPP : Cardiovascular Prevention and Pharmacotherapy

Sumissioin : submit your manuscript
SEARCH
Search
Advanced Search
mobile menu button

Articles

Page Path
HOME > Cardiovasc Prev Pharmacother > Volume 7(4); 2025 > Article
Review Article
 Managing hypertension, diabetes, and dyslipidemia in frail older adults
Jung-Yeon Choi1,2orcid, Cheol-Ho Kim1orcid, Kwang-il Kim1,2orcid
Cardiovascular Prevention and Pharmacotherapy 2025;7(4):135-140.
DOI: https://doi.org/10.36011/cpp.2025.7.e16
Published online: October 22, 2025

1Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

Correspondence to Kwang-il, Kim, MD Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Email: kikim907@snu.ac.kr
• Received: July 18, 2025   • Revised: September 19, 2025   • Accepted: September 19, 2025

© 2025 Korean Society of Cardiovascular Disease Prevention; Korean Society of Cardiovascular Pharmacotherapy.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

prev next
Full Article

Download PDF Download PDF

  • As the population ages, the prevalence of chronic conditions, such as hypertension, type 2 diabetes, and dyslipidemia, is rapidly increasing, particularly among frail older adults. These conditions share common pathophysiological mechanisms and substantially contribute to the development of atherosclerotic cardiovascular disease. Effective management is essential for reducing cardiovascular risk; however, older adults present unique challenges, including multimorbidity, polypharmacy, cognitive decline, and functional impairment. Frailty further complicates clinical decision-making and necessitates individualized treatment strategies. This review examines current evidence and clinical guidelines for managing hypertension, diabetes, and dyslipidemia in older adults, with a focus on frailty status. It highlights the importance of assessing functional capacity and life expectancy and prioritizing treatments with favorable risk–benefit profiles. Specific recommendations are discussed according to frailty status, including when to initiate or deintensify therapy. Ultimately, a person-centered, geriatric-informed approach is critical to optimize outcomes and preserve quality of life in this vulnerable population.
  • Keywords: Hypertension; Diabetes mellitus; Aged; Dyslipidemias; Frailty
The global population of older adults is expanding rapidly, making them the fastest-growing age group. In Korea, the proportion of individuals aged 65 years and older reached 19.5%, surpassing 10 million, in July 2024. The country officially entered the stage of a super-aged society, defined as having more than 20% of the population aged 65 years or older, in December 2024. This proportion is projected to rise to approximately 44% by 2050 [1]. As the number of older adults increases, the demand for managing both acute and chronic diseases will intensify, leading to heavier burdens on healthcare resources and higher societal costs.
According to the 2020 National Survey of Living Conditions and Welfare Needs of Older Koreans, the five most prevalent chronic diseases were hypertension (56.8%–64.4%), diabetes mellitus (24.2%–29.0%), dyslipidemia (17.1%–38.9%), osteoarthritis (16.5%), and lumbar pain or sciatica (10%) [2]. Among older adults, 84% reported at least one chronic condition, 54.9% experienced multimorbidity with two or more chronic diseases, and 27.8% had three or more [2]. Analysis of outpatient care data from 2010 to 2019 for individuals aged 65 years and older, covered by the National Health Insurance of Korea, showed a high prevalence of polypharmacy: 42% were prescribed five or more medications, and about 12% were prescribed 10 or more [3]. In older adults, multimorbidity and polypharmacy increase the risk of drug-related adverse events, decrease adherence, and contribute to suboptimal chronic disease management.
Hypertension, type 2 diabetes, and dyslipidemia share several risk factors, including insulin resistance, sedentary lifestyle, and obesity. Through overlapping vascular pathophysiology, these conditions promote cardiovascular disease. Shared risk factors accelerate the development of atherosclerosis, vascular inflammation, endothelial dysfunction, and structural remodeling, resulting in both macrovascular and microvascular complications. When these diseases coexist, vascular injury and endothelial dysfunction are amplified [4,5].
In older adults, effective management of chronic conditions that contribute to cardiovascular disease is critical for prevention. However, therapeutic decision-making must account for frailty and other geriatric syndromes, with a strong emphasis on maintaining quality of life. This review focuses on the essential considerations for setting treatment goals and making clinical decisions regarding hypertension, type 2 diabetes, and dyslipidemia in older adults.
Frailty is conceptually defined as a clinically recognizable condition marked by increased vulnerability due to age-related declines in physiological reserve and multisystem function, resulting in diminished ability to withstand acute stressors [6]. Fried et al. [7] proposed an operational definition based on the presence of at least three of five criteria reflecting diminished physical capacity: reduced grip strength, low energy, slow walking speed, low physical activity, and unintentional weight loss. Alternatively, frailty may be operationalized using the deficit accumulation model, known as the frailty index, which quantifies risk according to the number of health deficits accumulated over time. These deficits may include disabilities, chronic diseases, cognitive and physical impairments, psychosocial vulnerabilities, and geriatric syndromes such as falls, delirium, and urinary incontinence [8].
In clinical practice, Comprehensive Geriatric Assessment (CGA) is frequently used to derive a multidimensional frailty score that helps predict outcomes in older patients, particularly after surgery [9]. CGA is a multidisciplinary diagnostic process that evaluates an older adult’s medical, functional, psychological, and social status, with the aim of developing a coordinated and individualized care plan to improve health outcomes and preserve independence. It is widely applied in geriatric medicine to guide clinical decision-making and optimize allocation of healthcare resources for frail older adults. In addition, the FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale, a brief five-item questionnaire, is commonly used to screen frailty status and estimate prognosis [10]. The Clinical Frailty Scale (CFS), a rapid tool that uses function-oriented descriptions and illustrations, has been validated in diverse care settings, including nursing homes, emergency departments, acute care wards, and intensive care units [11]. The CFS is particularly valuable for guiding therapeutic decisions and defining treatment goals in older adults with chronic disease [12].
The Hypertension in the Very Elderly Trial provided landmark evidence that lowering blood pressure in individuals aged 80 years and older is both safe and beneficial, significantly reducing the risks of stroke, heart failure, and mortality without increasing adverse events [13]. The SPRINT-senior cohort compared intensive treatment targeting systolic blood pressure <120 mmHg with standard treatment targeting 135 to 140 mmHg in adults aged 75 years and older. Older hypertensive patients tolerated intensive treatment well and experienced significant reductions in cardiovascular events and all-cause mortality [14]. Subsequent analyses indicated that frail older adults also derived net benefit from intensive blood pressure control, though they had a higher incidence of treatment-related side effects [15].
In frail older adults, vascular stiffness contributes to elevated systolic blood pressure and widened pulse pressure. Age-related changes further increase blood pressure variability, including postural fluctuations such as orthostatic hypotension [16]. Observational studies have shown that in individuals aged 60 years and older, both systolic and diastolic blood pressure decline during the decade preceding death, with this decline being more strongly linked to frailty than to multimorbidity [17]. Given the substantial heterogeneity in functional status among the very old, standardized treatment strategies cannot be uniformly applied.
Recent hypertension guidelines recommend a geriatric-oriented approach that incorporates assessment of functional status, frailty, and level of independence to guide individualized treatment. The 2024 European Society of Cardiology hypertension guideline endorses the use of the CFS, an intuitive tool validated against 5-year mortality risk, to assess frailty [12]. Older adults with a CFS score of 1 to 5, reflecting relative robustness, are generally recommended to receive active blood pressure management consistent with standard guidelines, including combination therapy, to reduce cardiovascular risk.
For individuals with a CFS score of 6 to 9, the risk–benefit balance of intensive blood pressure reduction is less certain. In such cases, shared decision-making is advised, with treatment initiated using monotherapy and close monitoring for orthostatic hypotension, preferably through ambulatory blood pressure monitoring [12].
First-line antihypertensive therapy may include a long-acting dihydropyridine calcium channel blocker, an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, or a low-dose thiazide or thiazide-like diuretic. In contrast, β-blockers are generally less favored because they may lower heart rate, induce fatigue, and increase systolic pulse wave amplitude, an effect poorly buffered by stiffened central elastic arteries [12].
When functional decline or reduced ability to perform activities of daily living occurs, treatment strategies should be carefully reevaluated, with consideration of deprescribing. Deprescribing may involve tapering or discontinuing one or more agents and monitoring blood pressure at intervals of at least 4 weeks [18]. Further randomized controlled trials and robust observational studies are required to clarify the benefit–risk profile of antihypertensive therapy in frail older populations [19].
According to the Diabetes Fact Sheet in Korea 2022, the prevalence of diabetes among adults aged 65 years and older was approximately 30.1%, meaning nearly 3 in 10 older adults were affected, up from 22.7% in 2012 [20]. The prevalence of prediabetes, a high-risk state for progression to diabetes, was 50.4% in this age group, affecting one in two older adults [21]. Older adults often present with multiple comorbidities and are frequently subject to polypharmacy. They also face heightened risks of cognitive impairment and depression. In addition, age-related changes in financial circumstances, social support systems, and living environments must be considered.
The primary goals of diabetes management in older adults are threefold: first, to control hyperglycemia and its symptoms while minimizing glycemic variability and preventing hypoglycemia; second, to prevent or delay complications; and third, to maintain overall health and support independent functioning [22].
The 2025 American Diabetes Association Standards of Care in Diabetes emphasize that management in older adults should be individualized according to overall health, cognitive and functional status, comorbidities, and life expectancy [23]. Rather than relying solely on chronological age, clinicians are encouraged to use instruments such as the CFS or CGA to tailor treatment intensity. Annual screening for geriatric syndromes is also recommended, as these syndromes significantly affect quality of life. For robust older adults, standard glycemic targets may be appropriate, whereas more relaxed goals are preferable for those with advanced frailty, cognitive decline, or limited life expectancy. The “4Ms (mentation, medications, mobility, and what matters most)” framework is likewise recommended to deliver person-centered, age-friendly care [24].
Prioritizing safety by minimizing hypoglycemia risk is essential in older patients with diabetes. This involves simplifying medication regimens, selecting agents with low hypoglycemia risk (e.g., avoiding sulfonylureas and sliding-scale insulin), and accounting for nonglycemic factors such as fall risk, depression, and treatment burden. Robust older adults may benefit from intensive glycemic control to reduce cardiovascular risk, whereas those who are frail, institutionalized, or in end-of-life care should follow more conservative glycemic targets and simplified treatment strategies [23].
The prevalence of dyslipidemia among adults aged 60 years and older ranges from 50% to 75% and increases with advancing age [25]. Lipid-lowering therapy remains a cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. In older adults, studies have shown that each 1-mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) corresponds to an approximate 20% to 25% decrease in major ASCVD events [26].
In adults aged 75 years and older with established ASCVD, moderate-intensity statin therapy is recommended for secondary prevention and is usually well tolerated [27]. Although statins are highly effective for lowering LDL-C and reducing ASCVD risk, concerns persist regarding possible adverse effects in older populations. These concerns include cognitive decline, functional impairment from statin-associated muscle symptoms, and increased risk of diabetes [22]. Although some studies have suggested an association between statin use and cognitive decline, subsequent research indicates that statins may actually reduce the risk of dementia by preventing cardiovascular events [28,29]. Statin-associated myopathy can occur at any age, but it is typically reversible after discontinuation [30]. In individuals with metabolic syndrome or those at high risk of diabetes, statin therapy has been associated with increased diabetes incidence in a dose-dependent manner [31,32]. Accordingly, when initiating statin therapy in older adults, clinicians should carefully balance potential risks against anticipated benefits and engage patients in shared decision-making. Based on the American Diabetes Association recommendations, management goals for diabetes, hypertension, and dyslipidemia according to health status are summarized in Table 1 [23].
As the global population ages, the burden of chronic diseases, such as hypertension, type 2 diabetes, and dyslipidemia, continues to rise, particularly among frail older adults. Effective management of these conditions is critical not only for reducing cardiovascular risk but also for preserving quality of life and functional independence. Treatment strategies, however, must be individualized, taking into account frailty, cognitive and functional capacity, life expectancy, and patient preferences. Current evidence supports a geriatric-centered approach that balances therapeutic benefits against potential risks, with an emphasis on safety, shared decision-making, and person-centered care. Further research is needed to refine therapeutic targets and optimize outcomes in this heterogeneous population.

Author contributions

Conceptualization: JYC, KIK; Investigation: JYC, CHK; Writing–original draft: JYC, CHK: Writing–review & editing: JYC, KIK. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Table 1.
Treatment goals for glycemia, blood pressure, and dyslipidemia in older adults considering frailty status
Health status Rationale Treatment goal
Hemoglobin A1c Fasting glucose Bedtime glucose Blood pressure Lipid management
Healthy Longer life expectancy <7.0%–7.5% (53–58 mmol/mol) 80–130 mg/dL (4.4–7.2 mmol/L) 80–180 mg/dL (4.4–10.0 mmol/L) <130/80 mmHg Statin recommended unless contraindicated or not tolerated
Complex/intermediate Variable life expectancy (goals should consider comorbidities, cognitive/functional limitations, frailty, medication risk-benefit, and patient preferences) <8.0% (<64 mmol/mol) 90–150 mg/dL (5.0–8.3 mmol/L) 100–180 mg/dL (5.6–10.0 mmol/L) <130/80 mmHg Statin recommended unless contraindicated or not tolerated
Very complex/poor health Limited life expectancy (benefits of intensive management likely minimal) Avoid A1c reliance; focus on preventing hypoglycemia and symptomatic hyperglycemia 100–180 mg/dL (5.6–10.0 mmol/L) 110–200 mg/dL (6.1–11.1 mmol/L) <140/90 mmHg Evaluate potential benefit before prescribing statin
  • 1. The Lancet Regional Health-Western Pacific. South Korea's population shift: challenges and opportunities. Lancet Reg Health West Pac 2023;36:100865.ArticlePubMedPMC
  • 2. Baek JY, Lee E, Jung HW, Jang IY. Geriatrics fact sheet in Korea 2021. Ann Geriatr Med Res 2021;25:65–71. ArticlePubMedPMCPDF
  • 3. Cho HJ, Chae J, Yoon SH, Kim DS. Aging and the prevalence of polypharmacy and hyper-polypharmacy among older adults in South Korea: a national retrospective study during 2010-2019. Front Pharmacol 2022;13:866318.ArticlePubMedPMC
  • 4. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Can J Cardiol 2018;34:575–84. ArticlePubMed
  • 5. Du Z, Qin Y. Dyslipidemia and cardiovascular disease: current knowledge, existing challenges, and new opportunities for management strategies. J Clin Med 2023;12:363.ArticlePubMedPMC
  • 6. Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med 2011;27:1–15. ArticlePubMedPMC
  • 7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–56. ArticlePubMed
  • 8. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001;1:323–36. ArticlePubMedPMCPDF
  • 9. Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg 2014;149:633–40. ArticlePubMed
  • 10. Jung HW, Yoo HJ, Park SY, Kim SW, Choi JY, Yoon SJ, et al. The Korean version of the FRAIL scale: clinical feasibility and validity of assessing the frailty status of Korean elderly. Korean J Intern Med 2016;31:594–600. ArticlePubMedPDF
  • 11. Ko RE, Moon SM, Kang D, Cho J, Chung CR, Lee Y, et al. Translation and validation of the korean version of the clinical frailty scale in older patients. BMC Geriatr 2021;21:47.ArticlePubMedPMCPDF
  • 12. McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024;45:3912–4018. ArticlePubMed
  • 13. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887–98. ArticlePubMed
  • 14. Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA 2016;315:2673–82. ArticlePubMedPMC
  • 15. Wang Z, Du X, Hua C, Li W, Zhang H, Liu X, et al. The effect of frailty on the efficacy and safety of intensive blood pressure control: a post hoc analysis of the SPRINT trial. Circulation 2023;148:565–74. ArticlePubMed
  • 16. Benetos A, Petrovic M, Strandberg T. Hypertension management in older and frail older patients. Circ Res 2019;124:1045–60. ArticlePubMed
  • 17. Delgado J, Bowman K, Ble A, Masoli J, Han Y, Henley W, et al. Blood pressure trajectories in the 20 years before death. JAMA Intern Med 2018;178:93–9. ArticlePubMed
  • 18. Sheppard JP, Benetos A, McManus RJ. Antihypertensive deprescribing in older adults: a practical guide. Curr Hypertens Rep 2022;24:571–80. ArticlePubMedPMCPDF
  • 19. Kraut R, Lundby C, Babenko O, Kamal A, Sadowski CA. Antihypertensive medication in frail older adults: a narrative review through a deprescribing lens. Am Heart J Plus 2022;17:100166.ArticlePubMedPMC
  • 20. Moon JS, Kang S, Choi JH, Lee KA, Moon JH, Chon S, et al. 2023 Clinical practice guidelines for diabetes management in Korea: full version recommendation of the Korean Diabetes Association. Diabetes Metab J 2024;48:546–708. ArticlePubMedPMCPDF
  • 21. Bae JH, Han KD, Ko SH, Yang YS, Choi JH, Choi KM, et al. Diabetes fact sheet in Korea 2021. Diabetes Metab J 2022;46:417–26. ArticlePubMedPMCPDF
  • 22. Yoo HJ. Comprehensive approach for managing the older person with diabetes mellitus. Diabetes Metab J 2017;41:155–9. ArticlePubMedPMCPDF
  • 23. American Diabetes Association Professional Practice Committee. 13. Older adults: standards of care in diabetes: 2025. Diabetes Care 2025;48(1 Suppl 1): S266–82. ArticlePubMed
  • 24. Cacchione PZ. Age-friendly health systems: the 4Ms framework. Clin Nurs Res 2020;29:139–40. ArticlePubMedPDF
  • 25. Jin ES, Shim JS, Kim SE, et al. Dyslipidemia fact sheet in South Korea, 2022. J Lipid Atheroscler 2023;12:237–51. ArticlePubMedPMCPDF
  • 26. Gencer B, Marston NA, Im K, Cannon CP, Sever P, Keech A, et al. Efficacy and safety of lowering LDL cholesterol in older patients: a systematic review and meta-analysis of randomised controlled trials. Lancet 2020;396:1637–43. ArticlePubMedPMC
  • 27. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2): S1–45. ArticlePubMed
  • 28. Muldoon MF, Ryan CM, Sereika SM, Flory JD, Manuck SB. Randomized trial of the effects of simvastatin on cognitive functioning in hypercholesterolemic adults. Am J Med 2004;117:823–9. ArticlePubMed
  • 29. Lee JW, Choi EA, Kim YS, Kim Y, You HS, Han YE, et al. Statin exposure and the risk of dementia in individuals with hypercholesterolaemia. J Intern Med 2020;288:689–98. ArticlePubMedPDF
  • 30. Iwere RB, Hewitt J. Myopathy in older people receiving statin therapy: a systematic review and meta-analysis. Br J Clin Pharmacol 2015;80:363–71. ArticlePubMedPMC
  • 31. Preiss D, Seshasai SR, Welsh P, Murphy SA, Ho JE, Waters DD, et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA 2011;305:2556–64. ArticlePubMed
  • 32. Navarese EP, Buffon A, Andreotti F, Kozinski M, Welton N, Fabiszak T, et al. Meta-analysis of impact of different types and doses of statins on new-onset diabetes mellitus. Am J Cardiol 2013;111:1123–30. ArticlePubMed

Figure & Data

References

    Citations

    Citations to this article as recorded by  

      Related articles
      Managing hypertension, diabetes, and dyslipidemia in frail older adults
      Managing hypertension, diabetes, and dyslipidemia in frail older adults
      Health status Rationale Treatment goal
      Hemoglobin A1c Fasting glucose Bedtime glucose Blood pressure Lipid management
      Healthy Longer life expectancy <7.0%–7.5% (53–58 mmol/mol) 80–130 mg/dL (4.4–7.2 mmol/L) 80–180 mg/dL (4.4–10.0 mmol/L) <130/80 mmHg Statin recommended unless contraindicated or not tolerated
      Complex/intermediate Variable life expectancy (goals should consider comorbidities, cognitive/functional limitations, frailty, medication risk-benefit, and patient preferences) <8.0% (<64 mmol/mol) 90–150 mg/dL (5.0–8.3 mmol/L) 100–180 mg/dL (5.6–10.0 mmol/L) <130/80 mmHg Statin recommended unless contraindicated or not tolerated
      Very complex/poor health Limited life expectancy (benefits of intensive management likely minimal) Avoid A1c reliance; focus on preventing hypoglycemia and symptomatic hyperglycemia 100–180 mg/dL (5.6–10.0 mmol/L) 110–200 mg/dL (6.1–11.1 mmol/L) <140/90 mmHg Evaluate potential benefit before prescribing statin
      Table 1. Treatment goals for glycemia, blood pressure, and dyslipidemia in older adults considering frailty status

      Table 1.

      CPP : Cardiovascular Prevention and Pharmacotherapy
      © Korean Society of Cardiovascular Disease Prevention; Korean Society of Cardiovascular Pharmacotherapy.
      TOP