Managing hypertension, diabetes, and dyslipidemia in frail older adults
Article information
Abstract
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.
INTRODUCTION
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.
WHAT IS FRAILTY?
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].
HOW TO MANAGE HYPERTENSION IN OLDER PATIENTS CONSIDERING FRAILTY STATUS
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].
HOW TO MANAGE TYPE 2 DIABETES IN OLDER PATIENTS CONSIDERING FRAILTY STATUS
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].
HOW TO MANAGE DYSLIPIDEMIA IN OLDER PATIENTS CONSIDERING FRAILTY STATUS
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].
Treatment goals for glycemia, blood pressure, and dyslipidemia in older adults considering frailty status
CONCLUSIONS
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.
Notes
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.