Blood pressure medications — the balancing act of treatment

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

Blood pressure is one of those numbers that sounds simple but is actually complicated. High blood pressure is bad. Everyone knows that. It increases stroke risk, heart attack risk, kidney damage. But in older adults, the story is more complicated. Too-low blood pressure is also bad, especially low blood pressure that causes dizziness and increases fall risk. Your parent might be on blood pressure medications prescribed by one doctor, then another doctor says the target is too low, and now you're caught between two valid-sounding recommendations. Welcome to medication management where multiple conditions compete and there's no right answer, just trade-offs.

My father's blood pressure medication made him dizzy every afternoon. He'd have to sit down, sometimes for an hour, because the room was spinning. The medication was controlling his blood pressure beautifully. His numbers looked good. But he couldn't live his life. We spent months negotiating with his doctor to find a lower dose that was less aggressive but that he could actually tolerate. The medication was working. The dose just wasn't working for his life.

The complexity in older adults comes from the fact that your parent usually has multiple conditions that need management simultaneously. Blood pressure medication that helps their heart might make their diabetes harder to control. Medication that works great for blood pressure might interfere with kidney function. A dose that's appropriate for someone with a bigger body might be too much for someone who's frail. You're not just treating blood pressure. You're treating your parent as a whole complicated system.

Managing When Multiple Conditions Exist

If your parent has diabetes and high blood pressure, certain blood pressure medications are better than others. ACE inhibitors and ARBs help protect kidney function in diabetes and are often first-line choices. But they can cause high potassium levels, which is dangerous, so your parent needs regular blood work. Diuretics, which are water pills, can increase blood sugar and make diabetes harder to control. This doesn't mean your parent can't take them, just that the medication has trade-offs.

If your parent has heart failure, some blood pressure medications help and some hurt. ACE inhibitors and beta blockers actually help heart failure as well as lowering blood pressure. Diuretics help with the fluid overload of heart failure. But calcium channel blockers might not be ideal. The point is that the medication choice depends on the whole picture, not just blood pressure numbers.

Kidney disease complicates things further. As kidney function declines, how the body processes medications changes. Some medications can damage kidneys. Others need dose adjustment based on kidney function. Your parent's doctor should be checking kidney function regularly and adjusting medications accordingly. If you're not seeing regular blood work, ask about it.

Some medications interact in bad ways. Beta blockers, which are used for blood pressure and heart conditions, can slow the heart rate too much if combined with certain other medications. They can also cause fatigue or depression. If your parent is taking a beta blocker and complaining of feeling constantly exhausted, that might be the medication, and there might be alternatives.

When you have conflicting recommendations, it matters to understand the reasoning. If one doctor wants the blood pressure at 120 and another thinks 140 is acceptable, ask why. The guideline target for blood pressure has changed over the years. Older recommendations aimed for 140/90. Newer guidelines sometimes push for 130/80. But the evidence for pushing very hard in older adults is mixed. Someone who's 85 years old might do fine with blood pressure that's a bit higher than the guideline target. Someone who's 65 with recent stroke risk might need more aggressive control. Your parent's individual situation matters.

The Balancing Act

Dizziness from blood pressure medication is real and is one of the main reasons people don't take it consistently. When your parent stands up, blood pressure drops temporarily. This is normal. If they're on blood pressure medication, especially diuretics or certain other classes, the drop might be bigger. They get lightheaded, the room spins, they have to sit down. This is called orthostatic hypotension. It increases fall risk. If your parent is getting dizzy from their blood pressure medication, that's worth reporting to the doctor.

The problem is that the medication is working. The blood pressure is well controlled. The doctor might not want to lower the dose because the numbers look good. But if your parent can't function because they're dizzy all the time, the medication isn't really working for their life. You might need to have a conversation about acceptability. Is controlling blood pressure to a specific number more important than your parent being able to walk without falling?

Sometimes simple adjustments help. Taking the medication at a different time, with food instead of on an empty stomach, or changing how quickly your parent stands up can reduce dizziness. Increasing salt intake slightly might help, though this is controversial and depends on your parent's other conditions. Compression stockings can help blood pool less when standing. These aren't medication adjustments but they can improve tolerability.

Fatigue is another common complaint. Some beta blockers especially cause fatigue. Your parent might sleep twelve hours and still feel exhausted. If the medication started and the fatigue started around the same time, that's probably the connection. Again, the medication is lowering blood pressure, which is good. But if your parent can barely stay awake, you need to talk to the doctor about alternatives.

Monitoring at home can give you better information than office visits alone. Blood pressure varies throughout the day and with activity. What's measured in the doctor's office might not be representative. A home blood pressure monitor can show patterns. Is the blood pressure high all day, or just in the morning? Is it high with activity and lower at rest? This information helps doctors make better medication decisions.

Your parent should know their blood pressure numbers and their target range. If they're checking at home, they can see how medication changes affect their readings. They can notice if a medication dose change makes a difference. They become an active participant in management rather than just taking pills and hoping for the best.

Working With the Doctor

When your parent reports symptoms, you need to connect them to medication if that's likely the cause. Saying "I'm tired" is vague. Saying "I started feeling exhausted about two weeks after you prescribed this blood pressure medication, and I'm sleeping ten hours and still can't wake up" gives the doctor something to work with. Is this the medication? Is something else going on? Does the dose need adjustment? Does the medication need to change to something else?

Questioning medication targets is appropriate. If your parent's doctor is pushing for a very low blood pressure, it's fair to ask what the benefit is and what the risks are. What stroke or heart attack risk is your parent actually at? What's the evidence that getting blood pressure to 120 rather than 140 will make a meaningful difference in their life? Will they live longer or better? Or is the benefit mostly on paper, with side effects in real life?

Some people do benefit from aggressive blood pressure control. Others do fine with higher readings. Age matters, overall health matters, other medical conditions matter. Your parent's individual risk assessment should guide their target, not a one-size-fits-all number.

Medication timing and routine matter for compliance. If your parent takes blood pressure medication at dinner time, they need to remember to take it at dinner time, every day. If they take it at breakfast but sometimes skip breakfast, they skip the medication. Working with the pharmacist on a routine that fits your parent's actual life is more important than the perfect medication.

If your parent is taking multiple blood pressure medications, understanding what each one does helps with medication adherence. They might be on an ACE inhibitor, a diuretic, and a calcium channel blocker. Each works differently. The ACE inhibitor protects the kidneys and helps the heart. The diuretic removes excess fluid. The calcium channel blocker relaxes blood vessels. Together they control blood pressure better than any one alone, but each also has different side effects. If your parent understands why they're taking each one, they're more likely to keep taking them.

Your parent's blood pressure medication is probably preventing a stroke or heart attack. It's important. But it also needs to allow your parent to live their life without constant dizziness or fatigue or side effects that are worse than the condition they're treating. Finding the right balance between control and tolerability is what good medication management looks like.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.