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To define: (1) the prevalence of and (2) factors associated with undertreatment of hypertension in older persons; and (3) the prevalence of specific drug regimens and reasons for their selection.Cross-sectional survey of persons aged ≥ 65 years living in Dicomano, Italy.Prevalence of untreated and uncontrolled hypertension, both defined on the basis of two blood pressure (BP) cut-off points (≥ 140/90 and ≥ 160/90 mmHg) and of the presence of pharmacological treatment. Predictors of undertreatment were analysed for the higher BP cut-off only.Five hundred of 692 (72.3%) and 380/692 (54.9%) participants met the 140/90 and the 160/90 mmHg BP criterion, respectively. Of the latter, 162 (42.6%) were untreated, 119 (31.3%) had uncontrolled and 99 (26.1%) controlled hypertension. Women [odds ratio (OR), 0.4; 95% confidence interval (CI), 0.2–0.7], participants with coronary artery disease (CAD) (OR, 0.2; 95% CI, 0.1–0.6), stroke (OR, 0.3; 95% CI, 0.1–0.7), and preserved cognitive status (Mini Mental State Examination score >21: 0.3; 95% CI, 0.2–0.7) were more frequently treated. Uncontrolled hypertension was less likely in women (OR, 0.5; 95% CI, 0.3–1.0) and CAD patients (OR, 0.3; 95% CI, 0.1–0.7). Angiotensin converting enzyme (ACE)-inhibitors (55%), calcium (Ca)-antagonists (31%) and diuretics (20%) were the drugs most commonly prescribed. ACE-inhibitors were preferred, and diuretics rarely used, in diabetic subjects. Ca-antagonists were used mostly in CAD participants.Hypertension is undertreated in the majority of noninstitutionalized older adults, especially in men with impaired cognition and no vascular disease. Drug regimens are mostly based on ACE-inhibitors and Ca-antagonists, as a result of associated clinical conditions, requiring individualized treatment.