With the life-expectancy increased, the older population expected to grow all around the world. Especially, the increase of elderly population leads to increase of vulnerable or frail elderly people, who require special consideration in caring and managing chronic medical condition. Considering the substantial diversity in the prevalence of chronic medical conditions and functional impairment, elderly people are often highly heterogeneous and their physiological ability and vulnerability vary widely even in same chronological age. However, most of the evidences regarding the treatment for the elderly people were derived from randomized clinical trial which included relatively fit elderly people. Accordingly, the results have limitations when we apply the results to our daily clinical practice.
Contrasts to fit people, frail elderly people are vulnerable to stressor, thus considered to be candidates for the less intensive treatment. For this reason, most of the hypertension guidelines recommended less strict blood pressure control for the oldest-old or frail elderly people because of concerns regarding adverse clinical outcome associated with low blood pressure. Nevertheless, there has been very few well-designed clinical trial in frail older adults to support the recommendation.
Recent data regarding strict blood pressure control in patients with increased cardiovascular risk showed lower rates of fatal and nonfatal major cardiovascular with intensive treatment. Furthermore, pre-specified subgroup analysis confirmed the benefit of strict blood pressure in patients older than 75 years. Interestingly, the benefits of strict blood pressure control were more prominent in pre-frail or frail elderly patients than fit elderly patients. These findings seem contradictory to the previous recommendation and usual belief. However, frail elderly people have more cardiovascular risk factors and are associated with adverse clinical outcomes. Thus, they are considered to be high risk group for the development of future cardiovascular morbidity and mortality. Accordingly, more strict blood pressure control should be applied to the frail elderly people considering the clinical significance of frailty in the development of future cardiovascular event.