Alpha-blockers for hypertension in the geriatric patient
Insights from the Clinical Department: Dr. Shiri Guy-Alfandary, PharmD.
Alert Category: Geriatric module
Case Description: Doxazosin in an 85-year-old elderly female
Clinical Rationale:
According to guidelines for preventing inappropriate medication use in older adults (1,2,3,4), α1-blockers (Doxazosin, Prazosin, Terazosin) are not recommended for the treatment of hypertension in the elderly due to their high risk of orthostatic hypotension, which may increase the likelihood of falls (see Table 1). Their use is generally limited to cases of resistant hypertension as a last-line option after all standard therapeutic approaches have been exhausted.
Despite these concerns, α1-blockers remain widely prescribed for benign prostatic hyperplasia (BPH) and are still part of the antihypertensive treatment landscape, yet some older patients may continue to receive these medications due to historical prescribing patterns. A large retrospective cohort study in Canada found that 2% of hypertensive women aged 65 and older were prescribed α1-blockers. This study demonstrated an increased risk of hospitalization or emergency department visits due to hypotension and syncope; however, it did not show a significant difference in fall or fracture risk compared to other antihypertensive agents (6).
Given their potential to worsen urinary incontinence in women and the lack of strong clinical justification for their use in most cases, α1-blockers are generally considered less appropriate for elderly female patients. Seegnal decision support system can provide targeted alerts based on patient characteristics, helping to identify high-risk prescribing patterns—such as the use of α1-blockers in elderly women—where the likelihood of clinical misalignment is significant.
Recommendation
It is advisable to reassess the need for α1-blocker therapy in elderly patients, weighing treatment goals against comorbidities. If necessary, alternative therapy should be considered. Discontinuation of α1-blockers should be performed gradually over one to two weeks, carefully monitoring blood pressure and potential adverse effects such as urinary retention, palpitations, and headache (3,5) .
Hypertension is one of the most prevalent chronic health conditions. Numerous studies have demonstrated a reduction in morbidity and mortality with appropriate anti-hypertensive therapy. Although α1-blockers remain part of the antihypertensive treatment arsenal, the evidence supporting their benefits in terms of morbidity and mortality is weaker compared to other antihypertensive drug classes. Their use is of particular concern in elderly, frail patients at high risk of falls.
Several guidelines are available to assist clinicians in re-evaluating and safely deprescribing these medications (5):
Deprescribing in high-risk populations: Prioritize discontinuation of α1-blockers in frail older adults at risk of falls unless there is a strong clinical indication for continued use.
Shared decision-making: Individualized treatment goals and management plans based on patient preferences, symptoms, and overall risk profile.
Confirm the diagnosis: Assess for the presence of orthostatic hypotension by measuring blood pressure in different postural positions and repeating the test if necessary.
Confirm the diagnosis: Assess for the presence of orthostatic hypotension by measuring blood pressure in different postural positions and repeating the test if necessary.
Frailty and functional assessment: Consider conducting a comprehensive geriatric assessment.
Contraindications: Evaluate for concerning symptoms or conditions, such as syncope or heart failure, that may contraindicate continued use.
Adverse effect assessment: Consider both cardiovascular and non-cardiovascular side effects. Fatigue is the most common, affecting 5% to 15% of patients. Sleep disturbances and anxiety may also occur with α1-blockers but are typically mild. Both fatigue and sleep disturbances can contribute to fall risk. Another relevant adverse effect, particularly in women, is worsening urinary incontinence.
References:
American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults, J Am Geriatr Soc. 2023 Jul;71(7):2052-2081., doi: 10.1111/jgs.18372. Epub 2023 May 4.
STOPP/START criteria for potentially inappropriate prescribing in older people: version 2, Age Ageing. 2015 Mar;44(2):213-8. doi: 10.1093/ageing/afu145. Epub 2014 Oct 16.
STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs, Age Ageing. 2021 Jun 28;50(4):1189-1199. doi: 10.1093/ageing/afaa249.
The FORTA (Fit fOR The Aged) List 2021: Fourth Version of a Validated Clinical Aid for Improved Pharmacotherapy in Older Adults, Drugs Aging. 2022 Mar;39(3):245-247. doi: 10.1007/s40266-022-00922-5. Epub 2022 Feb 23.
Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas—a clinical review, Eur Geriatr Med. 2023 Jul 12;14(4):675–682
Alpha-Blocker Use and the Risk of Hypotension and Hypotension-Related Clinical Events in Women of Advanced Age, Hypertension. 2019 Sep;74(3):645-651. doi10.1161/HYPERTENSIONAHA.119.13289. Epub 2019 Jul 22.
7.FDB database 1.2025