High Blood Pressure (Hypertension) Care Staff Guide: NICE NG136

High blood pressure, also called hypertension, is very common, especially in older adults. It usually causes no symptoms, which is why it is so often missed. Left untreated, it puts strain on the blood vessels, heart, brain, kidneys and eyes. For care staff, understanding what the numbers mean, what treatment aims for, and what to report can make a real difference to residents' long-term health.

This guide covers the basics of hypertension, how it is diagnosed, the targets and medicines described in national guidance, and the practical part care staff play. It does not replace the advice of a resident's GP or pharmacist.

Why high blood pressure matters

The NHS explains that untreated high blood pressure increases the risk of heart disease, heart attacks, strokes, heart failure, kidney disease and vascular dementia. Risk factors include older age, a family history of high blood pressure, Black African, Black Caribbean or South Asian ethnic background, a diet high in salt, being overweight, smoking, drinking too much alcohol and long-term stress. Because many of these apply to people in care settings, blood pressure checks and reviews are a routine and important part of care.

Symptoms: usually none

The NHS is clear that there are usually no symptoms of high blood pressure. Rarely, people may have headaches, blurred vision or chest pain. The only way to know is to have blood pressure measured. Care staff should therefore never assume a resident's blood pressure is fine because they feel well.

Some symptoms need prompt action:

• Call NHS 111 or the GP if a resident has frequent headaches, blurred vision, chest pain that comes and goes, or other symptoms you think could relate to blood pressure.
• Call 999 for sudden chest pain or pressure that does not go away, pain spreading to the arm, neck, jaw, stomach or back, or chest pain with sweating, nausea, light-headedness or shortness of breath. These can be signs of a heart attack.

Sudden weakness on one side of the body, facial drooping or speech problems may point to a stroke, which is also a 999 emergency. Our guide to stroke recognition and the FAST test explains what to look for.

What the numbers mean

Blood pressure is written as two numbers, such as 140/90. The NHS says high blood pressure is usually indicated by a reading of 140/90 or higher in a clinic, or 135/85 or higher at home. NICE guideline NG136 sets out the stages:

• Stage 1 hypertension: clinic blood pressure of 140/90 to 159/99 mmHg, confirmed by an average of 135/85 to 149/94 mmHg on home or ambulatory monitoring.
• Stage 2 hypertension: clinic blood pressure of 160/100 to below 180/120 mmHg, with a home or ambulatory average of 150/95 mmHg or higher.
• Severe hypertension: clinic blood pressure of 180/120 mmHg or higher.

A single high reading does not diagnose hypertension. The NHS says people may be asked to take readings at home over several days, to return for a repeat check, or to wear a portable monitor for 24 hours. If you are asked to help with home monitoring, follow the device instructions and record every reading with the date and time. If a reading is very high, or the resident has symptoms, report it straight away using your escalation procedure.

Treatment targets in older people

NICE advises that for adults under 80, treatment aims to bring clinic blood pressure below 140/90 mmHg, and for adults aged 80 or over, below 150/90 mmHg. NICE also states that clinicians should use clinical judgement for people with frailty or multimorbidity. This is important in care homes, where a target that suits one person may not suit another. Care staff should not decide whether a reading is acceptable for a resident. Instead, follow the personalised advice in the care plan.

Medicines for high blood pressure

The NHS notes that most blood pressure medicines are taken as tablets once a day and that more than one may be needed. NICE guidance describes the usual first choices:

• An ACE inhibitor or an angiotensin II receptor blocker for adults with type 2 diabetes, or those under 55 who are not of Black African or African-Caribbean family origin.
• A calcium-channel blocker for adults aged 55 or over without type 2 diabetes, and for people of Black African or African-Caribbean family origin without type 2 diabetes.
• A thiazide-like diuretic, such as indapamide, if a calcium-channel blocker is not tolerated, for example because of ankle swelling, or alongside heart failure treatment.

NICE gives a cough as an example of why an ACE inhibitor might not be tolerated. Care staff are often the first to notice side effects such as a new cough, swollen ankles or dizziness. Report these rather than waiting for the next review, and never stop a blood pressure medicine without advice. Our guide to polypharmacy and deprescribing explains why regular medicines reviews matter for residents on several tablets.

Low blood pressure on standing

Treatment can sometimes lower blood pressure too far when a person stands up. NICE advises measuring blood pressure lying down and again after standing for at least one minute in people with symptoms such as falls or dizziness on standing. A fall in systolic pressure of 20 mmHg or more, or in diastolic pressure of 10 mmHg or more, is considered significant, and medicines may need to be reviewed. NICE also recommends checking for this in people with hypertension who are aged 80 or over or who have type 2 diabetes. Report any resident who feels faint, dizzy or unsteady after standing up, and see our guide to postural hypotension for practical steps.

Lifestyle support

The NHS recommends a healthy, balanced diet, at least 150 minutes of exercise a week where possible, losing weight if overweight, cutting down on salt, limiting caffeine and alcohol (no more than 14 units a week), and not smoking. In a care setting, that means offering lower-salt choices, encouraging movement that suits each person, and supporting residents who wish to cut down on alcohol or smoking. Choices belong to the resident, and any dietary change should respect their preferences and care plan.

Reviews and monitoring

NICE recommends an annual review of care for adults with hypertension, covering blood pressure, symptoms, lifestyle and medication. Before moving to the next treatment step, clinicians should check that medicines are being taken and are at the best tolerated dose. Accurate medication records and prompt reporting of missed doses help clinicians make the right decisions.

Frequently asked questions

Can a resident have high blood pressure and feel perfectly well?

Yes. The NHS says there are usually no symptoms, so regular checks matter.

Is one high reading a reason to panic?

No. A single reading is not a diagnosis. However, a very high reading, or any reading with symptoms such as chest pain, severe headache or blurred vision, should be reported at once.

Should care staff change a resident's blood pressure tablets?

No. Only the prescriber or pharmacist should change medicines. Staff should record doses accurately and report side effects.

Keep learning

Long-term conditions like hypertension appear in nearly every care setting. Explore our CPD learning for care staff to build confidence in recognising and responding to health changes. This article draws on the NHS high blood pressure pages (reviewed July 2024) and NICE guideline NG136.