One quarter of Americans will be older than 80 by 2030, and hypertension in this group will be ubiquitous. Most studies of hypertension exclude octogenarians and are not able to be generalized because of differences in physio-logic and social phenomena. This review evaluates the existing literature in an effort to identify unresolved issues and guide future areas of investigation. Hypertension has been well characterized in adults and the young elderly, and the focus is on optimizing treatment regimens. However, research specifically involving this rapidly growing minority is sparse. Most studies are still trying to characterize blood pressure goals, and only one major series has begun to evaluate treatment options. Based on available evidence, it appears that an appropriate blood pressure goal may be somewhat higher in octogenarians and that thiazide diuretics may be the initial treatment of choice. J Clin Hypertens (Greenwich). 2012;14:711-717. Ó2012 Wiley Periodicals, Inc. By 2030, one quarter of Americans will be older than 80 years. 1 Such increased longevity is partially due to improvements in the treatment of chronic diseases, namely hypertension. A continuous, linear, age-related increase in systolic blood pressure (SBP) has been documented in both sexes and in most racial and ethnic groups. 2,3 Treatment of hypertension in octogenarians, however , is challenging. End-organ damage complicates management, and response is not as predictable as for younger adults because of differences in physiology. Cognitive and social needs, such as reliance on care-givers, further complicate circumstances. Most of the existing studies on hypertension have upper age limits of 70 to 75 years. Even when octoge-narians are included, it is only as a small subgroup, making these studies nongeneralizable. Therefore, the authors of this article decided to review the literature on treatment of hypertension in the elderly with the intention of better characterizing the issues surrounding and the specific needs of the octogenarian subgroup. HYPERTENSION PATHOPHYSIOLOGY Pathophysiologic changes of aging are markedly present in octogenarians. Recognition of these changes allows for better understanding and management of age-related hypertension. Cumulative exposures to oxidative stress contribute to endothelial dysfunction and hypertrophy of vascular cells. In turn, the relaxation factor nitric oxide is compromised , and vessels become less distensible. 4,5 This results in increased pulse wave velocity and SBP, restricting forward flow and limiting organ perfusion. Autonomic and baroreceptor dysfunction, cardiac arrhythmias and impaired cerebral adjustments lead to fluctuance in blood pressure (BP) and disruption of vascular homeostasis, further compromising perfusion. Resultant hypoperfusion leads to falls and cerebrovas-cular accidents, left ventricular hypertrophy, and acute coronary syndromes. 6 In addition to intrinsic vascular changes, kidney function deteriorates over time. The glomerular filtration rate (GFR) declines by 8 m...