Heart Palpitations in Older Adults: Causes, Risks, and Evaluation

Why palpitations matter with aging

Palpitations in older adults have a different clinical significance compared with younger individuals. As age increases, the structure of the heart, the electrical conduction system, and the body’s regulatory mechanisms that affect the heart naturally change. For this reason, palpitations in older adults are more often related to cardiac causes than in younger people. Atrial fibrillation, medications, heart failure, valvular heart disease, anemia, and thyroid disorders are among the most common causes of palpitations in older adults.

New-onset palpitations, increasing frequency, or palpitations that were not previously present in advanced age should always be taken seriously. The goal is not to create fear, but to ensure timely and appropriate evaluation.

How palpitations are perceived

Older individuals may not always describe palpitations as a “fast heartbeat.” They may perceive them as chest discomfort, a feeling of irregularity, skipped beats, a sudden empty sensation, or a sense of internal unease. In some people, these sensations are accompanied by dizziness, weakness, or reduced exercise capacity.

Palpitations may be more noticeable at rest, while lying down at night, or during sudden changes in body position. In some cases, this is related not to heart rate itself but to increased awareness of rhythm irregularity.

Age-related changes in cardiac rhythm

The electrical conduction system that ensures regular heartbeats undergoes structural and functional changes with aging. These changes can predispose the heart to a more irregular rhythm. Electrical signal pathways may slow down, or conduction blocks may develop in certain areas.

As a result, premature beats may become more frequent or the heart may lose its regular rhythm. This is one of the main reasons why palpitations in older adults are more commonly related to arrhythmias than in younger individuals.

Atrial fibrillation

Atrial fibrillation is one of the most important and most common causes of palpitations in advanced age. In this arrhythmia, the atria do not contract regularly, leading to an irregular heartbeat. Palpitations may be prominent in some patients, while in others they present only with fatigue and shortness of breath.

The importance of atrial fibrillation is not limited to causing palpitations. This arrhythmia increases the risk of stroke and may contribute to the development of heart failure. Therefore, atrial fibrillation should always be ruled out in older adults with new-onset or irregular palpitations.

High blood pressure and palpitations

High blood pressure is one of the most common conditions associated with palpitations in older adults. Long-standing, poorly controlled hypertension can lead to thickening of the heart muscle and enlargement of the cardiac chambers. These structural changes affect the heart’s electrical conduction system and create a substrate for arrhythmias.

In patients with a long history of hypertension, the risk of developing atrial fibrillation increases significantly. In addition, sudden rises or rapid drops in blood pressure can make heartbeats more noticeable. For this reason, blood pressure values must always be considered when evaluating palpitations in older patients.

Orthostatic hypotension

A sudden drop in blood pressure upon standing is a common but often overlooked cause of palpitations in older adults. This condition is known as orthostatic hypotension. Under normal circumstances, when a person stands up, the body rapidly adjusts heart rate and vascular tone to maintain blood pressure. With aging, this compensatory mechanism may become less effective.

Palpitations that occur after standing, accompanied by dizziness, lightheadedness, or blurred vision, result from a reflex increase in heart rate. Blood pressure medications, diuretics, inadequate fluid intake, and prolonged bed rest can all contribute to this condition.

Therefore, palpitations that begin with postural changes in older adults should always be evaluated for orthostatic hypotension.

Diabetes and palpitations

Diabetes has subtle but powerful effects on the cardiovascular system. Long-standing diabetes can damage the nerves that regulate the heart, making normal control of heart rate and rhythm more difficult.

In addition, diabetes increases the risk of atherosclerosis, impairing oxygen delivery to the heart muscle. This can lead to palpitations, arrhythmias, and exertion-related cardiac symptoms. In older adults with diabetes, palpitations may sometimes be the first sign of underlying heart disease.

Coronary artery disease

Atherosclerosis is very common in older adults. Narrowing or stiffening of the coronary arteries can reduce blood flow to the heart muscle. While this may present as chest pain in some patients, in others it may manifest only as palpitations.

Palpitations that begin during physical exertion or occur after exertion should prompt evaluation for coronary artery disease. When the heart muscle is under stress, rhythm disturbances are more likely to occur.

Medication-related palpitations

The number of medications used typically increases with age, making drug-related palpitations an important consideration. Some blood pressure medications, cardiac drugs, respiratory medications, thyroid medications, and even certain eye drops can affect heart rhythm.

In some cases, the issue is not a single medication but interactions between multiple drugs. Palpitations that begin after a new medication is started or after a dose change should always be evaluated. Reviewing all medications is essential when assessing palpitations in older adults.

Heart failure and valve disease

Weakening of the heart muscle or the presence of valvular heart disease is common in older adults. These structural heart conditions can cause the heart to function more irregularly, leading to palpitations.

In patients with heart failure, palpitations may result from an increased heart rate or from rhythm disturbances. In valvular disease, the increased workload on the heart makes arrhythmias more likely. In some cases, palpitations may be the first sign of an underlying structural heart problem.

Anemia and thyroid disorders

Yes. Anemia is a common but frequently overlooked cause of palpitations in older adults. When the blood’s oxygen-carrying capacity is reduced, the heart compensates by beating faster and more forcefully, leading to palpitations, easy fatigue, and shortness of breath.

Overactive thyroid function is another important cause of palpitations in older adults. Thyroid hormones directly affect heart rate and contractility. Palpitations in this setting may be accompanied by weight loss, increased sweating, and restlessness. Both conditions can be identified with simple blood tests and often improve once treated.

Treatment approach

Treatment of palpitations in older adults focuses on the underlying cause rather than the symptom itself. Not all palpitations require the same approach, and treatment must be individualized.

If palpitations are due to benign premature beats and do not significantly affect quality of life, simple follow-up may be sufficient. Reducing triggering factors and correcting underlying conditions is the primary strategy.

In patients with documented arrhythmias, medications may be used to control heart rate or rhythm. In conditions such as atrial fibrillation, controlling heart rate and assessing stroke risk are central to management. Anticoagulant therapy may be lifesaving and is often crucial regardless of the severity of palpitations.

If high blood pressure, diabetes, anemia, or thyroid disease is identified, effective treatment of these conditions may resolve palpitations completely. In some patients, palpitations disappear once the underlying problem is corrected.

In patients who do not respond adequately to medications or who have specific arrhythmias, interventional treatments may be considered. These decisions are made on an individual basis, taking into account age, overall health, and the type of arrhythmia.

Goals of treatment

The goal of treating palpitations in older adults is not merely to slow the heart rate. The primary objective is to identify the underlying cause, detect serious arrhythmias early, and prevent long-term risks such as stroke and heart failure.

With accurate diagnosis and appropriate treatment, palpitations can be safely controlled in most older individuals, and quality of life can be preserved.

Daily life considerations

In older adults with palpitations, regular blood pressure monitoring, correct and consistent use of medications, and avoidance of sudden medication changes are important. Excessive caffeine intake, dehydration, and irregular eating habits can worsen palpitations.

Observing when palpitations occur and under what circumstances improves the quality of information provided to the physician and facilitates accurate treatment planning.

When to seek medical attention

Not every palpitation in advanced age is an emergency, but certain situations require particular attention. New-onset palpitations in someone who has never experienced them before, palpitations accompanied by fainting or near-fainting, chest pain, marked shortness of breath, or sudden weakness should always be evaluated.

Increasing frequency, prolonged duration, or palpitations that begin to interfere with daily life may indicate an underlying cardiac problem and should not be ignored.