NEW BLOG from Chris Farmer: Blood pressure medication in older people needs monitoring and review
Older people remain on blood pressure agents despite being hypotensive resulting in increased mortality and hospital admission.Yvonne Morrissey, Michael Bedford, Jean Irving, Chris K. T. Farmer
Age and Ageing 2016; 0: 1–6 doi: 10.1093/ageing/afw120
‘CHSS Clinical Professor Chris Farmer is a Consultant in Renal Medicine at East Kent Hospitals University NHS Foundation Trust. One of EKHUFT’s most prodigious researchers, Chris’ work has informed national policy in renal medicine.
Blood pressure medication in older people – the need for monitoring and review
‘High blood pressure (hypertension) may be detected at any age, but it is typically diagnosed in mid-life. High blood pressure does not cause symptoms. People take blood pressure tablets to reduce the risk of future strokes and heart disease. Once started, blood pressure medication may be continued for many years after. Over time changes in body composition and metabolism occur due to the ageing process. So the antihypertensive drug regime that suited the patient well in their 50’s or 60’s may be too much for them in their 70’s or 80’s.
With advancing age the patient may contract other medical ailments (co-morbidities) for which more medications are prescribed. By the time the patient reaches old age they may end up on quite a collection of tablets. What is more, the drugs prescribed for co-morbidities may lower blood pressure as a side effect. Medications for prostate symptoms for example also lower blood pressure.
In a recent paper, Professor Mary Tinetti1 demonstrated a ‘trade-off’ in older people with co-existing medical conditions between the benefits of blood pressure tablets to reduce the risk of future disease, and increased risks related to adverse effects of medication.
On the one hand the HYVET2 study demonstrated that blood pressure tablets reduce the risk of strokes and cardiovascular disease in older people. On the other hand it is argued the subjects of HYVET differed from the population we as Health Care of Older People physicians see on a clinical basis. For older patients with co-morbidities blood pressure tablets can be associated with falls and serious injuries.
We are becoming more cognizant of the need to be aware of the “heterogeneity” of the ageing population. We may need to take account of factors such as cognitive functioning, frailty and walking speed when considering antihypertensive treatment. In terms of evaluating outcomes of blood pressure treatment in older people it has been suggested that the effect on patient quality of life should be measured, as well as medical outcomes3.
In this study we found that a small but significant proportion of a population of primary care patients remain on antihypertensive drugs despite having low blood pressure. The data highlights the need for periodic re-evaluation of the older person’s antihypertensive medication regime to achieve the optimal level of blood pressure control for the individual. Furthermore, older people’s blood pressure varies throughout the day e.g. it drops on standing up and after meals; so we need to consider the effects of medication over the whole day.
One implication of this study is perhaps that clinical guidelines and quality standards in relation to blood pressure treatment should recognise the need for a more holistic and patient-centred approach for frail older people with medical complexity’.
1Beckett NS, et al. Treatment of hypertension in patients 80 years of age or older. The New England Journal of Medicine. 2008. 358(18):1887-1898
2Tinetti M, Ling H, Lee D et al. Antihypertensive Medications and Serious Fall Injuries in a Nationally Representative Sample of Older Adults. JAMA Internal Medicine 2014; 174(4):588-595. doi:10.1001/jamainternmed.2013.14764.
3Odden A discontinuation trial of antihypertensive treatment. The other side of the story. JAMA Internal Medicine 2015; 175(10):1630-1632
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