Dear editor
Treating hypertension in patients over the age of 85 years, ie, the “old-old”, presents a challenge that is different from that encountered when treating any other age group. In 2010, individuals aged over 85 years were estimated to comprise 1.85% of the US population, with an estimate of 2.03% projected for 2025.1 Clearly, this is a small percentage, but not an insignificant number. When treating hypertension in patients over the age of 85 years, the usual target blood pressure is 150/80 mmHg for reduction of the risk of stroke, heart attack, and other cardiovascular events.2 In medical practice today, blood pressure is measured by a nurse or health worker using an automated blood pressure device, but not after a short rest, sitting or standing (as recommended to measure orthostatic hypotension, particularly if the patient is on treatment with antihypertensive medications). I will continue to emphasize orthostatic hypotension, since during sleep, the elderly – either under medication treatment, or not – frequently get out of bed during the night to urinate, which is associated with the usual drop in blood pressure during sleep.
Primary care physicians, nurse practitioners, and others caring for the elderly must recalibrate which target and which range to use to treat this group of patients.3 My feeling is “less is more” in this group of patients. Perhaps one might consider the mantra of the legendary coach of the Green Bay Packers, ie, “When you throw a foot ball, three things could happen, and two are bad”. This is not a bad maxim when writing a prescription.
Moving on to consideration of the specifics of this letter, I will present evidence for “less is more” in order to prevent the serious complications of hypertension in the elderly and other age groups. In a recent issue of the Philadelphia Inquirer, two distinguished physicians (RT Townsend, Hypertension Program, Hospital University Penn Program, and Muriel L Jessup, Penn Heart and Vascular Center) recommended treatment for people older than 60 years, those with a systolic blood pressure of 150 mmHg, those with diabetes or kidney disease, and those with a blood pressure greater than 140/90 mmHg.
In a recent issue of JAMA, a paper entitled “Updated guidelines for the management of high blood pressure”4 states that hypertension is a major risk factor for cardiovascular disease and stroke, but approximately 50% are not adequately controlled. In the US, the strong beliefs of patients, physicians, and pharmaceutical companies make the production of guidelines for managing hypertension a progressively more difficult and controversial process.4 Further, it has been commented that current performance measures for blood pressure control modeled after the Joint National Committee guidelines indicate that a clinician is expected to lower blood pressure in a hypertensive patient to <140/90 mmHg (or at least treat with 2–3 antihypertensive medications).4 A potential unintended consequence of this target is that it could encourage physicians to become more aggressive in their management of older patients, simply to meet a specific metric.
I am in no way suggesting collusion to increase the use of medication to treat hypertension in the elderly. A recent essay entitled “Big Pharma–Big Fines/Bigger Profits” indicates that the American Hospital Association spends lots of money to lobby pharmaceutical companies.5
My final point is that a study from the University of Leiden in the Netherlands has reported that a systolic blood pressure of 180 mmHg is associated with resilience to physical and cognitive decline in patients with pre-existing disability.6
Footnotes
Disclosure
The author reports no conflicts of interest relevant to this communication.
References
1. Editorial. Lessons of the Census. New York Times. Jul 27, 2010. [Accessed May 29, 2014]. Available from: http://www.nytimes.com/2010/07/27/opinion/27tue3.html?_r=0.
2. Beckett NS, Peters R, Fletcher AE, et al.HYVET Study Group Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–1898. [PubMed] [Google Scholar]
3. Finestone AJ. Are new parameters needed in treating the “old-old” Clin Geriatr. 2009;17:46–47. [Google Scholar]
4. Bauchner H, Fontanarosa PB, Golub RM, et al. Updated guidelines for management of high blood pressure. JAMA. 2014;311:477–478. [PubMed] [Google Scholar]
5. Bukata WR. Big Pharma–Big Fines/Bigger Profits. Essay. Primary Care Medical Abstracts. 2014;23:1–4. [Google Scholar]
6. Sabayan B, Oleksik AM, Maier AB, et al. High blood pressure in resilience to physical and cognitive decline in oldest old: the Leiden 85+ study. J Am Geriatr Soc. 2013;60:2014–2019. [PubMed] [Google Scholar]
I've spent a considerable amount of time delving into the nuances of hypertension management, especially in the elderly population. Let me establish my credibility by citing some evidence that aligns with the concepts discussed in the article you provided.
Firstly, addressing the specific target blood pressure for patients over 85 years, the article emphasizes a target of 150/80 mmHg for reducing the risk of stroke, heart attack, and other cardiovascular events. This aligns with contemporary medical guidelines and practices.
The mention of orthostatic hypotension and the importance of considering it in the elderly, especially during nocturnal activities like getting up to urinate, resonates with my understanding. It's a crucial factor that often goes unnoticed but can significantly impact blood pressure management.
Now, onto the "less is more" philosophy for this age group, the article suggests reconsidering the treatment targets for elderly patients, advocating for a more conservative approach. This echoes the sentiments of renowned physicians mentioned in the Philadelphia Inquirer, advocating treatment for individuals over 60 years with a systolic blood pressure of 150 mmHg or those with diabetes or kidney disease.
The reference to the JAMA paper, "Updated guidelines for the management of high blood pressure," highlights the challenges in controlling hypertension adequately. It underlines the complex interplay between patient beliefs, physician practices, and the influence of pharmaceutical companies in shaping guidelines.
The caution against potential unintended consequences, such as physicians becoming more aggressive in their management to meet specific metrics, is a valid concern and aligns with the ongoing debate in healthcare.
Finally, the reference to a study from the University of Leiden in the Netherlands, reporting that a systolic blood pressure of 180 mmHg is associated with resilience to physical and cognitive decline in patients with pre-existing disability, introduces an interesting perspective. It suggests that a one-size-fits-all approach may not be suitable for the elderly, and individualized care is crucial.
In conclusion, the evidence presented in the article emphasizes the need for a nuanced and individualized approach when treating hypertension in the elderly, considering factors like orthostatic hypotension and potential unintended consequences of strict blood pressure targets.
