Hypertension in the frail elderly

Materson, Barry J.; Garcia-Estrada, Manuel; Preston, Richard A.

doi:10.1016/j.jash.2016.03.187

Cited by 26 publications

(16 citation statements)

References 33 publications

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“…In a recent meta-analysis comparing pro- and retrospective cohort studies, Zhang et al found that a higher SBP in frail oldest-old patients had a protective effect in lowering the risk of overall mortality [17]. Thus, current knowledge seems to be well summarized by Materson et al who suggested to evaluate and treat frail oldest-old patients individually, while the healthier oldest-old should be treated regardless of their chronological age [18]. …”

Section: Discussionmentioning

confidence: 99%

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

et al. 2017

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BackgroundIn oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision.MethodsUsing a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP.ResultsThe 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs’ decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48–0.59; ORs per country 0.11–1.78).ConclusionsAcross countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-017-0486-4) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

et al. 2017

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“…There is a need to carefully balance the risks and benefits of treatment in severely frail subjects. Indeed, there is no evidence in the latter that antihypertensive treatment reduces cardiovascular events or promotes established cognitive dysfunction,59 but much evidence suggesting that such treatment is not safe 60. Therefore, clinicians should carefully titrate BP lowering in persons with high comorbidity burden 5 60–62.…”

Section: Bp Goals For Older Adults With a High Burden Of Comorbidity mentioning

confidence: 99%

Blood pressure management in older people: balancing the risks

Naschitz

2018

Postgraduate Medical Journal

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Guidelines of arterial hypertension treatment based on individualised expected outcomes are not available for frail older persons. In this paper, we review the evidence, concerning management of arterial blood pressure (BP) in frail older patients. We focused on the best affordable methods for BP measurement; the age-related optimum BP; specific BP goals in agreement with the patients' general heath, frailty status, orthostatic and postprandial hypotension; balancing the benefits against risks of antihypertensive treatment. Lenient BP goals are generally recommended for older persons with moderate or severe frailty, multimorbidity and limited life expectancy. To this aim, there may be a need for deintensification of antihypertensive treatment.

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“…Taken together, this suggests that all elderly patients beneit from antihypertensive treatments, but there is an important caveat to both of these studies: enrolled patients tended to be relatively healthy patients and speciically excluded patients with heart failure, stroke, and end-stage renal disease [35,38]. The exclusion criteria for HYVET and SPRINT raise concern that their indings may not be generalizable to frail patients [43]. A subgroup analysis of patients enrolled in HYVET addressed this concern [44].…”

Section: Frailty and Hypertension (Htn)mentioning

confidence: 99%

Frailty and Cardiovascular Disease

Chainani¹,

Riehl²,

Chainani³

et al. 2017

Frailty and Sarcopenia - Onset, Development and Clinical Challenges

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Cardiovascular disease (CVD) comprises a vast spectrum of disease states ranging from hypertension (HTN) to valvular heart disease (VHD). CVD is known to be the leading cause of morbidity, mortality, and health-care expenditure throughout the world. According to the World Health Organization, coronary artery disease (CAD) and stroke, both subsets of CVD, are the world's biggest killers, accounting for a combined 15 million deaths in 2015. These diseases have remained the leading causes of death globally in the last 15 years. In 2010, CAD alone was projected to cost the U.S. $108.9 billion including the cost of health-care services, medications, and lost productivity. The presence of frailty signiicantly worsens outcomes for patients sufering from CAD. With just this one example of how frailty afects CVD, it is clear that understanding the impact of frailty upon patients alicted with the spectrum of cardiovascular disease is integral for the care of this very signiicant patient population.

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Hypertension in the frail elderly

Cited by 26 publications

References 33 publications

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

Blood pressure management in older people: balancing the risks

Frailty and Cardiovascular Disease

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