Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents

Bénétos, Athanase; Labat, Carlos; Rossignol, Patrick; Fay, Renaud; Rolland, Yves; Valbusa, Filippo; Salvi, Paolo; Zamboni, Mauro; Manckoundia, Patrick; Hanon, Olivier; Gautier, Sylvie

doi:10.1001/jamainternmed.2014.8012

Cited by 245 publications

(158 citation statements)

References 22 publications

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“…14,16,17 According to Japanese guidelines, 17 home blood pressure measurement is useful for preventing an excessive or insufficient antihypertensive effect of drugs. To our knowledge, the Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population Study (PARTAGE) 18,19 is the only survey based on the self-measured blood pressure in octogenarians. High blood pressure did not entail an increased risk of all-cause mortality or major cardiovascular events.…”

Section: Hypertensionmentioning

confidence: 99%

“…In view of the uncertainty about blood pressure targets to be achieved in the very elderly, we assessed the predictive value of the self-measured home blood pressure in octogenarians enrolled in the International Database on Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO). 20 In line with the PARTAGE findings, 19 we stratified our analysis according to treatment status.…”

Section: Hypertensionmentioning

confidence: 99%

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Defining Thresholds for Home Blood Pressure Monitoring in Octogenarians

et al. 2015

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To generate outcome-driven thresholds for home blood pressure (BP) in the elderly, we analyzed 375 octogenarians (60.3% women; 83.0 years [mean]) enrolled in the International Database on home BP in relation to cardiovascular outcome. Over 5.5 years (median), 155 participants died, 76 from cardiovascular causes, whereas 104, 55, 36, and 51 experienced a cardiovascular, cardiac, coronary, or cerebrovascular event, respectively. In 202 untreated participants, home diastolic in the lowest fifth of the distribution (≤65.1 mm Hg) compared with the multivariable-adjusted average risk was associated with increased risk of cardiovascular mortality and morbidity (hazard ratios [HRs], ≥1.96; P ≤0.022), whereas the HR for cardiovascular mortality in the top fifth (≥82.0 mm Hg) was 0.37 ( P =0.034). Among 173 participants treated for hypertension, the HR for total mortality in the lowest fifth of systolic home BP (<126.9 mm Hg) was 2.09 ( P =0.020). In further analyses of home BP as continuous variable (per 1-SD increment), higher diastolic BP predicted lower cardiovascular mortality and morbidity and cardiac and coronary risk (HR≤0.65; P ≤0.039) in untreated participants. In those treated, cardiovascular morbidity was curvilinearly associated with systolic home BP with nadir at 148.6 mm Hg and with a 1.45 HR ( P =0.046) for a 1-SD decrease below this threshold. In conclusion, in untreated octogenarians, systolic home BP ≥152.4 and diastolic BP ≤65.1 mm Hg entails increased cardiovascular risk, whereas diastolic home BP ≥82 mm Hg minimizes risk. In those treated, systolic home BP <126.9 mm Hg was associated with increased total mortality with lowest risk at 148.6 mm Hg.

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Section: Hypertensionmentioning

confidence: 99%

Section: Hypertensionmentioning

confidence: 99%

Defining Thresholds for Home Blood Pressure Monitoring in Octogenarians

et al. 2015

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“…17,18 It has even been proposed that lowering BP in older persons using antihypertensive medication may decrease CBF. 3,[19][20][21] These observations have led to the suggestion that low BP in old age could result in cerebral hypoperfusion, initiated by impaired cerebral autoregulation. Nevertheless, in older persons with low BP at risk of impaired cerebral autoregulation, limited data are available as to whether CBF is in fact impaired.…”

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confidence: 99%

Blood Pressure Is Not Associated With Cerebral Blood Flow in Older Persons

et al. 2015

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Abstract-Many studies showing a relation between low blood pressure (BP) and adverse health outcomes in older persons suggest that low BP gives rise to reduced cerebral blood flow (CBF). However, limited evidence is available about this association. Baseline data of 203 participants in the Discontinuation of Antihypertensive Treatment in the Elderly (DANTE) trial were used (mean age, 81 years, using antihypertensive medication and with mild cognitive deficits). BP, BP changes on standing, and CBF derived from pseudo-continuous arterial spin-labeling magnetic resonance imaging were assessed in all participants. In 102 participants who were randomly assigned to 4-month continuation (n=47) or discontinuation of antihypertensive treatment (n=55), BP and CBF change were evaluated at 4-month follow-up. Systolic and diastolic BP were not associated with CBF (B=−0.21, P=0.50 and B=−1.07, P=0.07), neither were mean arterial pressure, pulse pressure, and BP changes on standing. In subgroups of participants with small vessel-related cerebral pathologies, including high white matter hyperintensity volume, microbleeds, and lacunar infarcts, or in participants with lower cognition or diabetes mellitus, no association was found between any BP parameters and CBF. Furthermore, compared to the continuation group, CBF change at 4 months was not different in the discontinuation group (B=−0.12, P=0.23). Contrary to the notion that lower BP in old age is associated with decreased CBF, our data do not show this association in older persons using antihypertensive medication and with mild cognitive deficits. Also, this association was not present in subgroups of more vulnerable persons, reflected by small vessel-related cerebral pathologies, lower cognition, or diabetes mellitus.

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“…The Milan Geriatrics 75+ Cohort study [32] found that higher BPs among older outpatients were associated with higher levels of cognitive function (10mmHg increase in SBP associated with 0.26 point (95% CI 0.13 to 0.40) rise in MMSE score; median BP of cohort 145/80mmHg). The PARTAGE study, conducted on French and Italian nursing home residents (mean MMSE 23), found higher mortality in those with low SBP (defined as <130mmHg) receiving multiple BPlowering medications (HR 1.78 95% CI 1.34 to 2.37), after adjustment for cardiovascular comorbidities [33]. For individuals with established cognitive impairment, recent cross-sectional data identified an association between low daytime SBP (< 128mmHg) and greater decline in MMSE score (mean -2.8 [SD 3.8]), in those treated with antihypertensive medications [34].…”

Section: Epidemiological Considerationsmentioning

confidence: 99%

New horizons: the management of hypertension in people with dementia

et al. 2016

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The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful.Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high blood pressure a risk factor for cognitive decline in mid-life, whilst low blood pressure is predictive in later life. It is therefore possible that excessive blood pressure lowering in older people with dementia might harm cognition. From the existing literature there is no direct evidence of benefit or harm from treating hypertension in people with dementia.So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions; use ambulatory monitoring to thoroughly assess blood pressure; individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits.Future research might include pragmatic randomised trials of targeted deprescribing which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties. KeywordsHypertension, dementia, deprescribing, decision making, individualise Key points Randomised trials in hypertension have generally excluded people with dementia  The relationship between cognitive decline and blood pressure is complex, with a change in risk association over the life course  Although direct evidence is lacking for the benefits of treatment of hypertension in older adults with dementia, there is no definitive evidence that treatment is harmful  We advise clinicians to individualise treatment whenever possible, guided by patient priorities  Future research should include pragmatic randomised trials of targeted deprescribing studies with patient-centred outcome measures

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Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents

Cited by 245 publications

References 22 publications

Defining Thresholds for Home Blood Pressure Monitoring in Octogenarians

Defining Thresholds for Home Blood Pressure Monitoring in Octogenarians

Blood Pressure Is Not Associated With Cerebral Blood Flow in Older Persons

New horizons: the management of hypertension in people with dementia

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