[The following post was first published on The Health Care Blog, on 2/28/14. I also wrote a related post for family caregivers here.]
When
it comes to high blood pressure treatment in the elderly, the plot continues to
thicken.
it comes to high blood pressure treatment in the elderly, the plot continues to
thicken.
Last
December, a minor controversy erupted when the JNC hypertension
guidelines
proposed a higher blood pressure (BP) treatment target (150/90) for adults aged
60+.
December, a minor controversy erupted when the JNC hypertension
guidelines
proposed a higher blood pressure (BP) treatment target (150/90) for adults aged
60+.
And
this month, a study in JAMA
Internal Medicine
reports that over 3 years, among a cohort of 4961 community-dwelling Medicare
patients aged 70+ and diagnosed with hypertension, those on blood pressure
medication had more serious falls.
this month, a study in JAMA
Internal Medicine
reports that over 3 years, among a cohort of 4961 community-dwelling Medicare
patients aged 70+ and diagnosed with hypertension, those on blood pressure
medication had more serious falls.
Serious
falls as in: emergency room visits or hospitalizations for fall-related
fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In
other words, we are talking about real injuries and real human suffering, as
well as real healthcare utilization.
falls as in: emergency room visits or hospitalizations for fall-related
fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In
other words, we are talking about real injuries and real human suffering, as
well as real healthcare utilization.
How
many more serious falls are we talking? The study cohort was divided into three
groups: no antihypertensive medication (14.1%), moderate intensity treatment
(54.6%), and high-intensity treatment (31.3%).
many more serious falls are we talking? The study cohort was divided into three
groups: no antihypertensive medication (14.1%), moderate intensity treatment
(54.6%), and high-intensity treatment (31.3%).
Over
the three year follow-up period, a serious fall injury happened to 7.5% of
those in the no-antihypertensive group, 9.8% of the moderate-intensity group,
and 8.2% of the high-intensity group. In a propensity-matched subcohort,
serious falls occurred in 7.1% of the no-treatment group, 8.6% of the
moderate-intensity group, and 8.5% of the high-intensity group.
(Propensity-matching is a technique meant to adjust for confounding differences
– such as comorbidities — between the three groups.)
the three year follow-up period, a serious fall injury happened to 7.5% of
those in the no-antihypertensive group, 9.8% of the moderate-intensity group,
and 8.2% of the high-intensity group. In a propensity-matched subcohort,
serious falls occurred in 7.1% of the no-treatment group, 8.6% of the
moderate-intensity group, and 8.5% of the high-intensity group.
(Propensity-matching is a technique meant to adjust for confounding differences
– such as comorbidities — between the three groups.)
Press
coverage of the study reported that moderate-intensity and high-intensity
antihypertensive treatment increased the risk of falls by 40% and 28%,
respectively, based on the following results:
coverage of the study reported that moderate-intensity and high-intensity
antihypertensive treatment increased the risk of falls by 40% and 28%,
respectively, based on the following results:
“The adjusted hazard ratios for serious
fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28
(95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with
nonusers.”
fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28
(95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with
nonusers.”
The
adjusted hazard ratios for serious fall injury were even higher among the 503
people with previous history of serious fall: “2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31
(95% CI, 1.01-5.29) for the high-intensity antihypertensive groups.”
adjusted hazard ratios for serious fall injury were even higher among the 503
people with previous history of serious fall: “2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31
(95% CI, 1.01-5.29) for the high-intensity antihypertensive groups.”
The
methodologists in the audience will undoubtedly go read the paper in detail and
find things to pick apart, especially as some results have not reached
statistical significance. For the rest of us, what are the practical
take-aways?
methodologists in the audience will undoubtedly go read the paper in detail and
find things to pick apart, especially as some results have not reached
statistical significance. For the rest of us, what are the practical
take-aways?
Key take-aways on falls and blood
pressure treatment
The
main one, in my mind, is that when it comes to people aged 70+, there are more risks to treating high blood pressure
than are commonly recognized by clinicians and patients. As the study authors note, real-world
Medicare beneficiaries often have more chronic conditions than the older adults
who are enrolled in randomized trials of blood pressure treatment.
main one, in my mind, is that when it comes to people aged 70+, there are more risks to treating high blood pressure
than are commonly recognized by clinicians and patients. As the study authors note, real-world
Medicare beneficiaries often have more chronic conditions than the older adults
who are enrolled in randomized trials of blood pressure treatment.
Reducing
the risk of cardiovascular events (the main purpose of treating high blood
pressure) is laudable, but it’s been hard to prove a benefit to getting most people’s
blood pressure below 150/90.
the risk of cardiovascular events (the main purpose of treating high blood
pressure) is laudable, but it’s been hard to prove a benefit to getting most people’s
blood pressure below 150/90.
Given
the findings of this study, we should probably be more careful about starting –
and continuing – treatment with blood pressure medications in elderly patients.
the findings of this study, we should probably be more careful about starting –
and continuing – treatment with blood pressure medications in elderly patients.
And we should be especially careful when
it comes to patients who seem prone to falls, or who are experiencing blood
pressure levels well below the target of 150/90.
it comes to patients who seem prone to falls, or who are experiencing blood
pressure levels well below the target of 150/90.
Because
right now, when it comes to treating high blood pressure in older adults, we
are often not careful. Meaning that many clinicians don’t:
right now, when it comes to treating high blood pressure in older adults, we
are often not careful. Meaning that many clinicians don’t:
- Ask about falls or
near-falls before starting or adjusting blood pressure meds.
- Get more blood
pressure data points before making an adjustment in therapy. The convention is
to treat at a visit based on the blood pressure that the staff just obtained.
It would be better to base treatment on multiple readings, preferably taken in
the patient’s usual environment.
- Check on blood
pressure soon after making an adjustment in therapy. Often patients have
their meds adjusted and nobody checks on things until the next face-to-face
visit…which might be 6 months away.
- Find out what the
patient is actually taking before making adjustments. When looking at a given BP number, we should confirm that the
patient is actually ingesting the meds we think they are, at the dose we think
they are. Needless to say, this isn’t always the case! Also occasionally
important to have figured out when medications were taken relative to when the
BP was checked.
- Act to reduce BP meds
in vulnerable elders. If
a frail older person on BP meds sits in front of me and registers SBP of less
than 120, I generally look into things a little more. (I ask about falls, and I
check orthostatics.) Why? Because now we seem to be fair ways below my usual
target SBP of 140s. Is this person on more medication than they need? Are they
dropping their BP into worrisome low range when they stand up?
Now,
I’d love to see all primary care clinics for older adults implement the ideas
above, but I’m not going to hold my breath. All of these ideas require a little
more time, which is tough to find in today’s busy primary care environment.
I’d love to see all primary care clinics for older adults implement the ideas
above, but I’m not going to hold my breath. All of these ideas require a little
more time, which is tough to find in today’s busy primary care environment.
And
that extra time is something that patients and families have to contribute as
well. Whether it’s time coming back to the office a little more often, or time
tracking BP at home and connecting remotely with the clinical team: until we
have the technology and systems to make monitoring and communication much
easier, being more careful means patients and families will have to put in a
little more effort.
that extra time is something that patients and families have to contribute as
well. Whether it’s time coming back to the office a little more often, or time
tracking BP at home and connecting remotely with the clinical team: until we
have the technology and systems to make monitoring and communication much
easier, being more careful means patients and families will have to put in a
little more effort.
Last
but not least, we don’t know if outcomes would improve if the strategies above
were routinely used in primary care. Specifically, we don’t know how changing
our approach to blood pressure might reduce falls and other bad outcomes in
older adults. (This JAMA study found
that telemonitoring and pharmacist-managed medication adjustment improved BP
control,
but it’s a younger population and didn’t study potential harms of treatment.)
but not least, we don’t know if outcomes would improve if the strategies above
were routinely used in primary care. Specifically, we don’t know how changing
our approach to blood pressure might reduce falls and other bad outcomes in
older adults. (This JAMA study found
that telemonitoring and pharmacist-managed medication adjustment improved BP
control,
but it’s a younger population and didn’t study potential harms of treatment.)
Still,
I do recommend
older adults get a good home blood pressure cuff, preferably one
with the tech capabilities to make it easy to share data with a clinical team.
If there have been any falls or near falls, taking a closer look at what is
happening with blood pressure could very well help.
I do recommend
older adults get a good home blood pressure cuff, preferably one
with the tech capabilities to make it easy to share data with a clinical team.
If there have been any falls or near falls, taking a closer look at what is
happening with blood pressure could very well help.
Less
(medication) is often more (safety and wellbeing).
(medication) is often more (safety and wellbeing).
