Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care

  • Michelle Vu
  • Loren J. Schleiden
  • Michelle L. Harlan
  • Carolyn T. ThorpeEmail author
Guidelines/Clinical Trials/Meta-Analysis (WJ Kostis, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Guidelines/Clinical Trials/Meta-Analysis


Purpose of Review

We sought to summarize recent evidence regarding optimal blood pressure (BP) treatment targets and antihypertensive regimen intensity for nursing home (NH) residents and similar older, complex patients with hypertension.

Recent Findings

Recent trials have demonstrated cardiovascular benefits from more intensive BP targets among ambulatory, less complex older adults, but generalizability to NH residents is questionable. Other trials have demonstrated that de-intensifying antihypertensives in frail, older patients is feasible, with no or modest increases in BP, but most have not assessed effects on patient-centered outcomes. Observational studies with patients more representative of NH residents suggest harms associated with more intensive BP treatment and reduction in fall risk associated with deintensification, but findings and potential for bias vary across studies.


Randomized trials and rigorous observational studies examining effects of deintensified BP management on patient-centered outcomes in complex, older populations are needed to inform improved guidelines and treatment for NH residents.


Nursing homes Hypertension Antihypertensives Deprescribing Older adults Frailty 


Funding information

The authors’ work on this paper was supported by the U.S. Department of Veterans Affairs (IIR 14-306, PI C. Thorpe; Office of Academic Affairs Fellowship in Medication Safety & Pharmacy Outcomes, Michelle Vu).

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


The views expressed are those of the authors and do not represent the views of the Department of Veterans Affairs.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Harris-Kojetin L, Sengupta M, Lendon J, Rome V. Long-Term Care Providers and services users in the United States: data from the National Study of Long-Term Care Providers, 2015-2016. Vital Health Stat 3. 2019; x-xii:1–105.Google Scholar
  2. 2.
    Department of Health and Human Services. The future supply of long-term care workers in relation to the aging baby boom generation [Internet]. 2015. Available from: Accessed 4 September 2019.
  3. 3.
    U.S. Census Bureau. Population projections. 2014 National population projections: Summary tables. Table 3. Projections of the population by sex and selected age groups for the United States: 2015 to 2060 (NP2014–T3); and Table 6. Percent distribution of the projected population by sex and selected age groups for the United States: 2015 to 2060 (NP2014–T6). 2014. Available from:
  4. 4.
    Simonson W, Han LF, Davidson HE. Hypertension treatment and outcomes in US nursing homes: results from the US National Nursing Home Survey. J Am Med Dir Assoc. 2011;12:44–9.CrossRefGoogle Scholar
  5. 5.
    Könner F, Kuhnert R, Budnick A, Kolloch R, Scholze J, Dräger D, et al. Arterial hypertension, antihypertensive therapy, and visit-to-visit blood pressure variability of elderly nursing home residents. Dtsch Med Wochenschr. 2014;139:2441–7.CrossRefGoogle Scholar
  6. 6.
    Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F, et al. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in Older nursing home residents: the PARTAGE study. JAMA Intern Med. 2015;175:989–95.CrossRefGoogle Scholar
  7. 7.
    McCracken R, McCormack J, McGregor MJ, Wong ST, Garrison S. Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada. BMJ Open. 2017;7(8):e017430.CrossRefGoogle Scholar
  8. 8.
    Boockvar KS, Song W, Lee S, Intrator O. Hypertension treatment in US long-term nursing home residents with and without dementia. J Am Geriatr Soc. 2019.Google Scholar
  9. 9.
    Koka M, Joseph J, Aronow WS. Adequacy of control of hypertension in an academic nursing home. J Am Med Dir Assoc. 2007;8(8):538–40.CrossRefGoogle Scholar
  10. 10.
    Drawz PE, Bocirnea C, Greer KB, Kim J, Rader F, Murray P. Hypertension guideline adherence among nursing home patients. J Gen Intern Med. 2009;24:499–503.CrossRefGoogle Scholar
  11. 11.
    Krishnaswami A, Steinman MA, Goyal P, Zullo AR, Anderson TS, Birtcher KK, et al. Deprescribing in older adults with cardiovascular disease. J Am Coll Cardiol. 2019;73:2584–95.CrossRefGoogle Scholar
  12. 12.
    Mutasingwa DR, Ge H, Upshur RE. How applicable are clinical practice guidelines to elderly patients with comorbidities? Can Fam Physician. 2011;57:e253–62.PubMedPubMedCentralGoogle Scholar
  13. 13.
    James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.CrossRefGoogle Scholar
  14. 14.
    Athanase B, Bulpitt Christopher J, Mirko P, Andrea U, Enrico AR, Antonio C, et al. An expert opinion from the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects. Hypertension. 2016;67:820–5.CrossRefGoogle Scholar
  15. 15.
    Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104.CrossRefGoogle Scholar
  16. 16.
    Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017;33:557–76.CrossRefGoogle Scholar
  17. 17.
    Benetos A, Petrovic M, Strandberg T. Hypertension management in older and frail older patients. Circ Res. 2019;124:1045–60.CrossRefGoogle Scholar
  18. 18.
    Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673–82.CrossRefGoogle Scholar
  19. 19.
    Onder G, Vetrano DL, Villani ER, Carfì A, Lo Monaco MR, Cipriani MC, Manes Gravina E, Denkinger M, Pagano F, van der Roest HG, Bernabei R. Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors. J Am Med Dir Assoc. 2019; 20(9):1116–20.CrossRefGoogle Scholar
  20. 20.
    Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605–9.CrossRefGoogle Scholar
  21. 21.
    Huang X, Lin J, Demner-Fushman D. Evaluation of PICO as a knowledge representation for clinical questions. AMIA Annu Symp Proc. 2006;2006:359–63.PubMedCentralGoogle Scholar
  22. 22.
    Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension. 2018;71:e13–115.PubMedGoogle Scholar
  23. 23.
    Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166:430–7.CrossRefGoogle Scholar
  24. 24.
    Wilt TJ, Kansagara D, Qaseem A. Hypertension limbo: balancing benefits, harms, and patient preferences before we lower the bar on blood pressure. Ann Intern Med. 2018;168:369–70.CrossRefGoogle Scholar
  25. 25.
    Onder G, Landi F, Fusco D, Corsonello A, Tosato M, Battaglia M, et al. Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate medication use among elderly complex patients (CRIME) project. Drugs Aging. 2014;31:33–45.CrossRefGoogle Scholar
  26. 26.
    2019 American Geriatrics Society Beers Criteria® Update Expert Panel. 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67:674–94.Google Scholar
  27. 27.
    Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database Syst Rev. 2017;8:CD011575.PubMedGoogle Scholar
  28. 28.
    Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16.CrossRefGoogle Scholar
  29. 29.
    Odden MC, Peralta CA, Berlowitz DR, Johnson KC, Whittle J, Kitzman DW, et al. Effect of intensive blood pressure control on gait speed and mobility limitation in adults 75 years or older: a randomized clinical trial. JAMA Intern Med. 2017;177:500–7.CrossRefGoogle Scholar
  30. 30.
    Berlowitz DR, Foy CG, Kazis LE, Bolin LP, Conroy MB, Fitzpatrick P, et al. Effect of intensive blood-pressure treatment on patient-reported outcomes. N Engl J Med. 2017;377:733–44.CrossRefGoogle Scholar
  31. 31.
    Warwick J, Falaschetti E, Rockwood K, Mitnitski A, Thijs L, Beckett N, et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placeb. BMC Med. 2015;13:78.CrossRefGoogle Scholar
  32. 32.
    Kitagawa K, Yamamoto Y, Arima H, Maeda T, Sunami N, Kanzawa T, et al. Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: a randomized clinical trial and meta-analysis. JAMA Neurol. 2019.Google Scholar
  33. 33.
    Mant J, McManus RJ, Roalfe A, Fletcher K, Taylor CJ, Martin U, et al. Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (prevention after stroke—blood pressure) randomised controlled trial. BMJ. 2016;352:i708.CrossRefGoogle Scholar
  34. 34.
    Bath PM, Scutt P, Blackburn DJ, Ankolekar S, Krishnan K, Ballard C, et al. Intensive versus guideline blood pressure and lipid lowering in patients with previous stroke: main results from the pilot ‘prevention of decline in cognition after stroke trial’ (PODCAST) randomised controlled trial. PLoS One. 2017;12:e0164608.CrossRefGoogle Scholar
  35. 35.
    Gulla C, Flo E, Kjome RL, Husebo BS. Deprescribing antihypertensive treatment in nursing home patients and the effect on blood pressure. J Geriatr Cardiol. 2018;15:275–83.PubMedPubMedCentralGoogle Scholar
  36. 36.
    •• Moonen JE, Foster-Dingley JC, de Ruijter W, van der Grond J, Bertens AS, van Buchem MA, et al. Effect of discontinuation of antihypertensive treatment in elderly people on cognitive functioning--the DANTE Study Leiden: a randomized clinical trial. JAMA Intern Med. 2015;175:1622–30. This RCT included a relevant population of ambulatory, older adults with mild cognitive impairment and was the only recent RCT to include patient-centered, non-CV outcomes, specifically those associated with cognitive, psychological, and general daily functioning. Compared to usual care, deintensification or discontinuation of antihypertensives was associated with an increase in BP, but no harm or benefit in cognition or in secondary outcomes of functional and psychological assessments at 16-weeks. CrossRefGoogle Scholar
  37. 37.
    Sheppard JP, Burt J, Lown M, Temple E, Benson J, Ford GA, et al. OPtimising treatment for MIld systolic hypertension in the elderly (OPTiMISE): protocol for a randomised controlled non-inferiority trial. BMJ Open. 2018;8:e022930.CrossRefGoogle Scholar
  38. 38.
    Hernán MA, Robins JM. Using big data to emulate a target trial when a randomized trial is not available. Am J Epidemiol. 2016;183:758–64.CrossRefGoogle Scholar
  39. 39.
    Huitfeldt A, Hernan MA, Kalager M, Robins JM. Comparative effectiveness research using observational data: active comparators to emulate target trials with inactive comparators. EGEMS (Wash DC). 2016;4:1234.Google Scholar
  40. 40.
    Tinetti ME, Han L, Lee DS, McAvay GJ, Peduzzi P, Gross CP, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588–95.CrossRefGoogle Scholar
  41. 41.
    •• Song W, Intrator O, Lee S, Boockvar K. Antihypertensive drug deintensification and recurrent falls in long-term care. Health Serv Res. 2018;53:4066–86. This observational study included a representative population of nursing home residents diagnosed with hypertension and assessed the effect of antihypertensive deintensification on risk of recurrent falls, additionally identifying that this effect varies by baseline BP range. Deintensification was associated with a benefit of decreased likelihood of recurrent falls among those with the lowest BP ranges (80–100 mmHg), but also an increased risk of death in patients with SBP >100 mmHg to 120 mmHg, compared to those not deintensified. CrossRefGoogle Scholar
  42. 42.
    Marcum ZA, Perera S, Newman AB, Thorpe JM, Switzer GE, Gray SL, et al. Antihypertensive use and recurrent falls in community-dwelling older adults: findings from the health ABC study. J Gerontol A Biol Sci Med Sci. 2015;70:1562–8.CrossRefGoogle Scholar
  43. 43.
    Stessman J, Bursztyn M, Gershinsky Y, Hammerman-Rozenberg A, Jacobs JM. Hypertension and Its treatment at age 90 years: is there an association with 5-year mortality? J Am Med Dir Assoc. 2017;18:277.e13–9.CrossRefGoogle Scholar
  44. 44.
    •• Anderson TS., Jing B., Auerbach A., Wray CM., Lee S., Boscardin WJ., Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med. 2019;179(11):1528–36. This observational study was the only study in older adults to assess intensification of antihypertensive therapy and its association with CV and non-CV harm. The study minimized potential bias through a strong methodological design. Antihypertensive intensification at hospital discharge was associated with increased all-cause re-hospitalization rates and serious adverse events at 30-day follow-up, but there was no difference in CV events at one-year follow-up, compared to no intensification. There was an increased risk of CV events at 30-day follow-up in patients receiving antihypertensive intensification at discharge. Google Scholar
  45. 45.
    Hiremath S, Ruzicka M, Petrcich W, McCallum MK, Hundemer GL, Tanuseputro P, et al. Alpha-blocker use and the risk of hypotension and hypotension-related clinical events in women of advanced age. Hypertension. 2019;74:645–51.CrossRefGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020

Authors and Affiliations

  • Michelle Vu
    • 1
    • 2
  • Loren J. Schleiden
    • 1
    • 3
  • Michelle L. Harlan
    • 4
    • 5
  • Carolyn T. Thorpe
    • 1
    • 4
    Email author
  1. 1.Center for Health Equity Research and PromotionVeterans Affairs Pittsburgh Healthcare SystemPittsburghUSA
  2. 2.Center for Medication SafetyVeterans Affairs Pharmacy Benefits ManagementHinesUSA
  3. 3.Department of Pharmacy & TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghUSA
  4. 4.Division of Pharmaceutical Outcomes and Policy, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.Elon UniversityElonUSA

Personalised recommendations