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Blood Pressure in Older Adults: the Importance of Frailty

  • Resistant Hypertension (E Pimenta, Section Editor)
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Abstract

The importance of high blood pressure (BP) and the effect of BP lowering in older adults remain controversial due to the mixed evidence in this population. Frailty status may resolve the apparently conflicting findings and identify subpopulations who share common risk. Emerging evidence demonstrates that low BP is associated with poor outcomes in older frail adults or those with poor functional status. In contrast, in non-frail older adults, low BP appears beneficial. Frail older adults may be at increased risk of hypotension, serious fall injuries, and polypharmacy. Additionally, peripheral BP may not be the best prognostic measure in this population. The majority of clinical practice guidelines give little recommendation for frail older adults, which is likely due to their systematic underrepresentation in randomized controlled trials. Future studies need to consider modifications to safely include frail older adults, and guidelines should consider inclusion of evidence beyond randomized controlled trials.

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References

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

  1. McDonald M, Hertz RP, Unger AN, et al. Prevalence, awareness, and management of hypertension, dyslipidemia, and diabetes among United States adults aged 65 and older. J Gerontol A Biol Sci Med Sci. 2009;64(2):256–63.

    Article  PubMed  Google Scholar 

  2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.

    Article  PubMed  Google Scholar 

  3. Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol A Biol Sci Med Sci. 2003;58(7):653–8.

    Article  PubMed  Google Scholar 

  4. Diehr P, Williamson J, Burke GL, et al. The aging and dying processes and the health of older adults. J Clin Epidemiol. 2002;55(3):269–78.

    Article  PubMed  Google Scholar 

  5. Mattila K, Haavisto M, Rajala S, et al. Blood pressure and five year survival in the very old. Br Med J (Clin Res Ed). 1988;296(6626):887–9.

    Article  CAS  Google Scholar 

  6. Poortvliet RK, de Ruijter W, de Craen AJ, et al. Blood pressure trends and mortality: the Leiden 85-plus Study. J Hypertens. 2013;31(1):63–70.

    Article  CAS  PubMed  Google Scholar 

  7. Dorresteijn JA, van der Graaf Y, Spiering W, et al. Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease: J-curve revisited. Hypertension. 2012;59(1):14–21.

    Article  CAS  PubMed  Google Scholar 

  8. Vishram JK, Borglykke A, Andreasen AH, et al. Impact of age on the importance of systolic and diastolic blood pressures for stroke risk: the MOnica, Risk, Genetics, Archiving, and Monograph (MORGAM) Project. Hypertension. 2012;60(5):1117–23.

    Article  CAS  PubMed  Google Scholar 

  9. Sabayan B, Oleksik AM, Maier AB, et al. High blood pressure and resilience to physical and cognitive decline in the oldest old: the Leiden 85-plus Study. J Am Geriatr Soc. 2012;60(11):2014–9.

    PubMed  Google Scholar 

  10. Mossello E, Pieraccioli M, Nesti N, et al. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med. 2015;175(4):578–85. In patients with dementia or mild cognitive impairment, the authors found that among those treated with antihypertensives, those with the lowest daytime systolic blood pressure had the greatest decline in cognitive function.

    Article  PubMed  Google Scholar 

  11. Abreo AP, Glidden D, Painter P, et al. Association of physical function with predialysis blood pressure in patients on hemodialysis. BMC Nephrol. 2014;15:177.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.

  13. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet. 2014;383(9932):1899–911.

  14. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  15. Rockwood K, Stadnyk K, MacKnight C, et al. A brief clinical instrument to classify frailty in elderly people. Lancet. 1999;353(9148):205–6.

    Article  CAS  PubMed  Google Scholar 

  16. Odden MC, Peralta CA, Haan MN, et al. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med. 2012;172(15):1162–8. This was the first study to report a differential association of blood pressure and mortality by frailty status, as measured by performance on a gait test.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Odden MC, Covinsky KE, Neuhaus JM, et al. The association of blood pressure and mortality differs by self-reported walking speed in older Latinos. J Gerontol A Biol Sci Med Sci. 2012;67(9):977–83.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Peralta CA, Katz R, Newman AB, et al. Systolic and diastolic blood pressure, incident cardiovascular events, and death in elderly persons: the role of functional limitation in the cardiovascular health study. Hypertension. 2014;64(3):472–80.

    Article  CAS  PubMed  Google Scholar 

  19. Sabayan B, van Vliet P, de Ruijter W, et al. High blood pressure, physical and cognitive function, and risk of stroke in the oldest old: the Leiden 85-plus Study. Stroke. 2013;44(1):15–20. This study examined both physical and cognitive function as markers of frailty and found higher blood pressure was associated with lower risk of stroke in those with poor function.

    Article  PubMed  Google Scholar 

  20. Benetos A, Labat C, Rossignol P, 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. Published online. This observational study found that in nursing home residents, who are likely to be frail, the combination of multiple medications and lower blood pressure was associated with increased risk of mortality.

  21. Sardar MR, Badri M, Prince CT, et al. Underrepresentation of women, elderly patients, and racial minorities in the randomized trials used for cardiovascular guidelines. JAMA Intern Med. 2014;174(11):1868–70.

    Article  PubMed  Google Scholar 

  22. Golomb BA, Chan VT, Evans MA, et al. The older the better: are elderly study participants more non-representative? A cross-sectional analysis of clinical trial and observational study samples. BMJ Open. 2012;2(6).

  23. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98.

    Article  CAS  PubMed  Google Scholar 

  24. Odden MC, Peralta CA, Covinsky KE. Walking speed is a useful marker of frailty in older persons—reply. JAMA Intern Med. 2013;173(4):325–6.

    Article  PubMed  Google Scholar 

  25. Bejan-Angoulvant T, Saadatian-Elahi M, Wright JM, et al. Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. J Hypertens. 2010;28(7):1366–72.

    Article  CAS  PubMed  Google Scholar 

  26. Ambrosius WT, Sink KM, Foy CG, et al. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials. 2014;11(5):532–46.

    Article  PubMed  Google Scholar 

  27. Hajjar I. Commentary on Goodwin’s “Embracing complexity: a consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(12):M1146–8.

    Article  PubMed  Google Scholar 

  28. Newman AB. Commentary on “Embracing complexity: A consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(7):666–7. discussion 669–70.

    Article  PubMed  Google Scholar 

  29. Michel JP, Grab B, Perrenoud JJ. Commentary on “Embracing complexity: A consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(7):665–6. discussion 669–70.

    Article  PubMed  Google Scholar 

  30. Lowenthal DT. Commentary on “Embracing complexity: A consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(7):664–5. discussion 669–70.

    Article  PubMed  Google Scholar 

  31. Hajjar RR. Commentary on “Embracing complexity: A consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(7):661–2. discussion 669–70.

    Article  PubMed  Google Scholar 

  32. Aronow WS. Commentary on “Embracing complexity: A consideration of hypertension in the very old”. J Gerontol A Biol Sci Med Sci. 2003;58(7):659–60. discussion 669–70.

    Article  PubMed  Google Scholar 

  33. Muller M, Smulders YM, de Leeuw PW, et al. Treatment of hypertension in the oldest old: a critical role for frailty? Hypertension. 2014;63(3):433–41. This review article summarizes the pathophysiology of hypertension in the very old and emerging evidence on the role of frailty on treatment.

    Article  CAS  PubMed  Google Scholar 

  34. Benetos A, Gautier S, Labat C, et al. Mortality and cardiovascular events are best predicted by low central/peripheral pulse pressure amplification but not by high blood pressure levels in elderly nursing home subjects: the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study. J Am Coll Cardiol. 2012;60(16):1503–11.

    Article  PubMed  Google Scholar 

  35. Banach M, Aronow WS. Blood pressure j-curve: current concepts. Curr Hypertens Rep. 2012;14(6):556–66.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  36. Rockwood MR, Howlett SE, Rockwood K. Orthostatic hypotension (OH) and mortality in relation to age, blood pressure and frailty. Arch Gerontol Geriatr. 2012;54(3):e255–60.

    Article  PubMed  Google Scholar 

  37. Klein D, Nagel G, Kleiner A, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174(4):588–95. This methodologically sophisticated study found antihypertensive medications were associated with increased fall injuries, especially among those with previous fall injuries.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Butt DA, Mamdani M, Austin PC, et al. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med. 2012;172(22):1739–44.

    Article  PubMed  Google Scholar 

  40. Berry SD, Zhu Y, Choi H, et al. Diuretic initiation and the acute risk of hip fracture. Osteoporos Int. 2013;24(2):689–95.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  41. Fried TR, Tinetti ME, Towle V, et al. Effects of benefits and harms on older persons’ willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011;171(10):923–8.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Charlesworth CJ, Smit E, Lee DS, et al. Polypharmacy among adults aged 65 years and older in the United States: 1988–2010. J Gerontol A Biol Sci Med Sci. 2015.

  43. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011;123(21):2434–506.

    Article  PubMed  Google Scholar 

  44. Gomez-Huelgas R, Giner-Galvan V, Mostaza JM, et al. Unanswered clinical questions in the management of cardiometabolic risk in the elderly: a statement of the Spanish society of internal medicine. BMC Cardiovasc Disord. 2014;14:193.

    Article  PubMed Central  PubMed  Google Scholar 

  45. James PA, Oparil S, Carter BL, 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(5):507–20.

    Article  CAS  PubMed  Google Scholar 

  46. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–219.

    Article  PubMed  Google Scholar 

  47. Mallery LH, Allen M, Fleming I, et al. Promoting higher blood pressure targets for frail older adults: a consensus guideline from Canada. Cleve Clin J Med. 2014;81(7):427–37. This clinical practice guideline gives recommendation for both the stopping and starting of treatment for high blood pressure in frail older adults.

    Article  PubMed  Google Scholar 

  48. Institute of Medicine (U.S.). Committee on Standards for Developing Trustworthy Clinical Practice Guidelines., Graham R. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011.

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Acknowledgments

Support for this research was provided by the National Institute on Aging (K01AG039387, R01AG46206).

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Conflict of Interest

Michelle C. Odden, Pamela R. Beilby, and Carmen A. Peralta declare that they have no conflicts of interest.

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.

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Authors and Affiliations

  1. School of Biological and Population Health Sciences, Oregon State University, 141B Milam Hall, Corvallis, OR, 97331, USA

    Michelle C Odden

  2. Department of Biochemistry and Biophysics, Oregon State University, 2011 ALS, Corvallis, OR, 97331, USA

    Pamela R Beilby

  3. Department of Medicine, University of California, 521 Parnassus Avenue, C443, San Francisco, CA, 94143-0532, USA

    Carmen A Peralta

Authors
  1. Michelle C Odden
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  2. Pamela R Beilby
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  3. Carmen A Peralta
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Correspondence to Michelle C Odden.

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Odden, M.C., Beilby, P.R. & Peralta, C.A. Blood Pressure in Older Adults: the Importance of Frailty. Curr Hypertens Rep 17, 55 (2015). https://doi.org/10.1007/s11906-015-0564-y

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  • DOI: https://doi.org/10.1007/s11906-015-0564-y

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