When 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+.
And now 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 talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)
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%).
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 happened to 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 confounders – such as overall illness burden — between the three groups.)
The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?
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.
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.
Given the findings of this study, we should be 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.
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:
- 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 patients 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.
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.
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.)
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.
Less (medication) is often more (safety and wellbeing).
Leslie Kernisan, MD MPH, is a practicing geriatrician, cautious techno-optimist, and enthusiastic caregiver educator. She hopes to someday be surrounded by cool tools and innovations that will make great geriatric care totally doable for all, especially primary care providers and family caregivers. She is a regular THCB contributor, and blogs at Geritech.org and at drkernisan.net.
I am coming up to 76. I try hard to eat healthy food and to stay away from unhealthy beverages. My blood pressure was getting high and was noticed when I donated my blood. I cut down on the many mugs of coffee and my blood pressure dropped to a safe level. It is important to keep your arteries flushed out. I stay away from bad fat foods and I eat lots of fresh fruit and vegetables. Also I take a little apple cider vinegar a few time a week.
High blood pressure presents a high risk for heart attack and stroke. It is essential to receive treatment for high blood pressure and get it under control.
Yes, treating high blood pressure is important, but the vast majority of the benefit is in getting older adults from 170s or higher, down to 140s-150s.
As I note above, it’s been very hard to prove a reduction in heart attack and stroke once you get SBP below 150.
The issue is really about what we define as “control,” and what are the risks when we aim for varying levels of control.
Of course you want to use up to date information. My point is that you also have to use some common sense and knowledge of the patient you’re treating.
And your article is very appropriate.
Thanks, and thank you for the comments.
It’s called the ART of medicine, you can’t cookbook it.
Hm well…sometimes the artistry has to be revised in light of new information, and an improved understanding of what benefits and harms people.
I do think that informed patients (and family caregivers) can play a role in encouraging docs to update their artistry.
For instance, the art of medicine used to be that we used leeches and bloodletting for all kinds of ailments…
I’m 62, and my parents are both 90. All 3 of us are treated for HBP, and we all three have sustained quite a few falls over the last 15 years or so. Now, I will admit that I have been more prone to falls my entire life, but after I started taking meds, it started occurring more and being more serious: I broke a shoulder, and ended up with big lumps on my head and subsequent black eyes and facial bruising that would last for weeks. I also once fell five feet and landed on my back, resulting in a huge hematoma that took weeks to go down. My parents did not tend to fall before their elderly years on meds. But within the past ten years, they’ve suffered quite a bit: huge hematomas, deep cuts requiring lots of stitches, broken ribs. Recently, my father sustained his worst fall to date: just out for a daily walk, he said his legs “went out from under him,” and he sprawled on the road, suffering a concussion, cracked eye socket, broken jaw, crushed sinuses, broken wrist, dislocated fingers, and enough road rash to have stitches in his face and arm. He spent four days in hospital, and they ended up taking him completely off of Cumadin (sp?) which was for his A fib, and they have now taken him off of a BP medicine, and lowered another. He’s also diabetic. He’s still recovering from the concussion, so it’s hard to tell so far about the effects of getting off of the meds, but he hated taking the Wayfarin. He said it made him feel like a slug, no energy. We all check our pressure with home cuffs, and mine tends to waiver. Occasionally, I will have a day when it’s as low as 110 / 62 and I feel awful on those days. Other days, it’s usually around 130 / 80 or so. The reason my doctor put me on meds is because it was continually running about 170 / 100. I was taking Lotrel, Coreg,and HCTZ, but my doctor changed it to Coreg, Amlodopine, and Losartin HCTZ because I developed an allergy to yellow jackets, and ended up in the ER with anaphylactic shock. One of the prior meds I was on can cause Epiphedrine to not work properly, thus the change. I keep a pretty good weekly record of my pressures and would love to get off some of the meds. I do exercise regularly and the days when my pressure is higher, I feel so much better! I’m very interested in this and plan to discuss it with my doctor. Falling is so frightening, when it has happened, it has never been from doing anything risky…. just going through a normal day. My Dr. has been very concerned about my falls, and has not liked having to do a Cat Scan on my head 3 times within 18 months, but it had to be done. He questioned me a lot about balance issues, fainting spells, even if my spouse was harming me….. which was an important question but totally wrong… so he’s wondered why I fall so much. Maybe it’s the meds! He is a very good doctor, and I’m sure the new higher numbers that are acceptable will be something that he will address. Thanks for this article!
Wow, what a story! Thank you for sharing.
Well, falls are often “multi-factorial,” meaning that it’s the combination of many things at once that makes an older person prone to fall.
It’s certainly possible that reducing your blood pressure medication a little bit might help you feel better, and hopefully it will reduce your fall risk too.
Good luck discussing with your doctor! I hope you sort out a good approach for you (and for your parents) soon.
I wonder how many clinicians check their elderly patients’ blood pressure sitting AND standing. If there is an orthostatic drop, we should seriously consider how aggressive we really should be in treating “to target”. Plus, if the lower, orthostatic, blood pressure reading is entered in the right manner in the EMR, we might pass the QA requirements if the lower blood pressure reading is the one that is reported 🙂
I certainly would love to see clinicians doing more postural BP checks, esp if there have been any falls, syncope, or pre-syncope.
A 2009 study of Medicare beneficiaries presenting to the ED for syncope found that checking orthostatics had high yield, plus it’s an inexpensive test!
wait a minute here…..
We have to continue to find ways to pay for quality in our new innovative and progressive models of care delivery, and we all know that quality phsyicians practice in quality ways by getting more of their patients to meet quality numeric goals when treating hypertension.
Quit complicating things. You’re screwing up the plan.
We need to ding physicians if their patients’ SBPs are too low, along w dinging them if it’s too high.
The measures issue is tough…I did a quality improvement fellowship and used to really believe in quality meausres, but then I was very outraged in clinic when I got dinged for my patients’ SBP being over 140. The measure was inappropriate for my elderly patients AND didn’t consider that a single measurement in the office is often inaccurate.
So…not sure that we should measure all of this, but I do think it’s what we ideally should do. So I encourage patients and caregivers to ask for this care, and I hope the tech & systems people will make it easier for us to deliver this care.
Let’s agree that quality care of hypertension is not about what percentage of patients meet some pre-defined numerical goal.
Once we accept that, then we can get rid of this counterproductive and harmful incentive to overtreat because it’s good for our stats, when we should be doing what’s good for the patient.
hm…I’ll agree that given how we usually measure people’s BP, rating quality of hypertension care by what % of all adults meet a number goal is a bad idea. How about that?
Separately, although I do think many older adults are over-treated for HTN, not sure it’s mainly driven by stats and quality goals…would be interesting to find out more on this issue.