Management of Hypertension in the Elderly and Frail Patient

Relationship between frailty and executive function by age and sex in the Canadian Longitudinal Study on Aging

Frailty reflects age-related damage to multiple physiological systems. Executive dysfunction is often a presenting symptom of diseases characterized by cognitive impairment. A decline in cardiovascular health is associated with worse executive function. We tested the hypothesis that higher frailty would be associated with executive dysfunction and that cardiovascular health would mediate this relationship. Middle- and older-aged adults at baseline (n = 29,591 [51% female]) and 3-year follow-up (n = 25,488 [49% females]) from the Canadian Longitudinal Study on Aging (comprehensive cohort) were included. Frailty was determined at baseline from a 61-item index, a cumulative cardiovascular health score was calculated from 30 variables at baseline, and participants completed a word-color Stroop task as an assessment of executive function. Multiple linear regressions and mediation analyses of cardiovascular health were conducted between frailty, Stroop interference-condition reaction time, and cardiovascular health in groups stratified by both age and sex (middle-aged males [MM], middle-aged females [MF], older-aged males [OM], older-aged females [OF]). Frailty (MM, 0.15 ± 0.05; MF, 0.16 ± 0.06; OM, 0.21 ± 0.06; OF, 0.23 ± 0.06) was negatively associated with cardiovascular health (MM, 0.12 ± 0.08; MF, 0.11 ± 0.07; OM, 0.20 ± 0.10; OF, 0.18 ± 0.09; β > 0.037, p < 0.001), as well as the Stroop reaction time at 3-year follow-up (MM, 23.7 ± 7.9; MF, 23.1 ± 7.3; OM, 32.9 ± 13.1; OF, 30.9 ± 12.0; β > 2.57, p < 0.001) across all groups when adjusted for covariates. Cardiovascular health was a partial (~ 10%) mediator between frailty and reaction time, aside from MFs. In conclusion, higher frailty levels are associated with executive dysfunction, which was partially mediated by cardiovascular health. Strategies to improve frailty and better cardiovascular health may be useful for combatting the age-related decline in executive function.

Hypertension in an ageing population: Diagnosis, mechanisms, collateral health risks, treatments, and clinical challenges

Ageing population is considerably increasing worldwide, which is considered to reflect an improved quality of life. However, longevity in the human lifespan has increased the burden of late-life illnesses including cancer, neurodegeneration, and cardiovascular dysfunction. Of these, hypertension is the most common condition with huge health risks, with an increased prevalence among the elderly. In this review, we outline the current guidelines for defining hypertension and examine the detailed mechanisms underlying the relationship between hypertension and ageing-related outcomes, including sodium sensitivity, arterial stiffness, endothelial dysfunction, isolated systolic hypertension, white coat effect, and orthostatic hypertension. As hypertension-related collateral health risk increases among the elderly, the available management strategies are necessary to overcome the clinical treatment challenges faced among elderly population. To improve longevity and reduce adverse health effects, potential approaches producing crucial information into new era of medicine should be considered in the prevention and treatment of hypertension among elderly population. This review provides an overview of mechanisms underlying hypertension and its related collateral health risk in elderly population, along with multiple approaches and management strategies to improve the clinical challenges among elderly population.

Prediabetes Increases the Risk of Frailty in Prefrail Older Adults With Hypertension: Beneficial Effects of Metformin

BACKGROUND

Prediabetes has garnered increasing attention due to its association with cardiovascular conditions, especially hypertension, which heightens the risk of prefrailty and frailty among older individuals.

METHODS

We screened elders with prefrail hypertension from March 2021 to January 2023. We assessed the correlation linking cognitive dysfunction (Montreal Cognitive Assessment score), insulin resistance (triglyceride-to-glucose index), and physical impairment (5-meter gait speed). Then, we measured the risk of developing frailty after a 1-year follow-up period, adjusting the outcome using multivariable Cox regression analysis. We also investigated the impact of administering 500 mg of metformin once daily to a subset of frail subjects for an additional 6 months.

RESULTS

We assessed the relationship between the triglyceride-to-glucose index and the Montreal Cognitive Assessment score, observing a significant correlation (r, 0.880; P<0.0001). Similarly, we analyzed the association between the triglyceride-to-glucose index and 5-meter gait speed, uncovering a significant link between insulin resistance and physical impairment (r, 0.809; P<0.0001). Prediabetes was found to significantly (P<0.0001) elevate the risk of frailty development compared with individuals without prediabetes by the end of the 1-year follow-up, a finding confirmed via multivariable analysis with Cox regression. Furthermore, among the subgroup of subjects who developed frailty, those who received metformin exhibited a significant decrease in frailty levels (P<0.0001).

CONCLUSIONS

Insulin resistance and prediabetes play substantial roles in the development of cognitive and physical impairments, highlighting their importance in managing hypertension, even before the onset of frank diabetes. Metformin, a well-established drug for the treatment of diabetes, has shown favorable effects in mitigating frailty.

The intersection of frailty and metabolism

On average, aging is associated with unfavorable changes in cellular metabolism, which are the processes involved in the storage and expenditure of energy. However, metabolic dysregulation may not occur to the same extent in all older individuals as people age at different rates. Those who are aging rapidly are at increased risk of adverse health outcomes and are said to be "frail." Here, we explore the links between frailty and metabolism, including metabolic contributors and consequences of frailty. We examine how metabolic diseases may modify the degree of frailty in old age and suggest that frailty may predispose toward metabolic disease. Metabolic interventions that can mitigate the degree of frailty in people are reviewed. New treatment strategies developed in animal models that are poised for translation to humans are also considered. We suggest that maintaining a youthful metabolism into older age may be protective against frailty.

Association between the blood urea nitrogen-to-creatinine ratio and 3-month outcomes in patients with acute ischemic stroke: a secondary analysis based on a prospective cohort study

Introduction

This study aimed to assess the correlation between the blood urea nitrogen (BUN)-to-creatinine (BUN/Cr) ratio and adverse outcomes (AOs) at 3 months in patients with acute ischemic stroke (AIS) in the Korean population.

Methods

This cohort study encompassed 1906 cases of AIS at a South Korean hospital from January 2010 to December 2016. To determine the linear correlation between the BUN/Cr ratio and AOs in AIS, a binary logistic regression model (BLRM) was employed. Additionally, generalized additive models and techniques for smooth curve fitting were utilized to reveal the nonlinear dynamics between the BUN/Cr ratio and AOs in patients with AIS.

Results

The prevalence of AOs was 28.65%, with a median BUN/Cr ratio of 18.96. Following adjustments for covariates, the BLRM disclosed that the association between the BUN/Cr ratio and the risk of AOs in patients with AIS did not attain statistical significance. Nevertheless, a nonlinear relationship surfaced, pinpointing an inflection point at 21.591. To the left of this inflection point, a 31.42% reduction in the risk of AOs was noted for every 1-unit surge in the Z score of the BUN/Cr ratio [odds ratio (OR) = 0.686, 95% confidence interval (CI): 0.519, 0.906, p = 0.008]. On the right side of the inflection point, the effect size (OR = 1.405, 95% CI: 1.018, 1.902, p = 0.039) was determined.

Conclusion

The findings of this study underscore the intricate nature of the relationship between the BUN/Cr ratio and 3-month outcomes in patients with AIS, establishing a robust groundwork for future investigations.

Comparison of sacubitril/valsartan with olmesartan for hypertension: A meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of sacubitril/valsartan versus olmesartan remains controversial for the control of hypertension. We conduct a systematic review and meta-analysis to explore the influence of sacubitril/valsartan versus olmesartan on the control of hypertension.

METHODS

We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through July 2023 for randomized controlled trials assessing the effect of sacubitril/valsartan versus olmesartan on the control of hypertension. This meta-analysis is performed using the random-effect model or fixed-effect model based on the heterogeneity.

RESULTS

Seven randomized controlled trials and 3677 patients were included in the meta-analysis. Overall, compared with olmesartan treatment for hypertension, sacubitril/valsartan treatment was associated with substantially decreased systolic blood pressure (mean difference [MD] = -4.58; 95% confidence interval [CI] = -7.90 to -1.25; P = .007), diastolic blood pressure (MD = -1.70; 95% CI = -3.24 to -0.17; P = .03), and pulse pressure (MD = -2.31; 95% CI = -4.41 to -0.21; P = .03), as well as improved systolic blood pressure control (odds ratio [OR] = 1.65; 95% CI = 1.15 to 2.38; P = .006), but had no influence on diastolic blood pressure control (OR = 1.33; 95% CI = 0.93 to 1.88; P = .11) or adverse events (OR = 1.06; 95% CI = 0.90 to 1.24; P = .51).

CONCLUSIONS

Sacubitril/valsartan is better than olmesartan for the reduction of blood pressure for patients with hypertension.

Influence of Aging on Outcomes of Sacubitril/Valsartan in Hypertensive Patients with Heart Failure: A Multicenter Retrospective Study

BACKGROUND

The aim of this study was to investigate the influence of aging on the effectiveness and tolerance of sacubitril/valsartan (sac/val) among hypertensive patients complicated with heart failure in a real-world setting.

METHODS

This multicenter, retrospective study included patients (≥18 years old) admitted with a diagnosis of hypertension and heart failure, starting sac/val therapy between January 2020 and December 2021 from 3 medical centers. Patients were grouped by the cutoff age of 65 years. Outcomes were collected 31-365 days after the initiation of sac/val and were compared in a matched cohort after 1: 1 propensity score matching (PSM).

RESULTS

A total of 794 patients were finally analyzed. Blood pressure and cardiac functions improved significantly compared with values at baseline. There were 269 patients in each cohort (<65 years and ≥65 years) after PSM. After PSM, the incidence of hyperuricemia and hypotension in the elderly patients (≥65 years) was significantly higher than in those <65 years of age. Kaplan-Meier estimate suggested that the cumulative incidence of new or recurrent cardiovascular events increased significantly at the age of ≥65 years after the point of 3 months (log-rank P =.00087).

CONCLUSION

Sac/val benefited patients in both cohorts by improving blood pressure and cardiac function. Elderly patients (≥65 years) were susceptible to hypotension, low diastolic blood pressure, hyperuricemia, and underwent cardiac-related readmissions more frequently.

Prevalence and Impact of Frailty in Pancreatic Cancer: A Systematic Review and Meta-Analysis Based on 35,191 Patients

BACKGROUND

Frailty has been associated with increased mortality among patients with pancreatic cancer. Nevertheless, several lines of evidence regarding the prevalence of frailty in patients with pancreatic cancer and mortality in patients with pancreatic cancer and frailty have not been thoroughly investigated and require clarification.

METHODS

A systematic review and meta-analysis of studies indexed in PubMed, Scopus, Web of Science, and Embase through March 2023 were conducted, and the pooled prevalence and relative risk (RR) estimate were calculated.

RESULTS

A total of 18 studies containing 35,191 patients with pancreatic cancer were included. The prevalence of frailty in pancreatic cancer was 45% (95% CI = 29-62; I2 = 99.9%; p = 0.000). In patients with pancreatic cancer, frailty was associated with increased relative risk for mortality (RR = 1.70; 95% CI = 1.30-2.22; I2 = 84.8%, p = 0.000).

CONCLUSIONS

Frailty prevalence in pancreatic cancer is common and exerts a significant negative impact on the survival of patients with pancreatic cancer. Our findings are characterized by significant heterogeneity, and caution is warranted in their interpretation. However, these findings highlight the importance of evaluating frailty, which may provide prognostic data and inform decision-making priorities.

Associations among frailty status, hypertension, and fall risk in community-dwelling older adults

Objectives

Frailty and hypertension often coexist in older adults, which may lead to fall risks. This study aimed to examine the relationship between frailty status, hypertension, and fall risk.

Methods

In this cross-sectional study, a total of 401 older adults were conveniently recruited from communities in Wuxi, China, between September 2022 and November 2022. The fall risk self-assessment checklist from the Stopping Elderly Accidents, Deaths & Injuries (STEADI) Toolkit was used to evaluate their fall risks. The FRAIL scale questionnaire was used to assess frailty status. Participants' demographic information and comorbidities were collected. Multivariate logistic regression, generalized additive model, and smooth curve fitting were used to analyze the association between frailty, hypertension, and fall risk.

Results

Frailty had a strong association with increased prevalence of fall risk among the participants (OR 8.52, 95% CI 3.21-22.57; P < 0.001). Hypertension significantly increased the fall risk among older adults (OR 1.87, 95% CI 1.11-3.13; P = 0.019). The group with hypertension and frailty had the highest prevalence of fall risk (OR 12.24, 95% CI 3.51-42.65). Smooth curve fitting showed a nonlinear association between frailty and fall risk in hypertension status. In the progress of pre-frailty to frailty status, a higher tendency to fall was found among older adults with hypertension.

Conclusions

Frailty status and hypertension independently and jointly influenced the increased prevalence of fall risk. Enhanced frailty and hypertension management may help decrease fall risk among this population.

Hypertension Treatment in Frail Older Adults: A Systematic Review and Appraisal of Guidelines

BACKGROUND

Managing hypertension in frail older patients is challenging. Several institutions and organizations have published up-to-date hypertension guidelines suggesting frailty screening among older hypertensive patients, with new recommendations for blood pressure-lowering treatment among the frail population. However, the quality of current hypertension guidelines and the consistency of antihypertension treatment recommendations for frail older patients and their supporting evidence remain unknown.

OBJECTIVE

In this review, we aimed to systematically collect guidelines with antihypertension treatment recommendations for frail older patients, examine and compare these recommendations, and critically assess reporting and methodology quality of these guidelines.

METHODS

A literature search was conducted on two databases and three major websites of guideline development organizations. The AGREE instrument and RIGHT checklist were used to evaluate the methodology and reporting quality of the guidelines, respectively. The consistency of recommendations within the guidelines were compared using descriptive analysis.

RESULTS

We identified 13 hypertension guidelines. The overall methodology quality scores (range 23.35-79.07%) and reporting rates (range 10/35-29/35) varied among these guidelines. Four guidelines provided an explicit definition of frailty. Considering treatment tolerability or increased likelihood of adverse effects while using pharmacotherapy in frail older patients was mentioned in all guidelines. Ten guidelines recommended adjusting blood pressure targets or specific pharmacotherapy programs. Four guidelines recommended using clinical judgment when prescribing. However, the specific recommendations lacked clarity and unity without sufficient evidence.

CONCLUSIONS

There were considerable variations in methodology and reporting quality across the 13 included hypertension guidelines. Furthermore, the depth and breadth of antihypertension treatment recommendations for frail older patients were varied and inconsistent. Further trials exploring optimal treatment are urgently required to promote the development of specific guidelines for managing frail older hypertensive patients.

Sodium-Glucose Cotransporter-2 Inhibitors: Risks vs. Rewards When Caring for Older Adults

Managing multiple comorbidities is common in older adults. Thus, when a medication class, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, can potentially treat multiple conditions and prevent progression of chronic kidney disease, multiple guidelines must be followed when using these agents. The current article discusses risks and benefits of SGLT2 inhibitors, especially in the context of new evidence, and presents a case example. [Journal of Gerontological Nursing, 48(10), 7-13.].