Blood pressure control and management of very elderly patients with hypertension in primary care settings in Spain

Management instructions for elderly patients with hypertension

Aim: To compare the understanding of hypertension and antihypertensive treatment in Japanese patients (aged <75 years vs. ≥75 years) with blood pressure (BP) targets as per the 2014 Japanese guidelines.Methods: A 10-question survey was administered before and after treatment.Results: Majority of patients aged ≥75 years did not achieve their BP targets (75%); >50% of these patients had little knowledge of hypertension and poor understanding of their physician's explanation of it.Conclusions: Elderly patients with hypertension (aged ≥75 years) require daily BP monitoring and detailed and repeated explanation of hypertension and BP targets.

[Clinical and socio-sanitary characteristics in adults older than 65 years attended in the Primary Care setting. The PYCAF study]

OBJECTIVE

To describe the clinical and socio-sanitary characteristics of adults older than 65 years attended in a Primary Care setting.

MATERIAL AND METHODS

The PYCAF study (Prevalence and Characteristics of the Fragile Elderly) is a descriptive, cross-sectional and multicentre study, in which patients older than 65 years attended in clinical practice in Primary Care in Spain were consecutively included.

RESULTS

A total of 2,461 patients (mean age 76.0±6.9 years, 57.9% women) were included in the study. The coexistence of cardiovascular risk factors and comorbidities was frequent, with arterial hypertension (73.7%) being the most prevalent, followed by dyslipidaemia (58.3%), arthrosis (56.4%), obesity (34.0%), and diabetes (28.9%). Some degree of cognitive impairment was observed in 13.4% of patients. Women had higher rates of frailty (61.0% vs. 51.8%; P<.001). Just under half (47.4%) of subjects were taking more than 6 drugs, with the prescription being higher in women (44.2% vs. 49.8%; P=.047). Just under half (49.5%) of patients made more than 10 visits to Primary Care, 25.9% of patients 4 or more visits to the specialist, and 22.3% of patients were admitted to hospital in the last year.

CONCLUSIONS

The PYCAF study shows that elderly patients have a higher prevalence of chronic cardiovascular and non-cardiovascular diseases, which leads to high polypharmacy. The latter has consequences both on patient safety and on the direct and indirect costs of the National Health System that emanate from the care of patients over 65 years of age. Half the sample has fragility.

Declining blood pressure and intensification of blood pressure management among people over 80 years: cohort study using electronic health records

Background:

Management of high blood pressure (BP) in people over 80 years is controversial, but there is limited information available concerning the uptake of hypertension treatment at this age.

Objective:

To evaluate use of antihypertensive drugs and changes in SBP and DBP from 2001 to 2014 in men and women aged 80 years and over.

Methods:

Cohort study using primary care electronic health records of 265 225 participants from the UK Clinical Practice Research Datalink. Records of BP and antihypertensive medications were analysed. Linear trends were estimated by frailty category in multiple regression models.

Results:

Data were analysed for 116 401 men and 148 824 women. The proportion with BP recorded increased from 51% in 2001 to 78% in 2014. The proportion of patients prescribed antihypertensive medications increased from 64 to 76%. Mean SBP declined from 150 (SD 20) mmHg in 2001 to 135 (16) mmHg in 2014. In ‘fit’ participants, the decline in SBP was 12.4 (95% confidence interval 11.9–13.0) mmHg/decade in those treated for hypertension and 8.5 (7.8–9.1) mmHg in those not treated. The decline in SBP was smaller as frailty increased. The proportion of all participants with BP less than 140/90 mmHg increased from 14 to 44% in the study period.

Conclusion:

In octogenarians, BP treatment has intensified between 2001 and 2014. BP values have declined in both treated and untreated participants, with a substantial increase in the proportion achieving conventional BP targets.

Uncontrolled Hypertension Increases with Age in an Older Community-Dwelling Chinese Population in Shanghai

We determined the prevalence of hypertension, medication usage and attainment of blood pressure goals in older (≥65 to <80 years and ≥80 years) urban community-dwelling Chinese subjects. Data were obtained in 3950 subjects (mean age 72.0 years, 1745 male) including 609 subjects aged ≥80 years in the Shanghai Elderly Cardiovascular Health Study (SHECHS). Established cardiovascular disease was present in 7.7% of participants. The prevalence of hypertension was 74.8% overall and it was more than 80% in individuals considered to be in moderate and higher cardiovascular disease risk categories. In hypertensive subjects, 67.1% were on treatment and treatment was more frequent in high and very high cardiovascular risk individuals. Attainment of the systolic blood pressure goal <150 mmHg was 62.9% and was greater in the ≥65 to <80 years group than in the ≥80 years group. The most commonly used antihypertensive treatments were calcium channel blockers (54.2%), followed by angiotensin receptor blockers (43.1%). Diuretics were used in 2.6%. Fixed-dose combination antihypertensive tablets were used in some of the ≥65 to <80 years group (12.4%) and more of the ≥80 years group (18.2%) and 70.9% of the ≥65 to <80 years group and 80.2% of the ≥80 years group were on monotherapy. There were high prevalence and high treatment rates of hypertension, but poor attainment of the systolic blood pressure goal of <150 mmHg, especially in the ≥80 years group of community-dwelling Chinese. Considering that more intensive treatment of hypertension in older subjects may be warranted after recent studies, this might be achieved by more frequent use of combinations of effective therapies and diuretics.

Hypertension in older patients, a retrospective cohort study

BACKGROUND

It is unknown to what extent General Practitioners (GPs) manage hypertension (HT) differently in older patients, as compared to younger age groups. The purpose of our study was to compare HT management in older patients to younger age groups.

METHODS

We performed a retrospective cohort study of patients of 159 GP's practices in the Integrated Primary Care Information (IPCI) database. The study period lasted from September 2010 through December 2012. The study population consisted of all patients aged 60 years or older with at least one blood pressure (BP) measurement during the inclusion period, without pre-existent HT, diabetes mellitus (DM) or atherosclerotic cardiovascular disease at time of study start. Study outcomes were a diagnosis of HT within one month after cohort entry and the use of antihypertensive medication within 4 months after cohort entry in HT diagnosed patients. We compared the incidence of outcomes between the age groups, stratified by systolic blood pressure (SBP). Logistic regression analysis was used to assess the influence of age-adjusted SBP Z-scores, age and gender on the outcomes.

RESULTS

We included 19,500 patients from 159 GP's practices of whom 1,181 (6.1 %) were newly diagnosed with HT. Corrected for age-adjusted SBP, older patients were less likely to be diagnosed with HT (odds ratio per year age increase 0.98, p < 0.001). Corrected for age-adjusted SBP, no significant effect of age on the probability of treatment in newly diagnosed HT patients was observed (p = 0.82).

CONCLUSIONS

This study showed that GPs are less inclined to diagnose HT with increasing patient age, but do not withhold treatment when they diagnose HT in older patients.

Challenges in the Management of Hypertension in Older Populations

The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.

Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review

Objectives

Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients.

Methods

A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged.

Results

The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified.

Conclusions

Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.

Trends in hypertension control among the older population of Spain from 2000 to 2001 to 2008 to 2010: role of frequency and intensity of drug treatment

BACKGROUND

The use of antihypertensive medication and hypertension control has significantly increased during recent decades in some developed countries, but the impact of improved drug treatment on blood pressure (BP) control in the population is unknown.

METHODS AND RESULTS

Data were taken from 2 surveys representative of the population aged ≥ 60 years in Spain conducted with the same methodology in 2000 to 2001 and in 2008 to 2010. BP was measured 6×. The first BP reading was discarded, and the average of the remaining 3 to 5 BP readings was taken for analysis. Hypertension prevalence was 68.7% in 2000 to 2001 and 66.0% in 2008 to 2010. Between both time periods there was an improvement in hypertension awareness (63.6%-67.7%), drug treatment among those aware (84.5%-87.5%), and BP control among treated hypertensives (30.3%-42.9%). Overall, BP control among all hypertensives increased from 16.3% to 25.4%. After adjustment for age, sex, education, hypertension duration, smoking, alcohol consumption, body mass index, sedentary behavior, diabetes mellitus, cardiovascular disease, and visits to the physician through logistic regression, ≈ 7% of the improvement in BP control among all hypertensives was explained by higher hypertension awareness, and 36.2% was explained by a higher treatment rate. Among the treated hypertensives, 22.6% of the progress in BP control was because of the increase in the number of BP medications used in each patient.

CONCLUSIONS

BP control among the older hypertensive population in Spain has improved from 2000 to 2001 to 2008 to 2010 because of a higher treatment rate and more intense antihypertensive drug treatment.

Increasing complexity: which drug class to choose for treatment of hypertension in the elderly?

Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.