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Pan HY, Yang PL, Lin CH, Chi CY, Lu CW, Lai TS, Yeh CF, Chen MYC, Wang TD, Kao HL, Lin YH, Wang MC, Wu CC. Blood pressure targets, medication consideration and special concerns in elderly hypertension part I: General principles and special considerations. J Formos Med Assoc 2024:S0929-6646(24)00443-1. [PMID: 39322497 DOI: 10.1016/j.jfma.2024.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 09/06/2024] [Accepted: 09/18/2024] [Indexed: 09/27/2024] Open
Abstract
To achieve a consensus on optimal blood pressure (BP) targets for older adults remains challenging, necessitating a trade-off between cardiovascular benefits and the risk of impaired organ perfusion. Evidence suggests that age and frailty have a minimal influence on the cardiovascular benefits of intensive BP control in community-dwelling elderly. Nonetheless, an increased incidence of acute kidney injury with intensive BP control has been observed in octogenarians. Therefore, it is recommended to maintain systolic BP below 130 mmHg for hypertensive patients aged 65-80 years. If well-tolerated, a systolic BP target below 120 mmHg can be recommended for patients with chronic kidney disease (CKD). However, no conclusive evidence supports a stringent BP target for patients aged 80 years and older. The selection of antihypertensive medications for elderly patients requires consideration of their cardiovascular condition and potential contraindications. Combination therapy may be necessary to achieve the desired BP target. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are the primary choices for patients with CKD. Newer generation mineralocorticoid receptor antagonists may further reduce the risk of cardiovascular or renal events in this population. In conclusion, managing hypertension in elderly patients requires a personalized approach that balances cardiovascular benefits with potential risks, considering individual health profiles and tolerability.
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Affiliation(s)
- Heng-Yu Pan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Po-Lung Yang
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei City, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chun-Hsien Lin
- Division of Metabolism and Endocrinology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Chun-Yi Chi
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin County, Taiwan
| | - Chia-Wen Lu
- Department of Family Medicine, National Taiwan University Hospital, Taipei City, Taiwan.
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan.
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tzung-Dau Wang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Mu-Cyun Wang
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei City, Taiwan.
| | - Chih-Cheng Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan.
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Habib MH, Alibhai SMH, Puts M. How representative are participants in geriatric oncology clinical trials? The case of the 5C RCT in geriatric oncology: A cross-sectional comparison to a geriatric oncology clinic. J Geriatr Oncol 2024; 15:101703. [PMID: 38228054 DOI: 10.1016/j.jgo.2024.101703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/25/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Frail older adults make up a substantial portion of the older adult population. However, frail patients are often excluded from randomized controlled trials. This underrepresentation restricts the extent to which trial findings can be generalized to this population. We compared a sample from the Canadian 5C Randomized Controlled Trial investigating comprehensive geriatric assessment (CGA) in the geriatric oncology setting in terms of frailty to patients referred to the Older Adults with Cancer Clinic (OACC) to determine if the trial sample was representative of the normal geriatric oncology practice. MATERIALS AND METHODS Baseline CGA data of 5C Trial participants seen at the Princess Margaret Cancer Centre (PM), were compared to data from OACC patients that were seen during the duration of the 5C trial (between April 2018 and April 2020) and that satisfied the 5C inclusion criteria. To assess the frailty of samples, sex, age, disease site, comorbidity level, medical optimization, social supports, functional status, falls risk, nutrition, cognition, and mood were compared between 5C participants and OACC patients using Fisher's exact and independent samples t-test. RESULTS A sample of 115 5C participants and 205 OACC patients were included. The mean age of 5C participants and OACC patients was 75.4 and 81.6 years, respectively (p < 0.001). The distribution of disease sites was significantly different between the samples (p < 0.001) and OACC patients were also significantly more impaired compared to 5C participants in comorbidity (23.4% versus 10.4% high comorbidity) (p = 0.001), IADL dependence (55.1% versus 42.6%) (p = 0.036), impaired physical function (70.6% versus 31.3%) (p < 0.001), falls risk (67.8% versus 27%) (p < 0.001), impaired nutrition (55.6% versus 40.9%) (p = 0.014), and cognition (47.2% versus 10%) (p < 0.001). There were no differences in sex, medication optimization, poor social supports, and impaired mood between the samples. DISCUSSION The 5C sample was less frail and younger than patients seen in the geriatric oncology clinic. Finding strategies to address barriers to the inclusion of frailer older adults is important to increase their representation in future trials to allow findings to be generalized to this vulnerable population. TRIAL REGISTRATION Clinicaltrials.gov # NCT03154671.
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Affiliation(s)
- Mohammed H Habib
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
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3
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Hanlon P, Welsh SA, Evans NR. Constructing a quality frailty index: you get out what you put in. Age Ageing 2024; 53:afad248. [PMID: 38266125 DOI: 10.1093/ageing/afad248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Indexed: 01/26/2024] Open
Affiliation(s)
- Peter Hanlon
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Silje A Welsh
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Rivasi G, Ceolin L, Turrin G, Tortu’ V, D’Andria MF, Testa GD, Montali S, Tonarelli F, Brunetti E, Bo M, Romero-Ortuno R, Mossello E, Ungar A. Prevalence and correlates of frailty in older hypertensive outpatients according to different tools: the HYPER-FRAIL pilot study. J Hypertens 2024; 42:86-94. [PMID: 37698894 PMCID: PMC10713004 DOI: 10.1097/hjh.0000000000003559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/15/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES To date, few studies have investigated frailty in hypertensive individuals. This study aimed at identifying the prevalence of frailty in a sample of hypertensive older outpatients using six different identification tools. Clinical correlates of frailty and agreement between different frailty definitions were also investigated. METHODS The HYPER-FRAIL pilot study recruited hypertensive patients aged at least 75 years from two geriatric outpatient clinics of Careggi Hospital, Florence, Italy. Four frailty scales [Fried Frailty Phenotype, Frailty Index, Clinical Frailty Scale (CFS), Frailty Postal Score] and two physical performance tests [Short Physical Performance Battery (SPPB) and usual gait speed] were applied. The Cohen's kappa coefficient was calculated to assess agreement between measures. Multiple logistic regression was used to identify clinical features independently associated with frailty. RESULTS Among 121 participants (mean age 81, 60% women), frailty prevalence varied between 33 and 50% according to the tool used. Moderate agreement was observed between Fried Frailty Phenotype, Frailty Index and SPPB, and between Frailty Index and CFS. Agreement was minimal or weak between the remaining measures (K < 0.60). Use of walking aids and depressive symptoms were independently associated with frailty, regardless of the definition used. Frailty correlates also included dementia, disability and comorbidity burden, but not office and 24-h blood pressure values. CONCLUSION Frailty is highly prevalent among older hypertensive outpatients, but agreement between different frailty tools was moderate-to-weak. Longitudinal studies are needed to assess the prognostic role of different frailty tools and their clinical utility in the choice of antihypertensive treatment.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Ludovica Ceolin
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giada Turrin
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Virginia Tortu’
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Maria Flora D’Andria
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Sara Montali
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Francesco Tonarelli
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology and Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
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Karayiannis CC. Hypertension in the older person: is age just a number? Intern Med J 2022; 52:1877-1883. [PMID: 36326489 PMCID: PMC9828098 DOI: 10.1111/imj.15949] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
Older patients with hypertension are at a higher risk of cardiovascular events compared to younger adults but are also more vulnerable to the adverse effects of blood pressure (BP) lowering. Frailty is an important predictor of vulnerability to such adverse events, and age alone may not best reflect underlying risk. Therefore, an individualised approach to management of hypertension in the older person is required. Such an approach requires knowledge of frailty, the physiology of hypertension and ageing and a contextual understanding of best evidence. Management needs to be holistic and take account of the older person's care needs, wishes and priorities. This review describes physiological considerations and current guidelines and best practices regarding BP lowering in older people and highlights areas with paucity of evidence. A proposed and testable approach to managing hypertension in the older person (≥70 years) is discussed.
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Affiliation(s)
- Christopher C. Karayiannis
- Department of MedicinePeninsula HealthMelbourneVictoriaAustralia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
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Abstract
Hypertension is a frequent finding in elderly patients. Hypertension in older age can be both associated with frailty and represent a risk factor for frailty. Hypertension is recognized as a main risk factor for cardiovascular diseases such as heart failure, atrial fibrillation, and stroke and the occurrence of these diseases may provoke a decline in health status and/or worsen the degree of frailty. Blood pressure targets in hypertensive older and frail patients are not completely defined. However, specific evaluations of individual patients and their co-morbidities and assessment of domains and components of frailty, together with weighted consideration of drug use, may help in finding the appropriate therapy.
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7
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Shin J, Kim KI. A clinical algorithm to determine target blood pressure in the elderly: evidence and limitations from a clinical perspective. Clin Hypertens 2022; 28:17. [PMID: 35701854 PMCID: PMC9199158 DOI: 10.1186/s40885-022-00202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/22/2022] [Indexed: 01/14/2023] Open
Abstract
As the elderly population is growing rapidly, management of hypertension in South Korea faces major challenges because the proportion of elderly hypertension patients is also increasing. The characteristics of this population are also much more complex than younger patients. Elderly hypertension is characterized by wide variations in (1) fitness or biological age, (2) white-coat effect, (3) poor functional status or frailty, (4) dependency in activities of daily living or institutionalization, (5) orthostatic hypotension, and (6) multiple comorbidities. All of these should be considered when choosing optimal target blood pressure in individual patients. Recent randomized clinical trials have shown that the benefits of intensive blood pressure control for elderly patients is greater than previously thought. For generalization of these results and implementation of the guidelines based on these studies, defining the clinician's role for individualization is critically important. For individualized decisions for target blood pressure (BP) in the elderly with hypertension, four components should first be checked. These consist of (1) the minimum requirement of functional status and capability of activities of daily living, (2) lack of harmful evidence by the target BP, (3) absence of white-coat hypertension, and (4) standing systolic BP ≥ 110 mmHg without orthostatic symptoms. Risk of decreased organ perfusion by arterial stenosis should be screened before starting intensive BP control. When the target BP differs among comorbidities, the lowest target BP should be given preference. After starting intensive BP lowering therapy, tolerability should be monitored, and the titration should be based on the mean level of blood pressure by office supplemented by out-of-office BPs. Applications of the clinical algorithms will be useful to achieve more standardized and simplified applications of target BP in the elderly.
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Affiliation(s)
- Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Internal Medicine, Geriatric Center, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, 13620, Seongnam, Korea.
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Tharmaratnam D, Karayiannis CC, Collyer TA, Arima H, McClure LA, Chalmers J, Anderson CS, Benavente OR, White CL, Algra A, Moran C, Phan TG, Wang WC, Srikanth V. Is Blood Pressure Lowering in the Very Elderly With Previous Stroke Associated With a Higher Risk of Adverse Events? J Am Heart Assoc 2021; 10:e022240. [PMID: 34913363 PMCID: PMC9075242 DOI: 10.1161/jaha.121.022240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background We investigated whether blood pressure lowering for secondary prevention is associated with a reduction in recurrent stroke risk and/or a higher risk of adverse events in very elderly compared with younger trial participants. Methods and Results This is a random effects meta-analysis of randomized controlled trials of blood pressure lowering for secondary stroke prevention to evaluate age-stratified (<80, ≥80 years) risk of adverse events. Ovid-MEDLINE was searched for trials between 1970 and 2020. Summary-level data were acquired including outcomes of stroke, cardiovascular events, mortality, and adverse events. Seven trials were included comprising 38 596 participants, of whom 2336 (6.1%) were aged ≥80 years. There was an overall reduction in stroke risk in the intervention group compared with controls (risk ratio [RR], 0.90 [95% CI, 0.80, 0.98], I2=49%), and the magnitude of risk reduction did not differ by age subgroup (<80, ≥80 years). There was no increase in the risk of hypotensive symptoms in the intervention group for patients aged <80 years (RR, 1.19 [95% CI, 0.99], 1.44, I2=0%), but there was an increased risk in those ≥80 years (RR, 2.17 [95% CI, 1.22], 3.86, I2=0%). No increase was observed in the risk of falls, syncope, study withdrawal, or falls in either age subgroup. Conclusions Very elderly people in secondary prevention trials of blood pressure lowering have an increased risk of hypotensive symptoms, but with no statistical increase in the risk of falls, syncope, or mortality. However, evidence is lacking for frail elderly with multiple comorbidities who may be more vulnerable to adverse effects of blood pressure lowering.
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Affiliation(s)
- Damien Tharmaratnam
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Christopher C Karayiannis
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Taya A Collyer
- Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
| | - Hisatomi Arima
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia.,Department of Preventive Medicine and Public Health Faculty of Medicine Fukuoka University Fukuoka Japan
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics Dornsife School of Public Health Drexel University Philadelphia PA
| | - John Chalmers
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia
| | - Craig S Anderson
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia
| | - Oscar R Benavente
- Division of Neurology Department of Medicine Brain Research Center University of British Columbia Vancouver British Columbia Canada
| | - Carole L White
- School of Nursing University of Texas Health Science Center at San Antonio TX
| | - Ale Algra
- Department of Neurology and Neurosurgery UMC Utrecht Brain Center, and Julius Center for Health Sciences and Primary Care University Medical Center Utrecht and Utrecht University Utrecht The Netherlands
| | - Chris Moran
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Department of Aged Care The Alfred Melbourne Australia.,Geriatric Medicine Unit Peninsula Health Melbourne Australia
| | - Thanh G Phan
- Stroke Unit Department of Neurosciences Monash Health Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Wei C Wang
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
| | - Velandai Srikanth
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke Unit Department of Neurosciences Monash Health Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia.,Geriatric Medicine Unit Peninsula Health Melbourne Australia
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Howlett SE, Rutenberg AD, Rockwood K. The degree of frailty as a translational measure of health in aging. NATURE AGING 2021; 1:651-665. [PMID: 37117769 DOI: 10.1038/s43587-021-00099-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 07/06/2021] [Indexed: 04/30/2023]
Abstract
Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.
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Affiliation(s)
- Susan E Howlett
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew D Rutenberg
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada.
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Hanlon P, Corcoran N, Rughani G, Shah ASV, Mair FS, Guthrie B, Renton JP, McAllister DA. Observed and expected serious adverse event rates in randomised clinical trials for hypertension: an observational study comparing trials that do and do not focus on older people. THE LANCET. HEALTHY LONGEVITY 2021; 2:e398-e406. [PMID: 34240062 PMCID: PMC8245327 DOI: 10.1016/s2666-7568(21)00092-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Representativeness of antihypertensive drug trials is uncertain, as many trials recruit few or no older people. Some trials specifically recruit older participants to address this. Here, we assess the representativeness of trials focusing on older people by comparing the rates of serious adverse events in these trials with the rates in trials of a general adult population (ie, standard trials), and comparing these findings to the rate of hospitalisations and deaths in people with hypertension starting a similar treatment in routine clinical practice. METHODS For this observational study, we identified randomised controlled trials (phase 2/3, 3, or 4) of renin-angiotensin-aldosterone system (RAAS) drugs for hypertension registered from 1999 onwards with ClinicalTrials.gov. Serious adverse events are routinely included in trial reports and are predominantly accounted for by all-cause hospitalisations and deaths. We compared serious adverse event rates in older-people trials (minimum inclusion age ≥60 years) and standard trials (minimum inclusion age <60 years) using Poisson regression models adjusted for trial characteristics (drug type, comparison type, phase, and outcome type). We identified a community cohort of 56 036 adults with hypertension commencing similar drugs to obtain an expected rate of emergency or urgent hospitalisations or deaths, and compared this rate to observed serious adverse event rates in each trial, adjusted for age and sex. For standard trials and for older-people trials, we calculated the standardised ratio of the expected to the observed rate of serious adverse events using Poisson regression models. FINDINGS We included 110 trials, of which 11 (10%) were older-people trials and 99 (90%) were standard trials. Older-people trials had a higher rate of serious adverse events than did standard trials (median events per person per year 0·18 [IQR 0·12-0·29] vs 0·11 [0·08-0·18]; adjusted incidence rate ratio 1·76 [95% CI 1·01-3·03]). The hospitalisation and death rate in the community for those taking RAAS antihypertensives was much greater than the rate of serious adverse events reported in standard trials (standardised ratio [SR] 4·23, 95% CI 3·51-5·09) and older-people trials (4·76, 2·89-7·86), adjusting for age and sex. The magnitude of risk increase for serious adverse events in community patients taking RAAS did not differ when comparing older-people and standard trials (ratio of SRs 1·13, 95% CI 0·66-1·92). INTERPRETATION Trials report substantially fewer serious adverse events than expected from rates of hospitalisations and deaths among similar-aged people receiving equivalent treatments in the community. Serious adverse event rates might be a useful metric to assess trial representativeness. Clinicians should be cautious when applying trial recommendations to older people, even when trials focus on older participants. FUNDING Wellcome Trust, Medical Research Council.
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Affiliation(s)
- Peter Hanlon
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Neave Corcoran
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Guy Rughani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Anoop S V Shah
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Bruce Guthrie
- Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanne P Renton
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - David A McAllister
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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11
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Ungar A, Rivasi G, Coscarelli A, Boccanelli A, Marchionni N, Alboni P, Baldasseroni S, Bo M, Palazzo G, Rozzini R, Terrosu P, Vetta F, Zito G, Desideri G. Hypertension in older persons: why one size does not fit all. Minerva Med 2021; 113:616-625. [PMID: 33832215 DOI: 10.23736/s0026-4806.21.07502-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over recent years, managing hypertension in older people has gained increasing attention, with particular reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g. patients with disability, cognitive impairment, and poor physical performance. Consequently, one size doesn't fit all and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. This review illustrates the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.
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Affiliation(s)
- Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy - .,SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy -
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | - Antonio Coscarelli
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | | | | | - Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giuseppe Palazzo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovambattista Desideri
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy.,Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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12
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Mashozhera S, Bamitale SK, Godman B, Kibuule D. Compliance to hypertensive prescribing guidelines and blood pressure control in elderly patients in Namibia: findings and implications. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmaa017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Objective
Resources-limited countries in sub-Saharan Africa are facing a crisis of hypertensive-related morbidity, mainly due to poor blood pressure (BP) control. The study aimed to evaluate BP control and hypertensive prescribing for elderly patients in a resource-limited setting.
Methods
Hospital-based survey assessing hypertensive prescribing practices among elderly patients (age, ≥60years) at a leading ambulatory care clinic in Namibia. The primary and secondary outcomes were compliance with prescribing guidelines, prescribing patterns and BP control respectively. Data were collected using patient exit interviews and a review of their prescription records. Data were analyzed using descriptive statistics using SPSS v25.
Key findings
Of the 189 elderly patients recruited, 69.3% were females, mean age was 70.3 ± 8.5 years and 2.6% had HIV. 61.4% of the prescriptions complied with the prescribing guidelines in terms of treatment choice and 78.3% (n = 148) had a poor BP control. 61.4% had at least one comorbidity, mainly diabetes mellitus (32.2%) or cardiac disease (20%). On average, 4.5 medicines were prescribed per patient and 4.8% were out of stock. Prevalence of non-INN prescribing was 64%. Diuretics, renin-angiotensin inhibitors were the most prescribed antihypertensive, 73.9% (n = 138/189) and 51.9% (n = 98/189) respectively. 90% of patients with good BP control were on ≥3 medicines compared to 77% for patients with poor BP controlled.
Conclusion
Whilst compliance with prescribing guidelines is modest, the sub-optimal BP control, high prevalence of co-morbidities and over prescribing with non-INN products is discouraging. Pharmacist-led medication audits could improve hypertensive prescribing and BP control among elderly patients, and we will be following this up
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Affiliation(s)
- Shylet Mashozhera
- Department of Pharmacology and Therapeutics, School of Pharmacy, Faculty of Health Sciences, University of Namibia, Namibia
| | - Samuel Kayode Bamitale
- Department of Pharmacology and Therapeutics, School of Pharmacy, Faculty of Health Sciences, University of Namibia, Namibia
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
| | - Dan Kibuule
- Department of Pharmacy Practice & Policy, School of Pharmacy, Faculty of Health Sciences, University of Namibia, Namibia
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13
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Abstract
Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.
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14
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Camafort M, Redón J, Pyun WB, Coca A. Intensive blood pressure lowering: a practical review. Clin Hypertens 2020; 26:21. [PMID: 33292735 PMCID: PMC7603713 DOI: 10.1186/s40885-020-00153-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022] Open
Abstract
According to the last Hypertension guideline recommendations, it may be concluded that intensive BP lowering is only advisable in a subgroup of patients where there is a clear net benefit of targeting to lower BP goals. However, taking into account the relevance of correct BP measurement, estimates of the benefits versus the harm should be based on reliable office BP measurements and home BP measurements. There is still debate about which BP goals are optimal in reducing morbidity and mortality in uncomplicated hypertensives and in those with associated comorbidities. In recent years, trials and meta-analyses have assessed intensive BP lowering, with some success. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. This article reviews the evidence on and controversies about intensive BP lowering in general and in specific clinical situations, and the importance of obtaining reliable BP readings in patients with hypertension and comorbidities.
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Affiliation(s)
- Miguel Camafort
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain. .,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain. .,Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.
| | - Josep Redón
- Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.,Hypertension Clinic. Hospital Clinico, University of Valencia, Valencia, Spain
| | - Wook Bum Pyun
- Department of Cardiology, Ewha Womans University. Seoul Hospital, Seoul, South Korea
| | - Antonio Coca
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain
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15
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16
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Rivasi G, Lucenteforte E, Turrin G, Balzi D, Bulgaresi M, Nesti N, Giordano A, Rafanelli M, Lombardi N, Bonaiuti R, Vannacci A, Mugelli A, Di Bari M, Masud T, Ungar A. Blood pressure and long-term mortality in older patients: results of the Fiesole Misurata Follow-up Study. Aging Clin Exp Res 2020; 32:2057-2064. [PMID: 32227283 DOI: 10.1007/s40520-020-01534-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/12/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) control can prevent major adverse health events, but target values are still controversial, especially in older patients with comorbidities, frailty and disability. AIMS To evaluate mortality according to BP values in a cohort of older adults enrolled in the Fiesole Misurata Study, after a 6-year follow-up. METHODS Living status as of December 31, 2016 was obtained in 385 subjects participating in the Fiesole Misurata Study. Patients' characteristics were analysed to detect predictors of mortality. At baseline, all participants had undergone office BP measurement and a comprehensive geriatric assessment. RESULTS After a 6-year follow-up, 97 participants had died (25.2%). After adjustment for comorbidities and comprehensive geriatric assessment, mortality was significantly lower for SBP 140-159 mmHg as compared with 120-139 mmHg (HR 0.54, 95% CI 0.33-0.89). This result was also confirmed in patients aged 75 + (HR 0.49, 95% CI 0.29-0.85), and in those with disability (HR 0.36, 95% CI 0.15-0.86) or taking antihypertensive medications (HR 0.49, 95% CI 0.28-0.86). DISCUSSION An intensive BP control may lead to greater harm than benefit in older adults. Indeed, the European guidelines recommend caution in BP lowering in older patients, especially if functionally compromised, to minimize the risk of hypotension-related adverse events. CONCLUSIONS After a 6-year follow-up, mortality risk was lower in participants with SBP 140-159 mmHg as compared with SBP 120-139 mmHg, in the overall population and in the subgroups of subjects aged 75 + , with a disability or taking anti-hypertensive medications.
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Affiliation(s)
- Giulia Rivasi
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giada Turrin
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Daniela Balzi
- Epidemiology Unit, Local Health Unit 10, Florence, Italy
| | - Matteo Bulgaresi
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Nicola Nesti
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Antonella Giordano
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Martina Rafanelli
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Niccolò Lombardi
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Mauro Di Bari
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Tahir Masud
- Department of Geriatric Medicine, Nottingham University Hospitals Trust NHS, Nottingham, UK
| | - Andrea Ungar
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy.
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17
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Multiple antihypertensive use and risk of mortality in residents of aged care services: a prospective cohort study. Aging Clin Exp Res 2020; 32:1541-1549. [PMID: 31473981 DOI: 10.1007/s40520-019-01336-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/21/2019] [Indexed: 12/22/2022]
Abstract
AIMS The objective of this study is to investigate the association between multiple antihypertensive use and mortality in residents with diagnosed hypertension, and whether dementia and frailty modify this association. METHODS This is a two-year prospective cohort study of 239 residents with diagnosed hypertension receiving antihypertensive therapy across six residential aged care services in South Australia. Data were obtained from electronic medical records, medication charts and validated assessments. The primary outcome was all-cause mortality and the secondary outcome was cardiovascular-related hospitalizations. Inverse probability weighted Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Covariates included age, sex, dementia severity, frailty status, Charlson's comorbidity index and cardiovascular comorbidities. RESULTS The study sample (mean age of 88.1 ± 6.3 years; 79% female) included 70 (29.3%) residents using one antihypertensive and 169 (70.7%) residents using multiple antihypertensives. The crude incidence rates for death were higher in residents using multiple antihypertensives compared with residents using monotherapy (251 and 173/1000 person-years, respectively). After weighting, residents who used multiple antihypertensives had a greater risk of mortality compared with monotherapy (HR 1.40, 95%CI 1.03-1.92). After stratifying by dementia diagnosis and frailty status, the risk only remained significant in residents with diagnosed dementia (HR 1.91, 95%CI 1.20-3.04) and who were most frail (HR 2.52, 95%CI 1.13-5.64). Rate of cardiovascular-related hospitalizations did not differ among residents using multiple compared to monotherapy (rate ratio 0.73, 95%CI 0.32-1.67). CONCLUSIONS Multiple antihypertensive use is associated with an increased risk of mortality in residents with diagnosed hypertension, particularly in residents with dementia and among those who are most frail.
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18
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Frailty and hypertension in older adults: current understanding and future perspectives. Hypertens Res 2020; 43:1352-1360. [PMID: 32651557 DOI: 10.1038/s41440-020-0510-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 12/17/2022]
Abstract
Hypertension is an important factor affecting the health of older adults. Antihypertensives can reduce stroke, cardiovascular events, and mortality in older hypertensive patients. Blood pressure management is difficult in older adults since geriatric syndromes such as frailty and comorbidities often coexist with hypertension. Recent guidelines propose taking functional status into account when targeting blood pressure in older people. Therefore, a better understanding and control of frailty risk factors could improve the prognosis of older adults with hypertension. However, there are relatively few studies on hypertension and frailty in older adults, especially studies focused on antihypertensive treatment. The goals, target values, and choice of antihypertensive treatment for frail older adults are still disputed. We reviewed the recent literature focusing on frailty and hypertension in older adults and propose a management process for screening and assessing frailty and hypertension before the use of antihypertensives. The process can support older adults with lifestyle interventions and frailty management and help them begin taking a single antihypertensive medication.
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19
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Blood pressure management in hypertensive patients with syncope: how to balance hypotensive and cardiovascular risk. J Hypertens 2020; 38:2356-2362. [DOI: 10.1097/hjh.0000000000002555] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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20
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Giffin A, Madden KM, Hogan DB. Blood Pressure Targets for Older Patients-Do Advanced Age and Frailty Really Not Matter? Can Geriatr J 2020; 23:205-209. [PMID: 32494337 PMCID: PMC7259922 DOI: 10.5770/cgj.23.429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In 2017, Hypertension Canada removed advanced age and frailty as considerations for caution when deciding on intensive therapy in their guidelines for the diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Dementia is not mentioned. In this commentary, we review why advanced age and frailty were removed, and examine what is currently known about the relationship between hypertension and both incident and prevalent dementia. We make the case that the presence of frailty (especially when severe) and dementia should be considered when deciding on intensive therapy in future iterations of Hypertension Canada guidelines.
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Affiliation(s)
- Amanda Giffin
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kenneth M Madden
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada
| | - David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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21
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[Implications of the SPRINT study on the clinical practice of hypertensive elderly people]. HIPERTENSION Y RIESGO VASCULAR 2019; 37:91. [PMID: 31831400 DOI: 10.1016/j.hipert.2019.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/11/2019] [Accepted: 11/18/2019] [Indexed: 11/21/2022]
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22
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Ungar A, Rivasi G, Petrovic M, Schönenberger A, Martínez-Sellés M, Gasowski J, Bahat-Ozturk G, Bo M, Dallmaier D, Fumagalli S, Grodzicki T, Kotovskaya Y, Maggi S, Mattace-Raso F, Polidori MC, Rajkumar R, Strandberg T, Werner N, Benetos A. Toward a geriatric approach to patients with advanced age and cardiovascular diseases: position statement of the EuGMS Special Interest Group on Cardiovascular Medicine. Eur Geriatr Med 2019; 11:179-184. [PMID: 32297238 DOI: 10.1007/s41999-019-00267-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) are highly prevalent in older adults and represent a major geriatric health-care concern. Management of CVD in older patients may be challenging due to specific geriatric issues, such as frailty and multi-morbidity, which may influence patients' outcomes. In this clinical context, diagnostic and therapeutic strategies should target those outcomes that have higher priority in geriatric health care, including disability prevention and quality of life. Older adults with CVD should be offered a reasonably optimized treatment, customized to the individual's frailty level and functional status. Yet, most clinical trials excluded comorbid and frail patients and evidence to support CVD management in this vulnerable population is lacking. Therefore, a geriatric approach is needed in cardiovascular medicine, characterized by a holistic, patient-centered perspective focusing on functional status and quality of life. With a view to promote the geriatric approach in the management of older patients with CVD, the EuGMS Special Interest Group (SIG) on Cardiovascular Medicine was founded in 2018, consisting of a network of geriatricians with an extensive expertise in geriatric cardiovascular medicine. The present position paper aims to present the Cardiovascular SIG and illustrate its main purposes and action programs.
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Affiliation(s)
- Andrea Ungar
- Geriatric Intensive Care Medicine, Hypertension Centre, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Giulia Rivasi
- Geriatric Intensive Care Medicine, Hypertension Centre, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, and Ghent University, Ghent, Belgium
| | | | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Universidad Europea and Universidad Complutense, Madrid, Spain
| | - Jerzy Gasowski
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
| | - Gülistan Bahat-Ozturk
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Istanbul, Turkey
| | - Mario Bo
- Section of Geriatric, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Dhayana Dallmaier
- Research Unit on Aging, AGAPLESION Bethesda Clinic Ulm, Ulm, Germany
| | - Stefano Fumagalli
- Geriatric Intensive Care Medicine, Hypertension Centre, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
| | - Yulia Kotovskaya
- Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Stefania Maggi
- CNR Aging Branch, Aging Program National Research Council, Padua, Italy
| | - Francesco Mattace-Raso
- Division of Geriatrics, Department of Internal Medicine, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Maria Cristina Polidori
- Medizin des Alterns und des alten Menschen, Klinische Altersforschung Oberärztin, Klinik II für Innere Medizin, Universitätsklinik Köln, Cologne, Germany
| | - Raj Rajkumar
- Geriatric and Stroke Medicine, Academic Department of Geriatric Medicine, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Timo Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Nikos Werner
- Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Athanase Benetos
- Geriatric Department and Federation Hospital-University on Cardiovascular Aging (FHU-CARTAGE), University Hospital of Nancy, Université de Lorraine, Vandoeuvre-lès-Nancy, France
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Abstract
Hypertension in older adults is extremely common. It constitutes the major modifiable risk factor of cardiovascular disease, premature disability, and death. Despite proven benefits of blood pressure (BP) reduction in older individuals, there is a considerable disagreement between major guidelines surrounding the optimal levels of BP treatment and control to be achieved. Given the high prevalence of older adults with hypertension, nurse practitioners should critically examine the overall benefit of treatment, use of antihypertensive therapies, and BP targets to provide high-quality care to this patient population. The purpose of this article is to outline the evidence surrounding the management of BP in older adults and to offer strategies to reconcile conflicting guideline recommendations.
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24
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Walston J, Bandeen-Roche K, Buta B, Bergman H, Gill TM, Morley JE, Fried LP, Robinson TN, Afilalo J, Newman AB, López-Otín C, De Cabo R, Theou O, Studenski S, Cohen HJ, Ferrucci L. Moving Frailty Toward Clinical Practice: NIA Intramural Frailty Science Symposium Summary. J Am Geriatr Soc 2019; 67:1559-1564. [PMID: 31045254 DOI: 10.1111/jgs.15928] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/27/2019] [Accepted: 03/19/2019] [Indexed: 01/25/2023]
Abstract
Frailty has long been an important concept in the practice of geriatric medicine and in gerontological research, but integration and implementation of frailty concepts into clinical practice in the United States has been slow. The National Institute on Aging (NIA) Intramural Research Program and the Johns Hopkins Older Americans Independence Center sponsored a symposium to identify potential barriers that impede the movement of frailty into clinical practice and to highlight opportunities to facilitate the further integration of frailty into clinical practice. Primary and subspecialty care providers, and investigators working to integrate and translate new biological aging knowledge into more specific preventive and treatment strategies for frailty provided the meeting content. Recommendations included a call for more specific language that clarifies conceptual differences between frailty definitions and measurement tools; the development of randomized controlled trials to test whether specific intervention strategies for a variety of conditions differently affect frail and non-frail individuals; development of implementation studies and therapeutic trials aimed at tailoring care as a function of pragmatic frailty markers; the use of deep learning and dynamic systems approaches to improve the translatability of findings from epidemiological studies; and the incorporation of advances in aging biology, especially focused on mitochondria, stem cells, and senescent cells, toward the further development of biologically targeted intervention and prevention strategies that can be used to treat or prevent frailty. J Am Geriatr Soc 67:1559-1564, 2019.
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Affiliation(s)
- Jeremy Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Brian Buta
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Howard Bergman
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Thomas M Gill
- Department of Geriatric Medicine, Yale University, New Haven, Connecticut
| | - John E Morley
- Division of Geriatrics, St. Louis University, St. Louis, Missouri
| | - Linda P Fried
- Mailman School of Public Health Columbia University, New York, New York
| | | | - Jonathan Afilalo
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Anne B Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carlos López-Otín
- Biochemistry and Molecular Biology at the University of Oviedo, Oviedo, Spain
| | - Rafa De Cabo
- National Institute of Health, Baltimore, Maryland
| | - Olga Theou
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Harvey J Cohen
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
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25
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Espejo Guerrero J, García Jiménez E, Torres Antiñolo A, Marin Magan FJ, Virués Avila A, Vaquero Prada JP. [Diagnostic validity of the isolated measurement of blood pressure in the community pharmacy. Optimum cut-off points]. HIPERTENSION Y RIESGO VASCULAR 2019; 36:137-144. [PMID: 30833223 DOI: 10.1016/j.hipert.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study is to determine the diagnostic validity of blood pressure measurement in the community pharmacy (CPBP), and to set the cut-off points in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in order to maximise the aforementioned validity, using 24 hour ambulatory blood pressure monitoring (ABPM) as the reference method. MATERIAL AND METHODS A cross-sectional study with consecutive selection of patient users of the community pharmacy in Andalusia. The CPBP was measured, followed by 24-hour ABPM, which assessed the diagnostic validity of the CPBP. The AUC of the ROC curve was also calculated for SBP and DBP, along with the positive and negative predictive values, for different prevalences and the variation of sensitivity and specificity for the different cut-off points for SBP/DBP. RESULTS A total of 167 community pharmacy participated with 1,170 patients, of which 1,110 were valid. The CPBP showed a sensitivity of 60.41% (95% CI: 56.40-64.29), and a specificity of the 79.77% (95% CI: 76.12-82.99), a positive predictive values of 76.96% (95% CI: 72.89-80.57), and a negative predictive values of 64.31% (95% CI: 60.55%-67.90%). By using the ROC curve method, the optimal cut-off points are 134/81mm Hg, the point where the sensitivity and specificity and are balanced and the Youden index is maximised. CONCLUSIONS The sensitivity is relatively low. To improve it tends to lower the cut-off points of SBP and DBP. The calculated optimum is 134/81mm Hg. This provides data on the desirability to review the current cut-off points (140/90), as proposed by the ACC/AHA 2017.
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Affiliation(s)
- J Espejo Guerrero
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España.
| | - E García Jiménez
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España
| | - A Torres Antiñolo
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España
| | - F J Marin Magan
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España
| | - A Virués Avila
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España
| | - J P Vaquero Prada
- Grupo de trabajo MAPAFARMA del Consejo Andaluz de Colegios Oficiales de Farmacéuticos, Farmacéuticos Comunitarios, Sevilla, España
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26
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Ma L, Zhang L, Sun F, Li Y, Tang Z. Frailty in Chinese older adults with hypertension: Prevalence, associated factors, and prediction for long-term mortality. J Clin Hypertens (Greenwich) 2018; 20:1595-1602. [PMID: 30318776 DOI: 10.1111/jch.13405] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/20/2018] [Accepted: 09/07/2018] [Indexed: 11/30/2022]
Abstract
Hypertension and frailty are associated and often coexist in older adults. Few studies have examined the association between hypertension and frailty in Chinese population. We explored the prevalence of and the factors associated with frailty as well as whether frailty could identify patients at risk of adverse outcomes among older adults with hypertension. Data were from the Beijing Longitudinal Study of Aging. A total of 1111 hypertensive participants aged ≥60 years old who completed the comprehensive geriatrics assessment were included. All participants were followed up for 8 years. The total number of deaths was 604. Frailty was assessed by the 68-item frailty index. Stepwise forward logistic regression was used to explore the association between the associated factors and frailty in hypertensive participants. The prediction for mortality was assessed using the adjusted Cox proportional hazards model. Two hundred and eighteen older adults were determined as frail (prevalence rate: 19.6%). Frail older adults with hypertension had worse physical performance, worse psychological, and social function, as well as worse lifestyle habits, compared to nonfrail older adults with hypertension. Chair stand test failure, balance test failure, fracture, disability, depression, and physical frailty measured with modified frailty phenotype were independently associated with frailty. Frailty was associated with a higher 8-year mortality, hazard ratio (HR) = 3.40, adjusted for age and sex, HR = 2.61. Frailty is associated with poorer physical function and higher mortality in community-dwelling hypertensive older adults in China. These findings emphasize the importance and need for frailty intervention and prevention in older adults with hypertension.
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Affiliation(s)
- Lina Ma
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Geriatrics, Beijing, China.,Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Li Zhang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Geriatrics, Beijing, China.,Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Fei Sun
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Geriatrics, Beijing, China.,Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Yun Li
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Geriatrics, Beijing, China.,Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Zhe Tang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Geriatrics, Beijing, China.,Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Geriatric Disorders, Beijing, China
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