Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality

Clinical characteristics of atrial fibrillation in nonagenarian population and relationship with mortality

BACKGROUND

There is a considerable amount of literature available on well-known risk factors for atrial fibrillation (AF); however, available data specifically focused on the ninth decade are scarce. The main objective of this study was to assess the demographic and clinical characteristics of AF and sinus rhythm in a nonagenarian population.

METHODS

All individuals aged >90 years who were admitted to the Cardiology outpatient clinic between April 2018 and January 2019 were enrolled in the study. The demographic and clinical characteristics of all patients were recorded. All deaths that occurred during the two-year follow-up period were recorded.

RESULTS

In total, 112 nonagenarian individuals were included in the study. Of these patients, 50 (44.6%) had AF. The groups showed similarities in demographic and clinical characteristics. During a mean follow-up period of 596±44 days, 39 patients (78%) in the AF group and 35 patients (56.5%) in the sinus group died. Patients with AF showed a lower overall survival distribution than those with sinus rhythm (P=0.005, log-rank test χ2=7.734). AF was associated with an increased risk of mortality (P=0.002, hazard ratio [HR] =2.104, 95% confidence interval [CI] = 1.326-3.339) in multivariate Cox regression analysis, while waist circumference and total cholesterol (P=0.003, HR=0.969, 95% CI=0.949-0.989 and P=0.046, HR=0.993, 95% CI=0.986-1.000, respectively) showed a decreased risk of mortality.

CONCLUSIONS

Atrial fibrillation is very common in individuals over the age of 90 years (44.6%). Well-known risk factors do not appear to be effective in this age group, and AF is associated with a 2.1-fold increase in the risk of mortality.

Deep learning model for the prediction of all-cause mortality among long term care people in China: a prospective cohort study

This study aimed to develop a deep learning model to predict the risk stratification of all-cause death for older people with disability, providing guidance for long-term care plans. Based on the government-led long-term care insurance program in a pilot city of China from 2017 and followed up to 2021, the study included 42,353 disabled adults aged over 65, with 25,071 assigned to the training set and 17,282 to the validation set. The administrative data (including baseline characteristics, underlying medical conditions, and all-cause mortality) were collected to develop a deep learning model by least absolute shrinkage and selection operator. After a median follow-up time of 14 months, 17,565 (41.5%) deaths were recorded. Thirty predictors were identified and included in the final models for disability-related deaths. Physical disability (mobility, incontinence, feeding), adverse events (pressure ulcers and falls from bed), and cancer were related to poor prognosis. A total of 10,127, 25,140 and 7086 individuals were classified into low-, medium-, and high-risk groups, with actual risk probabilities of death of 9.5%, 45.8%, and 85.5%, respectively. This deep learning model could facilitate the prevention of risk factors and provide guidance for long-term care model planning based on risk stratification.

How blood pressure variation is associated with frailty and mortality in the elderly

How blood pressure variation is associated with frailty and mortality in the elderly: three-years follow-up blood pressure changes in 65+years old patients.

Disability level's impact on blood pressure-mortality association in older long-term care adults: evidence from a large Chinese cohort study

BACKGROUND

Evidence of the optimal blood pressure (BP) target for older adults with disability in long-term care is limited. We aim to analyze the associations of BP with mortality in older adults in long-term care setting with different levels of disability.

METHODS

This prospective cohort study was based on the government-led long-term care programme in Chengdu, China, including 41,004 consecutive disabled adults aged ≥ 60 years. BP was measured during the baseline survey by trained medical personnel using electronic sphygmomanometers. Disability profile was assessed using the Barthel index. The association between blood pressure and mortality was analyzed with doubly robust estimation, which combined exposure model by inverse probability weighting and outcome model fitted with Cox regression. The non-linearity was examined by restricted cubic spline. The primary endpoint was all-cause mortality, and the secondary endpoints were cardiovascular and non-cardiovascular mortality.

RESULTS

The associations between systolic blood pressure (SBP) and all-cause mortality were close to a U-shaped curve in mild-moderate disability group (Barthel index ≥ 40), and a reversed J-shaped in severe disability group (Barthel index < 40). In mild-moderate disability group, SBP < 135 mmHg was associated with elevated all-cause mortality risks (HR 1.21, 95% CI, 1.10-1.33), compared to SBP between 135 and 150 mmHg. In severe disability group, SBP < 150 mmHg increased all-cause mortality risks (HR 1.21, 95% CI, 1.16-1.27), compared to SBP between 150 and 170 mmHg. The associations were robust in subgroup analyses in terms of age, gender, cardiovascular comorbidity and antihypertensive treatment. Diastolic blood pressure (DBP) < 67 mmHg (HR 1.29, 95% CI, 1.18-1.42) in mild-moderate disability group and < 79 mmHg (HR 1.15, 95% CI, 1.11-1.20) in severe disability group both demonstrated an increased all-cause mortality risk.

CONCLUSION

The optimal SBP range was found to be higher in older individuals in long-term care with severe disability (150-170mmHg) compared to those with mild to moderate disability (135-150mmHg). This study provides new evidence that antihypertensive treatment should be administered cautiously in severe disability group in long-term care setting. Additionally, assessment of disability using the Barthel index can serve as a valuable tool in customizing the optimal BP management strategy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration Number: ChiCTR2100049973).

Relationship between changes in late-life blood pressure and the risk of frailty and mortality among older population in China: a cohort study based on CLHLS

The evidence regarding the effects of blood pressure changes on older individuals remains inconclusive, and the impact of frailty throughout the life course is not known. We investigated the associations of different change patterns of blood pressure during 3-year intervals with frailty and mortality. Participants included 7335 persons from 2008 to 2014 of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Change in blood pressure was calculated as the difference between follow-up and baseline. Frailty was evaluated using a 40-item frailty index. Mortality status was ascertained up to December 31, 2014. The mean age of participants was 82.6 ± 10.7 years. The optimal blood pressure level (SBP, 130-150 mmHg; DBP, 70-90 mmHg) was associated with the lowest risk of frailty while decreasing follow-up SBP and DBP were significantly correlated with frailty. Lower baseline blood pressure levels (SBP < 130 mmHg; DBP < 70 mmHg) were associated with decreased mortality risk when participants increased their blood pressure to optimal levels during follow-up SBP and DBP (0.78, 0.63-0.98), compared to maintaining a steady low SBP (< 130 mmHg) and DBP (< 70 mmHg). For those with DBP around 70-90 mmHg, decreasing follow-up DBP (< 70 mmHg) was associated with higher mortality (1.23, 1.07-1.42) compared to maintaining stable follow-up DBP (70-90 mmHg). These results remain significant after adjusting for frailty. Optimal blood pressure levels were associated with the lowest risk of frailty. The association between lower blood pressure and increased mortality risk persisted even after accounting for frailty. We used a nationally representative longitudinal cohort study by using 2008-2014 of the Chinese Longitudinal Healthy Longevity in China. Change in blood pressure was calculated as the difference between follow-up and baseline. We investigated the associations of different change patterns of blood pressure during 3-year intervals with frailty and mortality.

Blood pressure in the longevous population with different status of hypertension and frailty

Blood pressure(BP) of the longevous population with hypertension and/or frailty was under-investigated. To investigate the association between age, BP, variation of BP, and survival among the old adults with different status of hypertension and frailty, the present study included adults ≥65 years in the Chinese Longitudinal Healthy Longevity Survey (2008-2018), defined frailty using the Fried criteria, and identified hypertension by self-report or SBP/DBP ≥ 140/90 mm Hg. The association between age and BP were investigated using linear regression models. Variation of BP was defined if annual change of BP lower than quartile 1(sharp decrease) or higher than quartile 3(sharp increase). The association between age and BP variation were investigated using multinominal logistic regression models. The association between BP and survival was analyzed using Cox regression models. Among 13,447 adults (centenarian: 1965[14.6%]), age was positively associated with SBP in robust hypertensive elderly but negatively associated with it in frail hypertensive elderly. Annual change of BP was more likely to be increment among the normotensive elderly, but be decrement among the hypertensive elderly, especially among those with frailty. SBP < 120 mmHg was the risk factor of mortality among the frail oldest-old (≥85 years) while SBP ≥ 150 mmHg was that among the robust young-old (65-84 years). DBP ≥ 90 mmHg was the risk factor of mortality both in the robust young-old and the frail oldest old. In conclusion, age and frailty might be the criteria to predict the change of BP to guide the BP management of the longevous population.

Hospitalization for permanent pacemaker implantation in the context of isolated sinus node dysfunction is associated with increased mortality compared with an outpatient strategy

BACKGROUND

Permanent pacemaker (PPM) implantation is a well-established treatment for symptomatic sinus node dysfunction (SND). The optimal timing of this intervention is unclear, with atrioventricular blocks often prioritized in resource stressed waiting lists due to mortality concerns.

METHODS

Mortality data was compared between patients receiving elective outpatient (OP) PPM implantation, and those presenting to hospital for urgent inpatient (IP) management for symptomatic SND. Survival analysis was conducted using Kaplan-Meier plots and compared using the log-rank test. Univariable and multivariable Cox regression, as well as propensity score matching analyses were performed to assess the prognostic effect on 30-day and 1-year all-cause mortality of inpatient implant.

RESULTS

Of the 1269 patients identified with isolated SND, 740 (58%) had PPMs implanted on an OP and 529 (42%) on an IP basis. Mortality was significantly worse in patients where management was driven by hospital admission on an urgent basis (Log-Rank χ2 = 21.6, p < 0.001) and remained an independent predictor of 1-year all-cause mortality (HR 3.40, 95% CI 1.97-5.86, p < 0.001) on multivariable analysis.

CONCLUSIONS

SND is predominantly a disease associated with ageing and comorbid populations, where avoidance of deconditioning, hospitalization acquired infections, and polypharmacy is advantageous. Admission avoidance is therefore the preferable strategy.

Associations of blood pressure with cardiovascular and mortality outcomes in over 2 million older persons with or without diabetes mellitus: A systematic review and meta-analysis of 45 cohort studies

BACKGROUND

The impact of blood pressure on cardiovascular disease (CVD) and mortality outcomes in older people with diabetes mellitus (DM) is not well quantified. Using a systematic review and meta-analysis of observational cohort studies, we aimed to compare the associations of blood pressure levels with cardiovascular and mortality outcomes in older people aged ≥ 65 years with or without DM.

METHODS

Studies were identified from MEDLINE, Embase, Web of Science, and search of bibliographies to July 2022. Study-specific risk ratios (RRs) with 95% confidence intervals (CIs) were pooled.

RESULTS

Forty-five unique observational cohort studies (n = 2305,189 participants) assessing the associations of systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) levels with adverse cardiovascular outcomes were included. In the general population, the pooled RRs (95% CIs) of SBP ≥ 140 vs < 140 mmHg and per 10 mmHg increase for composite CVD/MACE were 1.26 (0.96-1.64) and 1.15 (1.08-1.23), respectively. The respective estimates were 1.56 (1.04-2.34) and 1.10 (1.04-1.18) for patients with DM. SBP ≥ 130 vs < 130 mmHg was not associated with an increased risk of adverse cardiovascular outcomes in both populations. SBP < 120 vs ≥ 120 mmHg was associated with an increased risk of all cause-mortality in the general population (n = 10 studies). DBP ≥ 90 mmHg was associated with an increased risk of some adverse cardiovascular outcomes in both populations. Interaction analyses suggested similar risk of outcomes in both populations.

CONCLUSIONS

Observational evidence suggests SBP and DBP confer similar cardiovascular and mortality risk in older adults in the general population and those with DM. A blood pressure target range of > 130/80 to < 140/90 mmHg may be optimal for patients ≥ 65 years with DM, but specific targets may need to be individualised based on patients' unique circumstances. Furthermore, findings do not support stringent blood pressure control in this population group. Definitive RCTs are needed to support these observational findings.

Antihypertensive treatment in people of very old age with frailty: time for a paradigm shift?

The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population.

Risk of adverse events following the initiation of antihypertensives in older people with complex health needs: a self-controlled case series in the United Kingdom

BACKGROUND

We assessed the risk of adverse events-severe acute kidney injury (AKI), falls and fractures-associated with use of antihypertensives in older patients with complex health needs (CHN).

SETTING

UK primary care linked to inpatient and mortality records.

METHODS

The source population comprised patients aged >65, with ≥1 year of registration and unexposed to antihypertensives in the year before study start. We identified three cohorts of patients with CHN, namely, unplanned hospitalisations, frailty (electronic frailty index deficit count ≥3) and polypharmacy (prescription of ≥10 medicines). Patients in any of these cohorts were included in the CHN cohort. We conducted self-controlled case series for each cohort and outcome (AKI, falls, fractures). Incidence rate ratios (IRRs) were estimated by dividing event rates (i) during overall antihypertensive exposed patient-time over unexposed patient-time; and (ii) in the first 30 days after treatment initiation over unexposed patient-time.

RESULTS

Among 42,483 patients in the CHN cohort, 7,240, 5,164 and 450 individuals had falls, fractures or AKI, respectively. We observed an increased risk for AKI associated with exposure to antihypertensives across all cohorts (CHN: IRR 2.36 [95% CI: 1.68-3.31]). In the 30 days post-antihypertensive treatment initiation, a 35-50% increased risk for falls was found across all cohorts and increased fracture risk in the frailty cohort (IRR 1.38 [1.03-1.84]). No increased risk for falls/fractures was associated with continuation of antihypertensive treatment or overall use.

CONCLUSION

Treatment with antihypertensives in older patients was associated with increased risk of AKI and transiently elevated risk of falls in the 30 days after starting antihypertensive therapy.

Attainment of NICE blood pressure targets among older people with newly diagnosed hypertension: nationwide linked electronic health records cohort study

BACKGROUND

it is not known if clinical practice reflects guideline recommendations for the management of hypertension in older people and whether guideline adherence varies according to overall health status.

AIMS

to describe the proportion of older people attaining National Institute for Health and Care Excellence (NICE) guideline blood pressure targets within 1 year of hypertension diagnosis and determine predictors of target attainment.

METHODS

a nationwide cohort study of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 years newly diagnosed with hypertension between 1st June 2011 and 1st June 2016. The primary outcome was attainment of NICE guideline blood pressure targets as measured by the latest blood pressure recording up to 1 year after diagnosis. Predictors of target attainment were investigated using logistic regression.

RESULTS

there were 26,392 patients (55% women, median age 71 [IQR 68-77] years) included, of which 13,939 (52.8%) attained a target blood pressure within a median follow-up of 9 months. Success in attaining target blood pressure was associated with a history of atrial fibrillation (OR 1.26, 95% CI 1.11, 1.43), heart failure (OR 1.25, 95% CI 1.06, 1.49) and myocardial infarction (OR 1.20, 95% CI 1.10, 1.32), all compared to no history of each, respectively. Care home residence, the severity of frailty, and increasing co-morbidity were not associated with target attainment following adjustment for confounder variables.

CONCLUSIONS

blood pressure remains insufficiently controlled 1 year after diagnosis in nearly half of older people with newly diagnosed hypertension, but target attainment appears unrelated to baseline frailty, multi-morbidity or care home residence.

Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries

BACKGROUND

Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries.

METHODS

Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes.

RESULTS

Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores.

CONCLUSIONS

Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Hospital Admission Due to Hypotension in Australia and in England and Wales

OBJECTIVES

Hypotension is overlooked because it is often harmless, easily reversed, and can have few or even no symptoms. However, complications of untreated hypotension are dangerous and can result in death. The aim of this study was to examine the trend of hospital admission due to hypotension in Australia and in England and Wales between 1999 and 2020.

METHOD

This was a secular trend analysis study that examined the hospitalisation pattern for hypotension in Australia, England, and Wales between 1999 and 2020. Hospitalisation data were obtained from the National Hospital Morbidity Database in Australia, Hospital Episode Statistics database in England, and Patient Episode Database for Wales. We analysed the variation in hospitalisation rates using the Pearson chi-square test for independence.

RESULTS

Our study showed that hypotension hospital admission rates increased significantly between 1999 and 2020 by 168%, 398%, and 149% in Australia, England, and Wales, respectively. The most common hypotension hospital admissions reason was orthostatic hypotension. All types of hypotension-related hospital admissions in Australia, England, and Wales were directly related to age, more common among the age group 75 years and above. Bed-days hypotension hospital admission patients accounted for 84.6%, 99.5%, and 99.7% of the total number of hypotension hospital admissions in Australia, England, and Wales.

CONCLUSION

In the past two decades, orthostatic hypotension was the most prevalent type of hypotension that required hospitalization in Australia, England, and Wales. Age was identified as the primary risk factor for hypotension across all causes. Future research should focus on identifying modifiable risk factors for hypotension and developing strategies to reduce the burden of orthostatic hypotension.

Impacto del control de la tensión arterial sobre la morbimortalidad en pacientes hipertensos mayores de 65 años en el ámbito comunitario

Objetivo: evaluar el impacto del control de la tensión arterial (TA) sobre la morbimortalidad en > 65 años, sin patología cardiovascular previa, en el ámbito comunitario. Métodos: estudio de cohortes retrospectivas. Se incluyeron todos los pacientes (≥ 65 años) con diagnóstico de hipertensión arterial (HTA) (01/01/2007-31/12/2008), sin eventos cardiovasculares previos de los centros de salud de la Comunidad de Madrid, con al menos dos registros de TA el primer año de seguimiento (n = 17.150). Se evaluaron la aparición de eventos cardiovasculares (incluida mortalidad cardiovascular) y la mortalidad total, mediante regresión de Cox. Resultados: la mediana de seguimiento para mortalidad fue de 90,48 meses (rango intercuartil [RIC]: 53,19-130,30 meses). Se produjeron 8.641 eventos cardiovasculares y 1.026 muertes por cualquier causa. Ajustado por género, grado de hipertensión, tabaquismo, diabetes e hipercolesterolemia, el buen control (TA < 140/90 mmHg) no se asociaba con una disminución de eventos cardiovasculares, pero sí con una disminución de mortalidad del 14,41% (hazard ratio [HR] 0,8559; intervalo de confianza [IC] 95%: 0,7776-0,9421%) entre 75 y 84 años. Cuando se utilizan las cifras de 130/80 mmHg para definir el buen control, este se asociaba con un exceso de mortalidad del 43,58% (IC 95%: 19,60-72,36%) entre 65 y 74 años y del 61,22% (IC 95%: 22,99-111,35%) en sujetos de 85 y más años. Conclusión: el control de la TA en sujetos >65 años se asocia con una disminución ligera de la mortalidad entre 75 y 84 años. Cifras de control más estrictas se relacionan con mayor ocurrencia de evento cardiovascular y de mortalidad, especialmente en el grupo de mayor edad. Palabras clave: hipertensión, indicadores de morbimortalidad, Atención Primaria de Salud, salud de la persona anciana.

Treating Hypertension in Older Adults in Light of the Recent STEP Trial: Can We Implement the Findings in Geriatric Practice?

Recently, major trials have explored blood pressure targets that would provide greater benefit and fewer adverse events in older adult population on antihypertensive treatment. The last study was the STEP study conducted in China, which included 8511 older people aged 60-80 years. When systolic blood pressure below 130 mmHg was targeted in older individuals, there was a 26% risk reduction in cardiovascular outcomes compared with higher (< 150 mmHg) blood pressure values. At this point, it is necessary to evaluate how much the study group represents the older population because this population group is very heterogeneous, and it is not possible to apply a single treatment strategy to all older people. In this context, when we examined the baseline characteristics of the study group, we saw that the individuals included in the study consisted mostly of young-older people with less accompanying comorbidities. In addition, vulnerable groups, such as those with dementia and nursing home residents who are susceptible to treatment adverse effects, appeared to be excluded from the study. Therefore, this trial is very important as it concludes that the goal of strict blood pressure control is beneficial in fit older individuals, but does not guide treatment strategy for other groups. When planning treatments in older adults, it is essential to consider the biological age of individuals and to determine a strategy by evaluating frailty, functionality and cognitive status. As stated in the STEP study protocol, additional analyses considering frailty and cognitive performance will aid in a healthier interpretation of the study in the future.

Hypertension in the older person: is age just a number?

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.

Controversies in Hypertension II: The Optimal Target Blood Pressure

The optimal target blood pressure in the treatment of hypertension is undefined. Whether more intense therapy is better than standard, typically <140/90 mm Hg, is controversial. The most recent American guidelines recommend ≤130/80 mm Hg for essentially all adults. There have been at least 28 trials targeting more versus less intensive therapy, including 13 aimed at reducing cardiovascular events and mortality, 11 restricted to patients with chronic kidney disease, and 4 with surrogate endpoints. We review these trials in a narrative fashion due to significant heterogeneity in targets chosen, populations studied, and primary endpoints. Most were negative, although some showed significant benefit to more intense therapy. When determining the optimal pressure for an individual patient, additional factors should be considered, including age, frailty, polypharmacy, baseline blood pressure, and the diastolic blood pressure J-curve. We discuss these modifying factors in detail. Whereas the tenet "lower is better" is generally true, one size does not fit all, and blood pressure control must be individualized.

Addressing Clinical and Therapeutic Inertia Through Comprehensive Medication Review

Avoiding clinical and therapeutic inertia, through pharmacist-led medication therapy management, can lead to avoidance of inappropriate medication use and adverse medication events. Clinical and therapeutic inertia are terms that have been used indistinctly. One definition is inertia that appears when clinicians do not initiate or intensify therapy appropriately when therapeutic goals are not reached. Another definition is failure to advance or deintensify treatment, and in a broader sense beyond escalation or deintensification of therapy; definitions include failure to screen, make appropriate referrals, manage risk factors, and complications. Failure of clinicians to address clinical and therapeutic inertia in office or hospital visits can contribute to patients using inappropriate medications, and lead to avoidable serious adverse events. Addressing therapeutic inertia may also be a means to minimize prescription costs and improve quality of life. This case illustrates the importance of identifying and addressing the therapeutic appropriateness of medications for an older person who has been prescribed numerous medications over a long period but now has complaints of dizziness as well as the inability to afford all medications.

Age and ageing cardiovascular collection: blood pressure, coronary heart disease and heart failure

As people age they are at increased risk of cardiovascular disease, the leading cause of mortality and morbidity worldwide. Understanding cardiovascular ageing is essential to preserving healthy ageing and preventing serious health outcomes. This collection of papers published in Age and Ageing since 2011 cover key themes in cardiovascular ageing, with a separate collection on stroke and atrial fibrillation planned. Treating high blood pressure remains important as people age and reduces strokes and heart attacks. That said, a more personalised approach to blood pressure may be even more important as people age to lower blood pressure to tight targets where appropriate but avoid overtreatment in vulnerable groups. As people age, more people experience blood pressure drops on standing (orthostatic hypotension), particularly as they become frail. This can predispose them to falls. The papers in this collection provide an insight into blood pressure and orthostatic hypotension. They highlight areas for further research to understand blood pressure changes and management in the ageing population. Inpatient clinical care of older people with heart attacks differs from younger people in UK national audit data. People aged over 80 had improved outcomes in survival after heart attack over time, but had lower rates of specialist input from cardiology compared with younger people. This may partly reflect different clinical presentations, with heart attacks occurring in the context of other health conditions, frailty and multimorbidity. The care and outcomes of acute and chronic cardiovascular disease are impacted by the frailty and health status of an individual at baseline. The research included in this collection reinforces the wide variations in the ageing population and the necessity to focus on the individual needs and priorities, and provide a person-centred multidisciplinary approach to care.

Management of Hypertension in the Elderly and Frail Patient

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.

Identifying Frail Patients by Using Electronic Health Records in Primary Care: Current Status and Future Directions

With the rapidly aging population, frailty, characterized by an increased risk of adverse outcomes, has become a major public health problem globally. Several frailty guidelines or consensuses recommend screening for frailty, especially in primary care settings. However, most of the frailty assessment tools are based on questionnaires or physical examinations, adding to the clinical workload, which is the major obstacle to converting frailty research into clinical practice. Medical data naturally generated by routine clinical work containing frailty indicators are stored in electronic health records (EHRs) (also called electronic health record (EHR) data), which provide resources and possibilities for frailty assessment. We reviewed several frailty assessment tools based on primary care EHRs and summarized the features and novel usage of these tools, as well as challenges and trends. Further research is needed to develop and validate frailty assessment tools based on EHRs in primary care in other parts of the world.

Impact of Frailty on the Relationship between Blood Pressure and Cardiovascular Diseases and Mortality in Young-Old Adults

The optimal blood pressure (BP) target in older people according to frailty status remains uncertain. This article investigates how frailty affects the association between BP and cardiovascular diseases or mortality, specifically in young-old adults. A retrospective cohort was created for 708,964 older adults with a uniform age of 66 years. The association between BP and myocardial infarction (MI), stroke, or mortality was analyzed using Cox proportional hazards models. The Timed Up and Go test (TUG) was used as a measure of physical frailty. Mean follow-up was 6.8 years, detecting 38,963 (5.5%) events. There was a linear association between increasing systolic BP (SBP) or diastolic BP (DBP) and increased risk of incident MI and stroke, compared to the reference BP (SBP, 110−119 mmHg or DBP, 80−89 mmHg). The risk patterns with high BP remained similar in each TUG group (<10, 10−14, or ≥15 s). A similar pattern of increased risks was found in those who took antihypertensive drugs and who did not, however they were more pronounced in those who did not. The findings support the need to achieve the same BP target in young-old adults with or without frailty to lower the risk of MI, stroke, and mortality.

Do the frail experience more adverse events from intensive blood pressure control? A 2-year prospective study in the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for management of hypertension in adults aged ≥65 years recommend a blood pressure (BP) treatment target of 130-139/70-79 mmHg if tolerated. Randomised controlled trials have advocated for lower BP, but this may have adverse outcomes in the frail. Yet, definitions of frailty vary.

METHODS

Using a prospective, observational study design, we compared two frailty classifications in their ability to predict short-term adverse outcomes associated with intensive BP control (<130/70 mmHg) in The Irish Longitudinal Study on Ageing (TILDA). Data from participants aged ≥65 treated for hypertension in Wave 1 (W1) between October 2009 and June 2011 were analysed. Frailty was identified by Frailty Phenotype (FP) and the Clinical Frailty Scale (CFS). We formulated 8 participant groups based on frailty-BP combinations. Outcomes at wave 2 (W2) in 2012-2013 were analysed with adjusted binary logistic regression models.

FINDINGS

Of 1920 W1 participants aged ≥65 and treated for hypertension, 1229 had full BP/FP and 1282 BP/CFS data. While the FP only identified risk of hospitalisation associated with intensive BP treatment, intensively treated frail-by-CFS participants had no increased or decreased risk of adverse outcomes, but those treated above the target had a higher risk of falls/fractures. In the non-frail by FP, intensive blood pressure treatment was associated with reduced risk of falls/fractures.

INTERPRETATION

Different frailty classifications may have different prognostic implications for the purpose of the application of hypertension management guidelines. Our study had limited power due to low frailty prevalences, so further research is needed. Guidelines should specify the recommended frailty identification method/s. In the frail, therapy personalisation is needed.

Low Blood Pressure, Comorbidities, and Ischemic Stroke Mortality in US Veterans

BACKGROUND AND PURPOSE

Low blood pressure (BP) is associated with higher stroke mortality, although the factors underlying this association have not been fully explored. We investigated prestroke BP and long-term mortality after ischemic stroke in a national sample of US veterans.

METHODS

Using a retrospective cohort study design of veterans hospitalized between 2002 and 2007 with a first ischemic stroke and with ≥1 outpatient BP measurements 1 to 18 months before admission, we defined 6 categories each of average prestroke systolic BP (SBP) and diastolic BP, and 7 categories of pulse pressure. Patients were followed-up to 12 years for primary outcomes of all-cause and cardiovascular mortality. We used Cox models to relate prestroke BP indices to mortality and stratified analyses by the presence of preexisting comorbidities (smoking, myocardial infarction, heart failure, atrial fibrillation/flutter, cancer, and dementia), race and ethnicity.

RESULTS

Of 29 690 eligible veterans with stroke (mean±SD age 67±12 years, 98% men, 67% White), 2989 (10%) had average prestroke SBP<120 mm Hg. During a follow-up of 4.1±3.3 years, patients with SBP<120 mm Hg experienced 61% all-cause and 27% cardiovascular mortality. In multivariable analyses, patients with the lowest SBP, lowest diastolic BP, and highest pulse pressure had the highest mortality risk: SBP<120 versus 130 to 139 mm Hg (hazard ratio=1.26 [95% CI, 1.19-1.34]); diastolic BP <60 versus 70 to 79 mm Hg (hazard ratio=1.35 [95% CI, 1.23-1.49]); and pulse pressure ≥90 versus 60 to 69 mm Hg (hazard ratio=1.24 [95% CI, 1.15-1.35]). Patients with average SBP<120 mm Hg and at least one comorbidity (smoking, heart disease, cancer, or dementia) had the highest mortality risk (hazard ratio=1.45 [95% CI, 1.37-1.53]).

CONCLUSIONS

Compared with normotension, low prestroke BP was associated with mortality after stroke, particularly among patients with at least one comorbidity.

Analysis of blood pressure and blood pressure variability pattern among older patients in long-term care hospitals: an observational study analysing the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) dataset

OBJECTIVES

There are limited data regarding blood pressure (BP) variability among older adults living in long-term care hospitals (LTCHs). We aimed to collect data from LTCH and analyse BP characteristics and its variability among these patients using a novel platform.

METHODS

The Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) platform was used to construct a daily BP dataset using data of 394 older patients from 6 LTCHs. BP variability was expressed as coefficient of variation (CV = standard deviation/mean of BP × 100). Physical frailty and cognitive function were evaluated using the K-FRAIL questionnaire and the Cognitive Performance Scale of the interRAI Long-Term Care Facilities tool, respectively.

RESULTS

From September 2019 to September 2020, 151,092 BP measurements, 346.5 (IQR 290.8-486.3) measurements per patient, were included. The mean BP was 123.4 ± 10.8/71.3 ± 6.5 mmHg. BP was significantly lower in frail patients (122.2 ± 11.3/70.4 ± 6.8 mmHg) than in pre-frail/robust patients (124.4 ± 10.4/72.1 ± 6.1 mmHg, P < 0.05). However, CV of systolic (10.7 ± 2.3% versus 11.3 ± 2.3%, P = 0.005) and diastolic (11.6 ± 2.3% versus 12.4 ± 2.4%, P < 0.001) BP was higher in frail patients. The mean BP was lower, but BP variability was higher in patients with cognitive impairment. The mean BP, but not BP variability, was higher in treated hypertensive patients, as the number of antihypertensive medications increased.

CONCLUSION

Older patients with physical or cognitive frailty had lower BP but higher BP variability. Relationship among frailty, increased BP variability and adverse clinical outcomes should be investigated.

Systolic Blood Pressure and Mortality in Community-Dwelling Older Adults: The Role of Frailty

OBJECTIVES

To investigate whether frailty modifies the association of systolic blood pressure (SBP) with cardiovascular mortality and all-cause mortality in community-dwelling older adults.

DESIGN

A prospective cohort study.

SETTING

A population-based study of nationally representative older Chinese adults in a community setting.

PARTICIPANTS

This study included participants aged 65 years or older from the Chinese Longitudinal Healthy Longevity Survey 2002-2014 and followed up to 2018.

MEASUREMENTS

Participants were divided into two groups according to a frailty index based on the accumulation of a 44-items deficits model. The association between SBP and mortality was analyzed using multivariable-adjusted Cox proportional hazards models.

RESULTS

Among 18,503 participants included, the mean age was 87.2 years and the overall median follow-up time was 42.7 months. We identified 7808 (42.2%) frail participants (mean frailty index=0.33), in which 7533 (96.5%) died during the follow-up. Effect modification by frailty was detected (P for interaction=0.032). Among frail participants, a U-shaped association was found with hazard ratios of 1.16 (95% CI, 1.02-1.32) for SBP < 100 mmHg, and 1.11 (95% CI, 1.00-1.24) for SBP ≥ 150 mmHg compared with SBP 120-130 mmHg. For non-frail older adults, a tendency toward higher risk among those with SBP ≥ 130 mmHg was observed. The analyses towards cardiovascular mortality showed similar results.

CONCLUSION

Our results suggest the presence of effect modification by frailty indicating a possible negative effect for elevated SBP in non-frail older adults and a U-shaped relationship of SBP in frail older adults with respect to mortality even after adjusting for diastolic blood pressure.

Association of Systolic and Diastolic Blood Pressure With All-Cause Mortality Among Community-Dwelling Older Adults: A Prospective Observational Study

OBJECTIVES

To assess the association of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with mortality among older adults in Singapore.

METHODS

Association of SBP and DBP measured in 2009 for 4443 older adults (69.5±7.4 years; 60-97 years) participating in a nationally representative study with mortality risk through end-December 2015 was assessed using Cox regression.

RESULTS

Higher mortality risk was observed at the lower and upper extremes of SBP and DBP. With SBP of 100-119 mmHg as the reference, multivariable mortality hazard ratios [HRs (95% confidence interval)] were SBP <100 mmHg: 2.41 (1.23-4.72); SBP 160-179 mmHg: 1.51 (1.02-2.22); and SBP ≥180 mmHg: 1.78 (1.12-2.81). With DBP of 70-79 mmHg as the reference, HRs were DBP <50 mmHg: 2.41 (1.28-4.54) and DBP ≥110 mmHg: 2.16 (1.09-4.31).

DISCUSSION

Management of high blood pressure among older adults will likely reduce their mortality risk. However, the association of excessively low SBP and DBP values with mortality risk needs further evaluation.

Risk from low blood pressure in frail older adults: diastolic pressure and pulse pressure are important

Blood pressure measurement with a cuff in patients with stiff arteries can be misleading, with false elevation of the diastolic pressure. Coronary flow, and most of the cerebral blood flow occur during diastole. There is a marked diastolic J curve in patients with diastolic pressure <60 mmHg and pulse pressure >60 mmHg. Aiming for a systolic target of 120 mmHg is not safe in some frail older patients.

The total and direct effects of systolic and diastolic blood pressure on cardiovascular disease and longevity using Mendelian randomisation

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guidelines lowered the hypertension threshold to ≥ 130/80 mmHg, but the role of diastolic BP remains contested. This two-sample mendelian randomisation study used replicated genetic variants predicting systolic and diastolic BP applied to the UK Biobank and large genetic consortia, including of cardiovascular diseases and parental lifespan, to obtain total and direct effects. Systolic and diastolic BP had positive total effects on CVD (odds ratio (OR) per standard deviation 2.15, 95% confidence interval (CI) 1.95, 2.37 and OR 1.91, 95% CI 1.73, 2.11, respectively). Direct effects were similar for systolic BP (OR 1.83, 95% CI 1.48, 2.25) but completely attenuated for diastolic BP (1.18, 95% CI 0.97, 1.44), although diastolic BP was associated with coronary artery disease (OR 1.24, 95% CI 1.03, 1.50). Systolic and diastolic BP had similarly negative total (- 0.20 parental attained age z-score, 95% CI - 0.22, - 0.17 and - 0.17, 95% CI - 0.20, - 0.15, respectively) and direct negative effects on longevity. Our findings suggest systolic BP has larger direct effects than diastolic BP on CVD, but both have negative effects (total and direct) on longevity, supporting the 2017 ACC/AHA guidelines lowering both BP targets.

Systolic Blood Pressure and Mortality in Community-Dwelling Older Adults: Frailty as an Effect Modifier

Current evidence is insufficient to support different hypertension treatment targets in older adults. We evaluated whether frailty modifies the association between systolic blood pressure (SBP) and 8-year all-cause mortality in community-dwelling older adults. Longitudinal data from the ActiFE Ulm study (Activity and Function in the Elderly in Ulm; Germany) was collected. The association between SBP and mortality was analyzed using Cox proportional hazards models adjusted for age, sex, education, smoking, alcohol consumption, sleep disturbance, diastolic blood pressure, and antihypertensive medications, evaluating the presence of effect modification by frailty according to a frailty index based on the accumulation of deficits. Among 1170 participants (median age 73.9 years, 41.6% women), the prevalence of history of hypertension was 53.8% (median SBP, 144.0 mm Hg [interquartile range, 135.0-149.5], median diastolic blood pressure 78.0 mm Hg [interquartile range, 71.0-86.5]). The median follow-up time was 8.1 years, detecting 268 deaths. We identified 251 (21.5%, 114 deaths) frail participants (frailty index ≥0.2). Effect modification by frailty was detected. Among non-frail a J-shaped association was found with hazard ratio, 4.01 (95% CI, 1.13-14.28) for SBP<110 mm Hg, hazard ratio, 0.92 (95% CI, 0.53-1.59) for SBP 140-150 mm Hg, and hazard ratio, 1.98 (95% CI, 0.75-5.27) for SBP≥160 mm Hg. For frail older adults, a tendency toward lower risk among those with SBP≥130 mm Hg was observed. Our results suggest the presence of effect modification by frailty indicating a possible protective effect for elevated SBP in frail older adults with respect to all-cause mortality even after adjusting for diastolic blood pressure and antihypertensive treatment.

Blood pressure, frailty and dementia

High blood pressure (BP) affects 75% of people aged over 70. Ageing alters BP homeostasis, resulting in postural hypotension and increased BP variability. Co-morbidity and frailty add complexity to understanding BP changes in later life. Longitudinal BP declines are likely driven by accumulating co-morbidity and are accelerated in both frailty and dementia. This narrative review summarises what is known about the association between BP and frailty, the clinical management of BP in frailty and the association between BP, cognitive decline and dementia.

Blood pressure in dementia, mild cognitive impairment, and subjective cognitive decline related to time of death

OBJECTIVE

It is unknown whether systolic blood pressure (SBP) drop is part of the normal aging process or due to the onset of dementia for some people. SBP drop is referring to the decrease in blood pressure often seen before death. Thus, the aim of this study was to examine whether SBP at time of diagnosis of dementia, mild cognitive impairment, or subjective cognitive decline was associated with years prior to death, and whether these associations were modified by diagnoses, age, and sex.

METHODS

Participants were 2,236 patients from the Norwegian Registry of Persons Assessed for Cognitive Symptoms (NorCog), who died during follow-up (2009-2017) for whom we had valid blood pressure measurements. Mean age at diagnosis was 77.5 years (SD 8.3), and patients were followed for an average of 3.9 years (SD 2.2, maximum 10.5 years). The patients had subjective cognitive decline (95), mild cognitive impairment (573), dementia (1,401), or no diagnoses related to cognitive deficits (167). SBP as dependent variable was regressed against years prior to death.

RESULTS

In men, SBP was 1.8 mmHg lower per year closer to death (p < .01), and this trend was linear without any acceleration. This association between years prior to death and SBP in men was not modified by age, year of diagnosis, or diagnosis. There was no such association in women.

CONCLUSION

SBP was significantly lower for those diagnosed close to death in men, but not in women. This association was not modified by either age or onset of diagnosis. Thus, the lowering of SBP is more related to closeness to death and sex than to dementia or age. The downward trend was linear all 10 years prior to death, with no acceleration closer to death.

The Impact of Frailty on the Effectiveness and Safety of Intensive Glucose Control and Blood Pressure-Lowering Therapy for People With Type 2 Diabetes: Results From the ADVANCE Trial

OBJECTIVE

To develop a frailty index (FI) and explore the relationship of frailty to subsequent adverse outcomes on the effectiveness and safety of more intensive control of both blood glucose and blood pressure (BP), among participants with type 2 diabetes in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial.

RESEARCH DESIGN AND METHODS

Cox proportional hazard models were used to estimate the effectiveness and safety of intensive glucose control and BP intervention according to frailty (defined as FI >0.21) status. The primary outcomes were macro- and microvascular events. The secondary outcomes were all-cause mortality, cardiovascular mortality, severe hypoglycemia, and discontinuation of BP treatment due to hypotension/dizziness.

RESULTS

There were 11,140 participants (mean age, 65.8 years; 42.5% women, 25.7% frail). Frailty was an independent predictor of all primary outcomes and secondary outcomes. The effect of intensive glucose treatment on primary outcomes showed some evidence of attenuation in the frail: hazard ratios for combined major macro- and microvascular events 1.03 (95% CI 0.90-1.19) in the frail versus 0.84 (95% CI 0.74-0.94) in the nonfrail (P = 0.02). A similar trend was observed with BP intervention. Severe hypoglycemia rates (per 1,000 person-years) were higher in the frail: 8.39 (6.15-10.63) vs. 4.80 (3.84-5.76) in nonfrail (P < 0.001). There was no significant difference in discontinuation of BP treatment between frailty groups.

CONCLUSIONS

It was possible to retrospectively estimate frailty in a trial population, and this FI identified those at higher risk of poor outcomes. Participants with frailty had some attenuation of benefit from intensive glucose-lowering and BP-lowering treatments.

Control of blood pressure in older patients with heart failure and the risk of mortality: a population-based prospective cohort study

BACKGROUND

treatment goals for blood pressure (BP) lowering in older patients with heart failure (HF) are unclear.

OBJECTIVE

to assess whether BP control < 140/90 mmHg is associated with a decreased risk of mortality in older HF patients.

DESIGN

population-based prospective cohort study.

SETTING/SUBJECTS

participants of the Berlin Initiative Study, a prospective cohort of community-dwelling older adults launched in 2009. Clinical information was obtained in face-to-face interviews and linked to administrative healthcare data.

METHODS

Cox proportional hazards models estimated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular death and all-cause mortality associated with normalised BP (systolic BP < 140 mmHg and diastolic BP < 90 mmHg) compared with non-normalised BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) in HF patients. The primary analysis considered only baseline BP ('time-fixed'); an additional analysis updated BP during follow-up ('time-dependent').

RESULTS

at baseline, 544 patients were diagnosed with HF and treated with antihypertensive drugs (mean age 82.8 years; 45.4% female). During a median follow-up of 7.5 years and compared with non-normalised BP, normalised BP was associated with similar risks of cardiovascular death (HR, 1.24; 95% CI, 0.84-1.85) and all-cause mortality (HR, 1.16; 95% CI, 0.89-1.51) in the time-fixed analysis but with increased risks of cardiovascular death (HR, 1.79; 95% CI, 1.23-2.61) and all-cause mortality (HR, 1.48; 95% CI, 1.15-1.90) in the time-dependent analysis.

CONCLUSIONS

BP control < 140/90 mmHg was not associated with a decreased risk of mortality in older HF patients. The increased risk in the time-dependent analysis requires further corroboration.

What you need to know about falls

Falls are a common presenting complaint, particularly in older patients, and are associated with significant morbidity. Inpatient falls also have financial implications for healthcare systems, including litigation costs. This article provides an approach to assessing a patient presenting with a fall, encompassing the cause and consequence of the event. It also highlights the need to consider both the acute and chronic factors that predispose a particular patient to fall. Chronic factors such as frailty, sarcopenia, cognitive impairment, and continence issues are often under-recognised and, as a result, not managed optimally. A comprehensive geriatric assessment is an ideal structure to identify modifiable risks. Practical interventions that can be of benefit to minimise a patient's risk of falling include a medication review, assessment of their mobility and their environment. In addition, continence review and visual assessment may be appropriate.

Multi-morbidity and blood pressure trajectories in hypertensive patients: A multiple landmark cohort study

BACKGROUND

Our knowledge of how to better manage elevated blood pressure (BP) in the presence of comorbidities is limited, in part due to exclusion or underrepresentation of patients with multiple chronic conditions from major clinical trials. We aimed to investigate the burden and types of comorbidities in patients with hypertension and to assess how such comorbidities and other variables affect BP levels over time.

METHODS AND FINDINGS

In this multiple landmark cohort study, we used linked electronic health records from the United Kingdom Clinical Practice Research Datalink (CPRD) to compare systolic blood pressure (SBP) levels in 295,487 patients (51% women) aged 61.5 (SD = 13.1) years with first recorded diagnosis of hypertension between 2000 and 2014, by type and numbers of major comorbidities, from at least 5 years before and up to 10 years after hypertension diagnosis. Time-updated multivariable linear regression analyses showed that the presence of more comorbidities was associated with lower SBP during follow-up. In hypertensive patients without comorbidities, mean SBP at diagnosis and at 10 years were 162.3 mm Hg (95% confidence interval [CI] 162.0 to 162.6) and 140.5 mm Hg (95% CI 140.4 to 140.6), respectively; in hypertensive patients with ≥5 comorbidities, these were 157.3 mm Hg (95% CI 156.9 to 157.6) and 136.8 mm Hg (95% 136.4 to 137.3), respectively. This inverse association between numbers of comorbidities and SBP was not specific to particular types of comorbidities, although associations were stronger in those with preexisting cardiovascular disease. Retrospective analysis of recorded SBP showed that the difference in mean SBP 5 years before diagnosis between those without and with ≥5 comorbidities was -9 mm Hg (95% CI -9.7 to -8.3), suggesting that mean recorded SBP already differed according to the presence of comorbidity before baseline. Within 1 year after the diagnosis, SBP substantially declined, but subsequent SBP changes across comorbidity status were modest, with no evidence of a more rapid decline in those with more or specific types of comorbidities. We identified factors, such as prescriptions of antihypertensive drugs and frequency of healthcare visits, that can explain SBP differences according to numbers or types of comorbidities, but these factors only partly explained the recorded SBP differences. Nevertheless, some limitations have to be considered including the possibility that diagnosis of some conditions may not have been recorded, varying degrees of missing data inherent in analytical datasets extracted from routine health records, and greater measurement errors in clinical measurements taken in routine practices than those taken in well-controlled clinical study settings.

CONCLUSIONS

BP levels at which patients were diagnosed with hypertension varied substantially according to the presence of comorbidities and were lowest in patients with multi-morbidity. Our findings suggest that this early selection bias of hypertension diagnosis at different BP levels was a key determinant of long-term differences in BP by comorbidity status. The lack of a more rapid decline in SBP in those with multi-morbidity provides some reassurance for BP treatment in these high-risk individuals.

Systolic blood pressure and outcomes in frail older adults

Hypertension is diagnosed in the majority of older people with frailty, in whom blood pressure prognosis is not well understood. This editorial describes recent evidence on blood pressure and outcomes in older people with frailty.

How to design a hypertension treatment trial that informs care of older people with frailty: a survey of clinicians in Ireland and the UK

INTRODUCTION

At all ages, randomised trials demonstrate lower mortality and cardiovascular disease incidence with blood pressure (BP) lowering. However, this may not generalise to older people with frailty. We aimed to determine the acceptability to clinicians of key aspects of trial designs using different BP targets and strategies to better manage hypertension in the context of frailty.

METHODS

We conducted a multinational survey of clinicians managing hypertension in older people, distributed using an online survey link amongst professional societies and social networks. Questions described case histories of patients who were frail with different systolic blood pressures (SBP), treatment target, strategy and target trial population.

RESULTS

In total, 114 responses were received (48 primary care, 66 secondary care). A majority would consider recruiting patients to a trial of relaxing treatment in those whose SBP < 130 mm Hg; a majority would consider recruiting to a trial intensifying treatment in patients with SBP > 150 mm Hg. Respondents elected to intensify treatment by: choosing the next step by NICE guidelines, adding a new treatment agent at full dose, or adding two agents at half dose.

CONCLUSION

A majority of clinicians surveyed would recruit older people to a trial intensifying treatment where SBP is more than 150 mm Hg and where patients have high cardiovascular risk or to a trial relaxing treatment where the SBP is below 130 mm Hg and where the patient has frailty.