Embracing complexity: A consideration of hypertension in the very old

Physical performance changes as clues to late-life blood pressure changes with advanced age: the osteoporotic fractures in men study

OBJECTIVES

This study examined whether changes in late-life physical performance are associated with contemporaneous changes in blood pressure (BP) in older men.

DESIGN

prospective cohort study over 7 years.

SETTING AND PARTICIPANTS

Physical performance (gait speed, grip strength, chair stand performance) and clinic-measured BP at baseline and at least one follow-up (year 7 or 9) were assessed in 3,135 men aged ≥65 y enrolled in the Osteoporotic Fractures in Men Study (MrOS).

METHODS

Generalized estimating equation analysis of multivariable models with standardized point estimates (β [95% CI]) described longitudinal associations between physical performance and BP changes in participants overall, and stratified by baseline cardiovascular disease (CVD), antihypertensive medication use (none, ≥1), and enrollment age (<75 years; ≥75 years).

RESULTS

Overall, positive associations (z-score units) were found between each increment increase in gait speed and systolic (SBP) (0.74 [0.22, 1.26]) and grip strength (0.35 [0.04, 0.65]) or gait speed (0.55 [0.24, 0.85]) with diastolic (DBP). Better grip strength and chair stand performance over time were associated with 1.83 [0.74, 2.91] and 3.47 [0.20, 6.74] mmHg higher SBP, respectively in men with CVD at baseline (both interaction P < .05). Gait speed increases were associated with higher SBP in men without CVD (0.76 [0.21, 1.32]), antihypertensive medication non-users (0.96 [0.30, 1.62]), aged <75 years (0.73 [0.05, 1.41]) and ≥75 years (0.76 [0.06, 1.47]). Similar positive, but modest associations for DBP were observed with grip strength in men with CVD, antihypertensive medication non-users, and aged <75 years, and with gait speed in men without CVD, aged <75 years, and irrespective of antihypertensive medication use.

CONCLUSION

In older men, better physical performance is longitudinally associated with higher BP. Mechanisms and implications of these seemingly paradoxical findings, which appears to be modified by CVD status, antihypertensive medication use, and age, requires further investigation.

Cardiovascular disease, associated risk factors, and risk of dementia: An umbrella review of meta-analyses

Introduction

Cardiovascular diseases (CVDs) have been associated with an increased risk of dementia; yet the evidence is mixed. This review critically appraises and synthesises current evidence exploring associations between dementia risk and CVD and their risk factors, including coronary heart disease, heart failure, atrial fibrillation, hypertension, hyperlipidaemia, and arterial stiffness.

Methods

MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews with meta-analyses investigating the association between at least one of the CVDs of interest and dementia risk. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews was used to assess methodological quality.

Results

Twenty-five meta-analyses published between 2007 and 2021 were included. Studies largely consisted of cohorts from North America and Europe. Findings were variable, with coronary heart disease, heart failure, and atrial fibrillation consistently associated with increased risk for all-cause dementia, but results were inconsistent for Alzheimer's disease. Hypertension was more frequently associated with dementia during mid-life compared to late life. Findings concerning cholesterol were complex, and while results were inconsistent for low-density lipoprotein cholesterol and total cholesterol, there appeared to be no associations between triglycerides and high-density lipoprotein cholesterol. All meta-analyses investigating hypercholesterolaemia showed significant increases in dementia risk. There was a paucity of research on the association between arterial stiffness and dementia risk.

Conclusion

Targeted CVD dementia prevention strategies could reduce dementia prevalence. Future research should determine the underpinning mechanisms linking heart and brain health to determine the most effective strategies for dementia risk reduction in CVD populations.

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.

Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation

Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.

Association of Thyroid Hormone Therapy with Mortality in Subclinical Hypothyroidism: A Systematic Review and Meta-Analysis

CONTEXT

Benefits of thyroid hormone therapy on mortality in adults with subclinical hypothyroidism remain undetermined.

OBJECTIVE

To summarize the impact of thyroid hormone therapy on mortality in adults with subclinical hypothyroidism.

DATA SOURCES

PubMed, Embase, Scopus, Web of Science, and Clinicaltrials.gov from inception until April 25, 2020.

STUDY SELECTION

Studies comparing the effect of thyroid hormone therapy with that of placebo or no therapy in adults with subclinical hypothyroidism on all-cause and/or cardiovascular mortality.

DATA EXTRACTION

Two reviewers independently extracted data and performed quality assessments. Random-effects models for meta-analyses were used.

DATA SYNTHESIS

Five observational studies and 2 randomized controlled trials with 21 055 adults were included. Overall, thyroid hormone therapy was not significantly associated with all-cause (pooled relative risk [RR] = 0.95, 95% confidence interval [CI]: 0.75-1.22, P = .704) or cardiovascular (pooled RR = 0.99, 95% CI: 0.82-1.20, P = .946) mortality. Subgroup analyses revealed that in younger adults (aged <65-70 years), thyroid hormone therapy was significantly associated with a lower all-cause (pooled RR = 0.50, 95% CI: 0.29-0.85, P = .011) and cardiovascular (pooled RR = 0.54, 95% CI: 0.37-0.80, P = .002) mortality. However, no significant association between thyroid hormone therapy and mortality was observed in older adults (aged ≥65-70 years).

CONCLUSIONS

Use of thyroid hormone therapy does not provide protective effects on mortality in older adults with subclinical hypothyroidism. However, thyroid hormone therapy for subclinical hypothyroidism may show benefits on morality in adults aged <65 to 70 years.

Frailty Syndrome among oldest old Individuals, aged ≥80 years: Prevalence & Correlates

OBJECTIVES

Objectives were to study prevalence of frailty among Indian oldest old population, and to detect its correlates.

METHODS

A cross sectional community based study was done including 200 healthy participants aged ≥80 years, randomly sampled from Hyderabad city in India. They completed an administered questionnaire and physical function tests including SPPB, grip strength. Cognitive function was assessed using MMSE and depression using GDS. Blood pressure, haemoglobin, and fasting blood sugar were measured for all participants. Frailty was defined using Fried phenotype criteria. Logistic regression was done to identify independently associated correlates.

RESULTS

The prevalence of frailty syndrome was 83.4% in our study population. Frailty among men was 80.3% and among women was 84.7%, and it increased with increasing age. The independent correlates which increased the odds of frailty were poor physical performance (SPPB) (OR: 4.21; 95% CI: 1.12-15.83), depression (OR: 3.35; 95% CI: 1.29-8.73), chronic joint pains (OR: 4.90; 95% CI: 1.97-12.18) and COPD (OR: 3.01; 95% CI: 1.03- 8.78), while hypertension showed inverse association (OR: 0.33;95% CI: 0.11-0.94).

CONCLUSION

The prevalence of frailty among the oldest old is very high. Geriatric medicine protocols must include routine screening for frailty, while also including early detection of poor physical performance, depression, COPD and osteoarthritis.

Patterns of Cardiovascular Risk Factors in Old Age and Survival and Health Status at 90

BACKGROUND

The population age 90 years and older is the fastest growing segment of the U.S. population. Only recently is it possible to study the factors that portend survival to this age.

METHODS

Among participants of the Cardiovascular Health Study, we studied the association of repeated measures of cardiovascular risk factors measured over 15-23 years of follow-up and not only survival to 90 years of age, but also healthy aging outcomes among the population who reached age 90. We included participants aged 67-75 years at baseline (n = 3,613/5,888) to control for birth cohort effects, and followed participants until death or age 90 (median follow-up = 14.7 years).

RESULTS

Higher systolic blood pressure was associated with a lower likelihood of survival to age 90, although this association was attenuated at older ages (p-value for interaction <.001) and crossed the null for measurements taken in participants' 80's. Higher levels of high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and body mass index (BMI) were associated with greater longevity. Among the survivors to age 90, those with worse cardiovascular profile (high blood pressure, LDL cholesterol, glucose, and BMI; low HDL cholesterol) had lower likelihood of remaining free of cardiovascular disease, cognitive impairment, and disability.

CONCLUSION

In summary, we observed paradoxical associations between some cardiovascular risk factors and survival to old age; whereas, among those who survive to very old age, these risk factors were associated with higher risk of adverse health outcomes.

The role of functional status on the relationship between blood pressure and cognitive decline: the Cardiovascular Health Study

OBJECTIVE

To examine whether self-reported functional status modified the association between blood pressure (BP) and cognitive decline among older adults.

METHODS

The study included 2097 US adults aged 75 years and older from the Cardiovascular Health Study, followed for up to 6 years. Functional status was ascertained by self-reported limitation in activities of daily living (ADL; none vs. any). Cognitive function was assessed by the Modified Mini Mental State Exam (3MSE). We used linear mixed models to examine whether the presence of at least one ADL limitation modified the association between BP and cognitive decline. Potential confounders included demographics, physiologic measures, antihypertensive medication use and apolipoprotein E ε4 allele. We conducted stratified analyses for significant interactions between BP and ADL.

RESULTS

The association between BP and change in 3MSE differed by baseline ADL limitation. Among participants without ADL limitation, elevated systolic BP (≥140 mmHg) was associated with a 0.15 decrease (95% CI -0.24 to -0.07); P value for interaction less than 0.001, whereas in those with an ADL limitation, elevated systolic BP was independently associated with a 0.30 increase in 3MSE scores per year (95% CI 0.06-0.55). Elevated diastolic BP (≥80 mmHg) was associated with an increase in cognitive function in both groups, although the increase was greater in those with ADL limitation (0.47 points per year vs. 0.18 points per year, P value for interaction = 0.01).

CONCLUSION

Elevated BP appears to be associated with a decrease in cognitive scores among functioning older adults, and modest improvements in cognitive function among poorly functioning elders.

Managing Hypertension in the elderly: What's new?

Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world. Hypertension is a major risk factor for cardiovascular events and mortality in the elderly. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 ​mm Hg or higher or a diastolic blood pressure of 80 ​mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 ​mm Hg For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment. Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes. Elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs also need to be included in randomized clinical trials. Data on patients older than 85 years treated for hypertension are also sparse. These patients need clinical trial data. Finally, the effect of different antihypertensive drugs on clinical outcomes including serious adverse events needs to be investigated in elderly frail patients with hypertension and different comorbidities.

Systolic blood pressure as a predictor of transient ischemic attack/minor stroke in emergency department patients under age 80: a prospective cohort study

BACKGROUND

Elevated blood pressure (BP) at emergency department (ED) presentation and advancing age have been associated with risk of ischemic stroke; however, the relationship between BP, age, and transient ischemic attack/minor stroke (TIA/MS) is not clear.

METHODS

A multi-site, prospective, observational study of 1084 ED patients screened for suspected TIA/MS (symptom onset < 24 h, NIHSS< 4) between December 2013 and April 2016. Systolic and diastolic BP measurements (SBP, DBP) were taken at ED presentation. Final diagnosis was consensus adjudication by stroke neurologists; patients were diagnosed as either TIA/MS or stroke-mimic (non-cerebrovascular conditions). Conditional inference trees were used to define age cut-points for predicting binary diagnosis (TIA/MS or stroke-mimic). Logistic regression models were used to estimate the effect of BP, age, sex, and the age-BP interaction on predicting TIA/MS diagnosis.

RESULTS

Over a 28-month period, 768 (71%) patients were diagnosed with TIA/MS: these patients were older (mean 71.6 years) and more likely to be male (58%) than stroke-mimics (61.4 years, 41%; each p < 0.001). TIA/MS patients had higher SBP than stroke-mimics (p < 0.001). DBP did not differ between the two groups (p = 0.191). SBP was predictive of TIA/MS diagnosis in younger patients, after accounting for age and sex; an increase of 10 mmHg systolic increased the odds of TIA/MS 18% (odds ratio [OR] 1.18, 95% CI 1.00-1.39) in patients < 60 years, and 23% (OR 1.23, 95% CI 11.12-1.35) in those 60-79 years, while not affecting the odds of TIA/MS in patients ≥80 years (OR 0.99, 95% CI 0.89-1.07).

CONCLUSIONS

Raised SBP in patients younger than 80 with suspected TIA/MS may be a useful clinical indicator upon initial presentation to help increase clinicians' suspicion of TIA/MS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03050099 (10-Feb-2017) and NCT03070067 (3-Mar-2017). Retrospectively registered.

Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies

Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.

Role of autonomic nervous activity, as measured by heart rate variability, on the effect of mortality in disabled older adults with low blood pressure in long-term care

AIM

Previous studies have shown the relationship between low blood pressure and high mortality in frail, disabled older adults in long-term care. However, the mechanism of this relationship is still unclear. We hypothesized that autonomic nervous activity decline is involved in the relationship between low blood pressure and high mortality.

METHODS

The present prospective cohort study recruited 61 participants aged ≥75 years. The data from 24-h Holter monitoring and blood pressure recorded by ambulatory blood pressure monitoring were collected. Measured data were divided into three categories: 24-h, daytime and night-time. From power spectral density in the electrocardiogram, low frequency, high frequency and low frequency/high frequency ratio were calculated. The primary end-point was death.

RESULTS

High blood pressure was connected to both high daytime low frequency and high frequency (partial correlation coefficients: 0.42, P < 0.05 and 0.35, P < 0.05, respectively). In addition, the low blood pressure group had higher mortality than the high blood pressure group, and disabled older adults in long-term care and those with elevated daytime systolic and diastolic blood pressure had less risk of mortality compared with those without (systolic: hazard ratio 0.89, 95% confidence interval 0.83-0.96, P = 0.003; diastolic: hazard ratio 0.98, 95% confidence interval 0.79-1.00, P = 0.049). The average blood pressures in the high blood pressure groups were approximately 140/80 mmHg and were connected to low mortality.

CONCLUSIONS

Attenuated autonomic nervous activity might lead to low blood pressure in the daytime and high mortality in disabled older adults in long-term care. Geriatr Gerontol Int 2018; 18: 1153-1158.

MANAGEMENT OF ENDOCRINE DISEASE: l-Thyroxine replacement therapy in the frail elderly: a challenge in clinical practice

The number of elderly people, mostly aged over 85 years (the 'oldest old'), is increasing worldwide. As a consequence, accompanying morbidity and disability have been increasing, and frailty, defined as an age-related condition of decline of physiological reserves and vulnerability, represents an emerging problem. Caring for older frail people may represent a challenge, since the elderly differ significantly from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics and greater vulnerability to adverse drug reactions. Specific criteria of therapeutic appropriateness and modified goals of care are needed in such patients, also in endocrine care settings. Indeed, thyroid dysfunctions are among the most common conditions in older, multimorbid populations. The prevalence of overt and subclinical hypothyroidism is as high as 20% and thyroid hormone prescription is common in the elderly, with a trend toward levothyroxine treatment of more marginal degrees of hypothyroidism. In addition, older patients have the highest rate of overtreatment during replacement therapy and are more susceptible to developing adverse effects from thyroid hormone excess. Recently, results of a multicentric randomized controlled trial, the TRUST-IEMO collaboration trial, added further insights to the debated question of whether and when levothyroxine treatment is required and if it is beneficial in the elderly. With this in mind, we revised the relevant literature on the impact of thyroid dysfunction and replacement therapy among older people, with the aim to better define indications, benefits and risks of l-T4 replacement therapy in the frail elderly.

Home blood pressure predicts stroke incidence among older adults with impaired physical function: the Ohasama study

OBJECTIVE

Several observational studies have found modifying effects of functional status on the association between conventional office blood pressure (BP) and adverse outcomes. We aimed to examine whether the association between higher BP and stroke was attenuated or inverted among older adults with impaired function using self-measured home BP measurements.

METHODS

We followed 501 Japanese community-dwelling adults aged at least 60 years (mean age, 68.6 years) with no history of stroke. Multivariate-adjusted hazard ratios for 1-SD increase in home BP and office BP measurements were calculated by the Cox proportional hazards model. Functional status was assessed by self-reported physical function.

RESULTS

During a median follow-up of 11.5 years, first strokes were observed in 47 participants. Higher home SBP, but not office SBP, was significantly associated with increased risk of stroke among both 349 participants with normal physical function and 152 participants with impaired physical function [hazard ratio (95% confidence interval) per 14.4-mmHg increase: 1.74 (1.12-2.69) and 1.77 (1.06-2.94), respectively], with no significant interaction for physical function (P = 0.56). Higher home DBP, but not office DBP, was also significantly associated with increased risk of stroke (P ≤ 0.029) irrespective of physical function (all P > 0.05 for interaction). Neither home BP nor office BP was significantly associated with all-cause mortality irrespective of physical function.

CONCLUSION

Higher home BP was associated with increased risk of stroke even among those with impaired physical function. Measurements of home BP would be useful for stroke prevention, even after physical function decline.

Functional Status Modifies the Association of Blood Pressure with Death in Elders: Health and Retirement Study

OBJECTIVE

To examine whether grip strength, gait speed, and the combination of the two physical functioning measures modified the association of systolic BP (SBP) and diastolic BP (DBP) with mortality.

DESIGN

Nationally representative cohort study.

SETTING

Health and Retirement Study.

PARTICIPANTS

7,492 U.S. adults aged ≥65 years.

MEASUREMENTS

Grip strength was measured by a hand dynamometer and classified as normal (≥16 kg for female; ≥26 kg for male) and weak. Gait speed was assessed over a 98.5-inch walk and classified as non-slow (≥0.60 m/s for female; ≥0.52 m/s for male) and slow.

RESULTS

Over an average follow-up time of 6.0 years, 1,870 (25.0%) participants died. After adjustment for socio-demographic, behavioral, and clinical measures, elevated SBP (≥150 mmHg) and DBP (≥90 mmHg) was associated with a 24% (95% CI, 7-43%) and 25% (95% CI, 5-49%) higher mortality among participants with normal grip strength. In contrast, elevated SBP and DBP was associated with a 6% (95% CI, 31 to -27%) and a 16% (95% CI, 46 to -26%) lower mortality among those with weak grip strength (P-values of interactions: both=.07). The inverse relations between BP with death were most pronounced among slow walkers with weak grip strength. The HRs of elevated SBP and DBP for death was 0.85 (95% CI, 0.56-1.29) and 0.53 (95% CI, 0.30-0.96), respectively, and was substantially different from non-slow walkers with normal grip strength (HR = 1.24 and 1.15, respectively; P-values of interactions: both <.001). Therefore, associations of BP with death varied modestly by gait speed.

CONCLUSION

Grip strength modified the association of BP with death. Combination of grip strength and gait speed has incremental value for modifying the association of BP with death.

Age of onset of hypertension and risk of dementia in the oldest-old: The 90+ Study

INTRODUCTION

We investigated the association between age of onset of hypertension and dementia risk in an oldest-old cohort.

METHODS

Participants are from The 90+ Study, a population-based longitudinal study of people aged 90+ who are survivors from the Leisure World Cohort Study. We estimated hypertension onset age using self-reported information from The 90+ Study and Leisure World Cohort Study, collected about 20 years earlier. A total of 559 participants without dementia were followed every 6 months for up to 10 years.

RESULTS

A total of 224 participants developed dementia during follow-up (mean = 2.8 years). Compared with those without hypertension, participants whose hypertension onset age was 80 to 89 years had a lower dementia risk (hazard ratio = 0.58, P = .04) and participants with an onset age of 90+ years had the lowest risk (hazard ratio = 0.37, P = .004).

DISCUSSION

Developing hypertension at older ages may protect against dementia. Understanding the mechanisms for this lower risk is important for determining ways to prevent dementia in the very elderly.

Functional Status and Antihypertensive Therapy in Older Adults: A New Perspective on Old Data

BACKGROUND

Functional status may be useful for identifying older adults who benefit from lower blood pressure. We examined whether functional status modifies the effect of antihypertensive treatment among older adults.

METHODS

Post hoc analyses of the Systolic Hypertension in the Elderly Program (SHEP), a randomized trial of antihypertensive therapy vs. placebo (1985-1991) in 4,736 adults aged 60 years or older with isolated systolic hypertension. Outcomes were all-cause death, cardiovascular (CV) death, myocardial infarction (MI), stroke, falls, and symptoms of hypotension. The effect modifier of interest was functional status, assessed by self-reported physical ability limitation (PAL).

RESULTS

Among persons with no PAL, those receiving treatment had a lower rate of death, CV death, and MI compared with placebo (4.0, 2.9, and 4.2 per 1,000 person-years lower, respectively). In contrast, among persons with a PAL, those receiving treatment had a higher rate of death, CV death, and MI compared with placebo (8.6, 5.3, and 2.7 per 1,000 person-years higher, respectively). These patterns persisted in Cox models, although interaction terms did not reach statistical significance. Treatment remained protective for stroke regardless of functional status. The rate of falls associated with treatment differed by functional status; incidence-rate ratio = 0.81, 95% confidence interval (CI) = (0.66, 0.99), and 1.32, 95% CI = (0.87, 2.00) in participants without and with a PAL, respectively, in models adjusted for demographics and baseline blood pressure (P-value for interaction, 0.04).

CONCLUSIONS

Functional status may modify the effect of antihypertensive treatment on MI, mortality, and falls, but not stroke, in older adults. Functional status should be examined in other trial settings.

Age and Outcomes Associated with BP in Patients with Incident CKD

BACKGROUND AND OBJECTIVES

Hypertension is the most important treatable risk factor for cardiovascular outcomes. Many patients with CKD are elderly, but the ideal BP in these individuals is unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

From among 339,887 patients with incident eGFR<60 ml/min per 1.73 m(2), we examined associations of systolic BP (SBP) and diastolic BP (DBP) with all-cause mortality, incident coronary heart disease (CHD), ischemic strokes, and ESRD from the time of developing CKD until the end of follow-up (July 26, 2013, for mortality, CHD, and stroke, and December 31, 2011, for ESRD) in multivariable-adjusted survival models categorized by patients' age.

RESULTS

Of the total cohort, 300,424 (88%) had complete data for multivariable analysis. Both SBP and DBP showed a U-shaped association with mortality. SBP displayed a linear association with CHD, stroke, and ESRD, whereas DBP showed no consistent association with either. SBP>140 mmHg was associated with higher incidence of all examined outcomes, but with an incremental attenuation of the observed risk in older compared with younger patients (P<0.05 for interaction) The adjusted hazard ratios and 95% confidence intervals associated with SBP≥170 mmHg (compared with 130-139 mmHg) in patients <50, 50-59, 60-69, 70-79, and ≥80 years were 1.95 (1.34 to 2.84), 2.01 (1.75 to 2.30), 1.68 (1.49 to 1.89), 1.39 (1.25 to 1.54), and 1.30 (1.17 to 1.44), respectively. The risk of incident CHD, stroke, and ESRD was incrementally higher with higher SBP in patients aged <80 years but showed no consistent association in those aged ≥80 years (P<0.05 for interaction for all outcomes).

CONCLUSIONS

In veterans with incident CKD, SBP showed different associations in older versus younger patients. The association of higher SBP with adverse outcomes was present but markedly reduced in older individuals, especially in those aged ≥80 years. Elevated DBP showed no consistent association with vascular outcomes in patients with incident CKD.

Gait Speed as a Guide for Blood Pressure Targets in Older Adults: A Modeling Study

OBJECTIVES

To evaluate the potential for gait speed to inform decisions regarding optimal systolic blood pressure targets in older adults.

DESIGN

Forecasting study from 2014 to 2023 using the Cardiovascular Disease Policy Model, a Markov model.

SETTING

National Health and Nutrition Examination Survey.

PARTICIPANTS

U.S. adults aged 60-94 stratified into fast walking, slow walking, and poor functioning (noncompleters) based on measured gait speed.

MEASUREMENTS

Lowering SBP to a target of 140 or 150 mmHg was modeled in persons with (secondary prevention) and without (primary prevention) a history of coronary heart disease or stroke. Based on clinical trials and observational studies, it was projected that slow-walking and poor-functioning participants would have greater noncardiovascular mortality. Myocardial infarctions (MIs), strokes, deaths, cost, and disability-adjusted life years (DALYs) were measured.

RESULTS

Regardless of gait speed, it was projected that secondary prevention to a systolic blood pressure (SBP) of 140 mmHg would prevent more events and save more money than secondary prevention to 150 mmHg. Similarly, primary prevention to 140 mmHg in fast-walking adults was projected to prevent events and save money. In slow-walking adults, primary prevention to 150 mmHg was projected to prevent MIs and strokes and save DALYs but was cost saving only in men; intensification to 140 mmHg is of uncertain benefit in slow-walking individuals. Primary prevention in poor-functioning adults to a target of 140 or 150 mmHg SBP is projected to decrease DALYs.

CONCLUSION

The most cost-effective SBP target varies according to history of cardiovascular disease and gait speed in persons aged 60-94. These projections highlight the need for better estimates of the benefits and harms of antihypertensive medications in a diverse group of older adults, because the net benefit is sensitive to the characteristics of the population treated.

Blood Pressure in Older Adults: the Importance of Frailty

The importance of high blood pressure (BP) and the effect of BP lowering in older adults remain controversial due to the mixed evidence in this population. Frailty status may resolve the apparently conflicting findings and identify subpopulations who share common risk. Emerging evidence demonstrates that low BP is associated with poor outcomes in older frail adults or those with poor functional status. In contrast, in non-frail older adults, low BP appears beneficial. Frail older adults may be at increased risk of hypotension, serious fall injuries, and polypharmacy. Additionally, peripheral BP may not be the best prognostic measure in this population. The majority of clinical practice guidelines give little recommendation for frail older adults, which is likely due to their systematic underrepresentation in randomized controlled trials. Future studies need to consider modifications to safely include frail older adults, and guidelines should consider inclusion of evidence beyond randomized controlled trials.

Rates and predictors of three-year mortality in older people in rural Tanzania

BACKGROUND

There are few data on mortality rates in the general elderly living in sub-Saharan Africa. We aimed to detail three-year mortality rates in a population of rural community-dwelling older adults in northern Tanzania.

METHODS

We performed a community-based study of 2232 people aged 70 years and over living in Hai district, Tanzania. At baseline, participants underwent clinical assessment for disability, neurological disorders, hypertension, atrial fibrillation and memory problems. At three-year follow-up mortality data were collected. Mortality rates were compared to UK estimates.

RESULTS

At follow-up, data were available for 1873 subjects (83.9%). Of those, 208 (11.1%, 95% CI 9.7-12.5) had died. The age-standardised mortality rate was 10.2% (95% CI 8.8-11.6). Age-standardised mortality rates were lower than estimated for the UK (13.9%). In Cox regression analysis, greater age, higher levels of functional disability, use of a walking aid, subjective report of memory problems, being severely underweight and being normotensive were significant predictors of mortality.

CONCLUSIONS

Those who survive to old age in Tanzania appear to have relatively low mortality rates. Physical and cognitive disabilities were strongly associated with mortality risk in this elderly community-dwelling population. The association between blood pressure and mortality merits further study.

Effects of Age and Functional Status on the Relationship of Systolic Blood Pressure With Mortality in Mid and Late Life: The ARIC Study

BACKGROUND

Impaired functional status attenuates the relationship of systolic blood pressure (SBP) with mortality in older adults but has not been studied in middle-aged populations.

METHOD

Among 10,264 stroke-free Atherosclerosis Risk in Communities participants (mean age 62.8 [5.7] years; 6,349 [62%] younger [<65 years]; 5,148 [50%] men; 2,664 [26%] Black), function was defined as good function (GF) for those self-reporting no difficulty performing functional tasks and basic or instrumental tasks of daily living; all others were defined as impaired function (IF). SBP categories were normal (<120 mmHg), prehypertension (120-139 mmHg), and hypertension (≥140 mmHg). Mortality risk associated with SBP was estimated using adjusted Cox proportional hazard models with a triple interaction between age, functional status, and SBP.

RESULTS

Mean follow-up was 12.9 years with 2,863 (28%) deaths. Among younger participants, 3,017 (48%) had IF; 2,279 of 3,915 (58%) older participants had IF. Prehypertension (hazard ratio [HR] = 1.48 [1.03, 2.15] p = .04) and hypertension (HR = 1.97 [1.29, 3.03] p = .002) were associated with mortality in younger GF and older (≥65 years) GF participants (prehypertension HR = 1.21 [1.06, 1.37] p = .005; hypertension HR = 1.47 [1.36, 1.59] p < .001). Among IF participants, prehypertension was not associated with mortality in younger participants (HR = 0.99 [0.85, 1.15] p = .93) and was protective in older participants (HR = 0.87 [0.85, 0.90] p < .001). Hypertension was associated with mortality in younger IF participants (HR = 1.54 [1.30, 1.82] p < .001) but not in older IF participants (HR = 0.99 [0.87, 1.14] p = .93).

CONCLUSIONS

Compared with younger and well-functioning persons, the additional contribution of blood pressure to mortality is much lower with older age and impaired function, particularly if both are present. Functional status and age could potentially inform optimal blood pressure targets.

Predicting mortality in older adults with kidney disease: a pragmatic prediction model

OBJECTIVES

To develop mortality risk prediction models for older adults with chronic kidney disease (CKD) that include comorbidities and measures of health status and use not associated with particular comorbid conditions (nondisease-specific measures).

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Northwest (KPNW) Health Maintenance Organization.

PARTICIPANTS

Individuals with severe CKD (estimated glomerular filtration rate<30 mL/min per 1.73 m2; N=4,054; n=1,915 aged 65-79, n=2,139 aged ≥80) who received care at KPNW between 2000 and 2008.

MEASUREMENTS

Cox proportional hazards analysis was used to examine the association between selected participant characteristics and all-cause mortality and to generate age group-specific risk prediction models. Predicted and observed risks were evaluated according to quintile. Predictors from the Cox models were translated into a points-based system. Internal validation was used to provide best estimates of how these models might perform in an external population.

RESULTS

The risk prediction models used 16 characteristics to identify participants with the highest risk of mortality at 2 years for adults aged 65 to 79 and 80 and older. Predicted and observed risks agreed within 5% for each quintile; a 4 to 5 times difference in 2-year predicted mortality risk was observed between the highest and lowest quintiles. The c-statistics for each model (0.68-0.69) indicated effective discrimination without evidence of significant overfit (slope shrinkage 0.06-0.09). Models for each age group performed similarly for mortality prediction at 6 months and 2 years in terms of discrimination and calibration.

CONCLUSION

When validated, these risk prediction models may be helpful in supporting discussions about prognosis and treatment decisions sensitive to prognosis in older adults with CKD in real-world clinical settings.

Longitudinal systolic blood pressure characteristics and integrity of white matter tracts in a cohort of very old black and white adults

BACKGROUND

We sought to determine which systolic blood pressure (SBP) characteristics are associated with reduced brain integrity and whether these associations are stronger for white or gray matter. We hypothesized that exposure to higher and variable SBP will be associated with lower structural integrity of both gray and white matter.

METHODS

Neuroimaging, SBP, and cognition were obtained in 311 community-dwelling adults in 2006–2008 (average age = 83 years; 58% women; 40% black). Antihypertensive medications, SBP, and health-related factors were collected from 1997 to 1998 to time of neuroimaging. SBP values obtained from 1997 to 1998 to time of neuroimaging were used to compute mean; pulse pressure; coefficient of variation; and peak, load, and group-based trajectories.

RESULTS

Higher mean SBP was associated with lower white matter integrity in uncinate and superior lateral fasciculi bilaterally, independent of age, stroke history, antihypertensive medication use (odds ratio of having white matter hyperintensities greater than or equal to the median for 10mm Hg of SBP = 10.4, 95% confidence interval = 10.2–10.6, P = 0.0001; standardized beta for fractional anisotropy = −13.54, SE = 4.58, P = 0.003). These neuroimaging markers attenuated the association between higher SBP and lower digit symbol substitution test. Results were similar for trajectories of SBP and stronger for those with previously higher and variable SBP even if SBP was normal at neuroimaging. Results were similar for those without stroke. Associations with gray matter measures were not significant.

CONCLUSIONS

If confirmed, these data suggest a history of higher and variable SBP for very old adults may be useful to alert clinicians to potential lower integrity in selected tracts, whereas cross-sectional SBP measurements may obscure the risk of underlying white matter hyperintensities. Whether lowering and/or stabilizing SBP levels in very old adults without a remarkable cardiovascular history would have neuroprotective effects and reduce dementia risk needs further study.

Association of physical function with predialysis blood pressure in patients on hemodialysis

BACKGROUND

New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects.

METHODS

We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature.

RESULTS

Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI 0.35-0.93) of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand (130-159 mmHg: OR 0.59, 95% CI 0.38-0.92) and gait speed (≥160 mmHg: OR 0.59, 95% CI 0.35-0.98). Blood pressure≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg.

CONCLUSIONS

Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined.

Risk factors for cardiovascular disease across the spectrum of older age: the Cardiovascular Health Study

OBJECTIVE

The associations of some risk factors with cardiovascular disease (CVD) are attenuated in older age; whereas others appear robust. The present study aimed to compare CVD risk factors across older age.

METHODS

Participants (n = 4883) in the Cardiovascular Health Study free of prevalent CVD, were stratified into three age groups: 65-74, 75-84, 85+ years. Traditional risk factors included systolic blood pressure (BP), LDL-cholesterol, HDL-cholesterol, obesity, and diabetes. Novel risk factors included kidney function, C-reactive protein (CRP), and N-terminal pro-B-type natriuretic peptide (NT pro-BNP).

RESULTS

There were 1498 composite CVD events (stroke, myocardial infarction, and cardiovascular death) over 5 years. The associations of high systolic BP and diabetes appeared strongest, though both were attenuated with age (p-values for interaction = 0.01 and 0.002, respectively). The demographic-adjusted hazard ratios (HR) for elevated systolic BP were 1.79 (95% confidence interval: 1.49, 2.15), 1.59 (1.37, 1.85) and 1.10 (0.86, 1.41) in participants aged 65-74, 75-84, 85+, and for diabetes, 2.36 (1.89, 2.95), 1.55 (1.27, 1.89), 1.51 (1.10, 2.09). The novel risk factors had consistent associations with the outcome across the age spectrum; low kidney function: 1.69 (1.31, 2.19), 1.61 (1.36, 1.90), and 1.57 (1.16, 2.14) for 65-74, 75-84, and 85+ years, respectively; elevated CRP: 1.54 (1.28, 1.87), 1.33 (1.13, 1.55), and 1.51 (1.15, 1.97); elevated NT pro-BNP: 2.67 (1.96, 3.64), 2.71 (2.25, 3.27), and 2.18 (1.43, 3.45).

CONCLUSIONS

The associations of most traditional risk factors with CVD were minimal in the oldest old, whereas diabetes, eGFR, CRP, and NT pro-BNP were associated with CVD across older age.

Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people

OBJECTIVES

To investigate relationships between the use of cardiovascular medications, including angiotensin system-blocking medications (ASBMs), orthostatic hypotension (OH), fall risk, and falls in community-dwelling older people.

DESIGN

Prospective cohort study.

SETTING

Sydney, Australia.

PARTICIPANTS

Five hundred twenty community-dwelling older adults.

MEASUREMENTS

Medical, medication and falls history were obtained from a standardized questionnaire in all participants. Blood pressure was measured in supine, seated, and tilted positions. Fall risk was assessed using the Physiological Profile Assessment (PPA). Falls data were collected prospectively for 12 months using monthly fall calendars. Participants were defined as nonfallers (no falls) and fallers (≥ 1 falls) at the end of the 12-month follow-up.

RESULTS

Participants taking medications affecting the angiotensin system had greater quadriceps strength, but after adjusting for sex, this difference became insignificant. People taking ASBMs were less likely to fall (odds ratio = 0.68, 95% confidence interval = 0.48-0.97), and the association between ASBMs and falls remained significant after adjusting for sex, body mass index, PPA score, and psychotropic medication and 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor (statin) use. OH was more frequently observed in participants taking alpha adrenergic receptor blockers (α-blockers), but the presence of OH did not increase fall risk.

CONCLUSION

The use of cardiovascular medications in older people did not increase the risk of falls, and the use of ASBMs was associated with lower fall risk. The mechanisms for this apparent protective effect are unclear and appear not to be directly related to muscle strength. More research is required to elucidate the possible protective effects of certain cardiovascular medications in relation to falls in older people.

Subclinical hypothyroidism in the elderly: to treat or not to treat?

Aging is associated with a host of alterations in thyroid gland structure and function. Some of these changes have favorable effects on longevity, whereas others are maladaptive and contribute to a decline in health and quality of life. An area of particular controversy is the diagnosis and management of subclinical hypothyroidism in the elderly. The clinical diagnosis of hypothyroidism in the elderly is difficult, because many signs and symptoms associated with hypothyroidism are commonly present in euthyroid elderly individuals. The biochemical profile of subclinical hypothyroidism includes normal serum levels of thyroid hormones with mildly elevated serum thyrotropin concentrations in the range of 4.5 to 10 mIU/L. In this article, the epidemiology of subclinical hypothyroidism in the elderly is reviewed, the potential advantages of mild hypothyroidism in people over the age of 75 years are discussed, and some guidelines for screening and management of this common thyroid dysfunction are suggested.

Implications of marital/partner relationship quality and perceived stress for blood pressure among older adults

OBJECTIVES

Although higher quality marriages are associated with better health outcomes, less is known about the mechanisms accounting for this association. This study examines links among marital/partner quality, stress, and blood pressure and considers both main and moderating effects.

METHOD

Participants from the National Social Life, Health, and Aging Project (N = 1,854; aged 57-85 years) completed in-person interviews regarding their marital/romantic partner relationships and perceived stress. Interviews included blood pressure assessments.

RESULTS

Linear regression models revealed no main effects of spousal/partner quality or stress on blood pressure. However, spousal/partner quality moderated the link between stress and blood pressure. Specifically, there were negative associations between stress and blood pressure among people reporting more confiding, less reliance, and greater demands from spouses/partners.

DISCUSSION

Findings highlight the complexity of relationship quality. Individuals appeared to benefit from aspects of both high- and low-quality spouse/partner relations but only under high levels of stress. Findings are inconsistent with traditional moderation hypotheses, which suggest that better quality ties buffer the stress-health link and lower quality ties exacerbate the stress-health link. Results offer preliminary evidence concerning how spousal ties "get under the skin" to influence physical health.

Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty

BACKGROUND

The association of hypertension and mortality is attenuated in elderly adults. Walking speed, as a measure of frailty, may identify which elderly adults are most at risk for the adverse effects of hypertension. We hypothesized that elevated blood pressure (BP) would be associated with a greater risk of mortality in faster-, but not slower-, walking older adults.

METHODS

Participants included 2340 persons 65 years and older in the National Health and Nutrition Examination Survey, 1999-2000 and 2001-2002. Mortality data were linked to death certificates in the National Death Index. Walking speed was measured over a 20-ft (6 m) walk and classified as faster (≥ 0.8 m/s [n = 1307]), slower (n = 790), or incomplete (n = 243). Potential confounders included age, sex, race, survey year, lifestyle and physiologic variables, health conditions, and antihypertensive medication use.

RESULTS

Among the participants, there were 589 deaths through December 31, 2006. The association between BP and mortality varied by walking speed. Among faster walkers, those with elevated systolic BP (≥ 140 mm Hg) had a greater adjusted risk of mortality compared with those without (hazard ratio [HR], 1.35; 95% CI, 1.03-1.77). Among slower walkers, neither elevated systolic nor diastolic BP (≥ 90 mm Hg) was associated with mortality. In participants who did not complete the walk test, elevated BP was strongly and independently associated with a lower risk of death: HR, 0.38; 95% CI, 0.23-0.62 (systolic); and HR, 0.10; 95% CI, 0.01-0.81 (diastolic).

CONCLUSIONS

Walking speed could be a simple measure to identify elderly adults who are most at risk for adverse outcomes related to high BP.

The association of blood pressure and mortality differs by self-reported walking speed in older Latinos

BACKGROUND

In some older adults, higher blood pressure (BP) is associated with a lower risk of mortality. We hypothesized that higher BP would be associated with greater mortality in high-functioning elders and lower mortality in elders with lower functional status.

METHODS

Participants were 1,562 Latino adults aged 60-101 years in the Sacramento Area Latino Study on Aging. Functional status was measured by self-reported walking speed, and BP was measured by automatic sphygmomanometer. Death information was determined from vital statistics records.

RESULTS

There were 442 deaths from 1998 to 2010; 53% were cardiovascular. Mean BP levels (mmHg) varied across fast, medium, and slow walkers: 136, 139, and 140 mmHg (systolic), p = .02 and 75, 76, and 77 mmHg (diastolic), p = .08, respectively. The relationship between systolic BP and mortality varied by self-reported walking speed: The adjusted hazard ratio for mortality in slow walkers was 0.96 per 10 mmHg higher systolic BP (95% confidence interval: 0.89, 1.02) and 1.29 (95% confidence interval: 1.08, 1.55) in fast walkers (p value for interaction <.001). We found a similar pattern for diastolic BP, although the interaction did not reach statistical significance; the adjusted hazard ratio per 10 mmHg higher diastolic BP was 0.89 (95% confidence interval: 0.78, 1.02) in slow walkers and 1.20 (95% confidence interval: 0.82, 1.76) in fast walkers (p value for interaction = .06).

CONCLUSIONS

In high-functioning older adults, elevated systolic BP is a risk factor for all-cause mortality. If confirmed in other studies, the assessment of functional status may help to identify persons who are most at-risk for adverse outcomes related to high BP.

Obesity and mortality risk among younger dialysis patients

BACKGROUND AND OBJECTIVES

Many studies show that obesity in dialysis patients is not strongly associated with mortality but not whether this modest association is constant over age. This study investigated the extent to which the relation of body mass index (BMI) and mortality differs between younger and older dialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Adult dialysis patients were prospectively followed from their first dialysis treatment for 7 years or until death or transplantation. Patients were stratified by age (<65 or ≥65 years) and baseline BMI (<20, 20-24 [reference], 25-29, and ≥30 kg/m(2)).

RESULTS

The study sample included 984 patients younger than 65 years and 765 patients 65 years or older; cumulative survival proportions at end of follow-up were 50% and 16%. Age-standardized mortality rate was 1.7 times higher in obese younger patients than those with normal BMI, corresponding to an excess rate of 5.2 deaths/100 patient-years. Mortality rates were almost equal between obese older patients and those with normal BMI. Excess rates of younger and older patients with low compared with normal BMI were 8.7 and 1.1 deaths/100 patient-years. After adjustment for age, sex, smoking, comorbidity, and treatment modality, hazard ratios by increasing BMI were 2.00, 1, 0.95, and 1.57 for younger patients and 1.07, 1, 0.88, and 0.91 for older patients, implying that obesity is a 1.7-fold (95% confidence interval, 1.1- to 2.9-fold) stronger risk factor in younger than older patients.

CONCLUSIONS

In contrast to older dialysis patients, younger patients with low or very high BMI had a substantially elevated risk for death.

Blood pressure control in the elderly: can you have too much of a good thing?

Hypertension (especially systolic hypertension) is very common in older persons. Systolic hypertension occurs because large conduit arteries become stiffer with age. Strong evidence from randomized trials suggests that treating systolic blood pressures initially higher than 160 mm Hg is extremely beneficial, and a recent trial extended this conclusion to healthy persons over 80 years of age. However, the only trial that has directly tested the use of more aggressive treatment goals (< 140 mm Hg) in the elderly did not show benefit in those older than 75. Risks of overtreating hypertension for the elderly include falls and orthostatic hypotension, and the most compromised older persons may be the most likely to experience adverse effects. Our current state of knowledge requires clinical judgment that balances the immediacy of adverse effects versus the potential but unproven benefits of treatment in deciding whether to treat the elderly more aggressively than the goals used in randomized trials.

Epidemiology of hypertension in the elderly with chronic kidney disease

As the population of the United States ages, the prevalence of age-related chronic conditions such as hypertension and chronic kidney disease (CKD) will also increase. Available studies in nationally representative samples and select outpatient populations indicate that hypertension is very common in older adults with CKD, and despite the use of medication it is often poorly controlled. Generally, less than one-third of the elderly patients with CKD achieve a level of blood pressure control consistent with that of the current guideline recommendations. However, limited evidence is available from observational studies and clinical trials to inform management of hypertension in the elderly population with CKD. The available published data suggest that the relationship between clinical outcomes and the treatment of hypertension among older adults with CKD is complex and distinct from that of their younger counterparts. Larger and more robust analyses are needed for a better understanding of the association between hypertension, its treatment, and clinical events in elderly patients with CKD.

Low blood pressure and depressive symptoms among Chinese older subjects: a population-based study

BACKGROUND

The relationships between blood pressure and depression are unclear. There are inconsistent reports of an association between low blood pressure and depressive symptoms.

METHODS

In a population-based sample of 2611 Chinese older adults aged 55 years and above, including participants with treated (n=1088), untreated (n=545), or no hypertension (n=978), depressive symptoms were determined by the 15-item Geriatric Depression Scale (> or =5), and current systolic blood pressure and diastolic blood pressure measurements were used to classify participants into high, normal, and low blood pressure groups. Estimates of association were adjusted for confounding by use of antihypertensive and depressogenic drugs and other covariables in hierarchical regression analyses.

RESULTS

Systolic blood pressure and diastolic blood pressure were negatively associated with Geriatric Depression Scale scores, independent of other variables. Low systolic blood pressure (odds ratio [OR] 1.54; 95% confidence interval [CI], 1.07-2.22), low diastolic blood pressure (OR 1.67; 95% CI, 0.98-2.85), and low systolic blood pressure or diastolic blood pressure (or both) (OR 1.55; 95% CI, 1.10-2.19) were independently associated with depressive symptoms. The associations with depressive symptoms were particularly observed for low systolic blood pressure (OR 2.13; 95% CI, 1.13-4.03) among treated hypertensive participants, and low diastolic blood pressure (OR 2.42; 95% CI, 1.26-4.68) among untreated or nonhypertensive participants.

CONCLUSION

Low blood pressure was independently associated with depressive symptoms in both older subjects who were treated for hypertension and those who were not.

Hypertension and cognitive function in the elderly

Alzheimer's disease is the most prevalent and common form of cognitive impairment, ie, dementia, in the elderly followed in second place by vascular dementia due to the microangiopathy associated with poorly-controlled hypertension. Besides blood pressure elevation, advancing age is the strongest risk factor for dementia. Deterioration of intellectual function and cognitive skills that leads to the elderly patient becoming more and more dependent in his, her, activities of daily living, ie, bathing, dressing, feeding self, locomotion, and personal hygiene. It has been known and demonstrated for many years that lowering of blood pressure from a previous hypertensive point can result in stroke prevention yet lowering of blood pressure does not prevent the microangiopathy that leads to white matter demyelinization which when combined with the clinical cognitive deterioration is compatible with a diagnosis of vascular dementia. It is known from many large studies, ie, SHEP, SCOPE, and HOPE, that lowering of blood pressure gradually will not and should not worsen the cognitive impairment. However, if the pressure is uncontrolled a stroke which might consequently occur would further worsen their cognitive derangement. So an attempt at slow reduction of blood pressure since cerebral autoregulation is slower as age increases is in the patient's best interest. It is also important to stress that control of blood glucose can also be seen as an attempt to prevent vascular dementia from uncontrolled hyperglycemia. Vascular dementia is not considered one of the reversible causes of dementia. Reversible causes of cognitive impairment are over medication with centrally acting drugs such as sedatives, hypnotics, antidepressants, and antipsychotics, electrolyte imbalance such as hyponatremia, azotemia, chronic liver disease, and poor controlled chronic congestive heart failure. Criteria for the clinical diagnosis of vascular dementia include cognitive decline in regards to preceding functionally higher level characterized by alterations in memory and in two or more superior cortical functions that include orientation, attention, verbal linguistic capacities, visual spacial skills, calculation, executive functioning, motor control, abstraction and judgment. Patients with disturbances of consciousness, delirium (acute confusional states), psychosis, serious aphasia, or sensory-motor alterations that preclude proper execution of neuro-psychological testing are also considered to have probably vascular dementia. Furthermore, these are ten of the other essential cerebral or systematic pathologies present that would be able to produce a dementia syndrome.

Hypertension in the elderly

Many elderly patients have hypertension, although it is more likely to go untreated in this population. Treatment goals are the same in elderly patients as in younger patients, but elderly patients are more likely to have multiple comorbidities, which must be factored into treatment plans. This article highlights the unique challenges in treating this population.

[Should all old hypertensive subjects have Mini-Mental State Examination?]

Hypertension constitutes a recognized risk factor of vascular dementia but also of Alzheimer-type dementia. Various longitudinal studies showed that midlife blood pressure level is one of the factors conditioning the onset of dementia syndrome in late life. The high risk of dementia is linked to leukoaraiosis, vascular rigidity, microcirculation disorders, oxidative stress, blood pressure fluctuations including orthostatic hypotension and strokes, all of those being associated with hypertension. Numerous clinical trials showed the positive effect of effective treatment of hypertension on the prevention of cognitive disorders and dementias. Thus, screening and early management of dementia and cognitive decline, in particular in the hypertensive subject, are essential. The Mini-Mental State Examination (MMSE) is a major first-intention screening test because it allows a full assessment of cognitive aptitudes. If cognitive decline is suspected and the MMSE score is considered to be abnormal, the elderly subject must be sent to a specialist or a referent memory centre; the MMSE is only a first stage in the diagnostic reasoning. MMSE should be included in the follow-up of all hypertensive elderly subjects and should be performed once a year by the general practitioner.

Treating hypertension in older adults: safety considerations

This article discusses the efficacy, use and adverse effects of antihypertensive drug therapy in older adults. Numerous double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces cardiovascular events in older adults. All antihypertensive drugs may predispose older patients to the development of symptomatic orthostatic hypotension and postprandial hypotension, and syncope or falls. Adverse effects of diuretics, beta-adrenergic receptor antagonists, ACE inhibitors, angiotensin receptor antagonists, calcium channel antagonists, alpha-adrenergic receptor antagonists, centrally acting drugs and direct vasodilators are discussed. The adverse effects depend on the antihypertensive drugs used, the doses used, the co-morbidities present in older patients taking these drugs and drug-drug interactions.