Association Between Blood Pressure and Survival over 9 Years in a General Population Aged 85 and Older

Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents

BACKGROUND

Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications.

METHODS

Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications).

RESULTS

More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group).

CONCLUSIONS

The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

Neurodegenerative diseases and blood pressure variability: A comprehensive review from HOPE Asia

Asia has an enormous number of older people and is the primary contributor to the rise in neurodegenerative diseases such as Alzheimer's and Parkinson's disease. The therapy of many neurodegenerative diseases has not yet progressed to the point where it is possible to alter the course of the disease. Mid-life hypertension is an important predictor of later-life cognitive impairment and brain neurodegenerative conditions. These findings highlight the pivotal role of preventing and managing hypertension as a risk factor for neurodegenerative disease. Autonomic dysfunction, neuropsychiatric and sleep disturbances can arise in neurodegenerative diseases, resulting in blood pressure variability (BPV). The BPV itself can worsen the progression of the disease. In older people with neurodegenerative disease and hypertension, it is critical to consider 24-h blood pressure monitoring and personalized blood pressure therapy.

Effect of blood pressure on the mortality of the elderly population with (pre)frailty: Results from NHANES 1999–2004

Backgrounds

The optimal blood pressure of elderly people with frailty or prefrailty is still unclear. We aimed to explore the relationship between blood pressure and mortality in the elderly with (pre)frailty.

Methods

A total of 528 participants aged 60 years and older were exacted for analyses of the association between blood pressure and mortality from the database of the National Health and Nutrition Examination Survey (NHANES) (1999–2004). Kaplan–Meier curves and log-rank tests were used to investigate the differences in survival between groups. Multivariable Cox regression and restricted cubic spline (RCS) analyses were applied to explore the relationship between blood pressure and mortality.

Results

During the median follow-up time of 116.5 [interquartile range (IQR) of 60–186] months, 363 all-cause deaths and 122 cardiac deaths were documented. For all-cause mortality, more participants died with systolic blood pressure (SBP) < 110 mmHg and SBP ≥ 170 mmHg (log-rank p = 0.004). After adjusting for confounders, SBP < 110 mmHg [hazard ratio (HR) 1.52, 95% CI: 0.96–2.41] and SBP ≥ 170 mmHg (HR 1.53, 95% CI: 1.09–2.15) had higher risks of all-cause mortality compared with SBP within 130–150 mmHg. There were no significant differences in all-cause mortality among DBP categories. A J-curve association was identified between the SBP and hazard ratio for all-cause mortality (p for non-linear = 0.028), with 138.6 mmHg as the lowest hazard ratio of all-cause mortality; each 10 mmHg of SBP rise was associated with a 9% increased risk in all-cause mortality (HR 1.09, 95% CI 1.00–1.18). Additionally, a non-linear relationship was determined between SBP and the hazard ratio for cardiac deaths (p for non-linear = 0.030), with 140.1 mmHg as the lowest hazard ratio of cardiac deaths. When SBP was higher than 140.1 mmHg, each 10 mmHg rise in SBP was associated with a 17% increased risk of cardiac deaths (HR 1.17, 95% CI: 1.02–1.34).

Conclusion

Both lower and higher SBP levels are associated with higher risks of all-cause mortality in older individuals with (pre)frailty. There are J-shaped associations between SBP and mortality, with the optimal SBP being approximately 140 mmHg for this population specifically.

Physiological Systems in Promoting Frailty

Frailty is a complex syndrome affecting a growing sector of the global population as medical developments have advanced human mortality rates across the world. Our current understanding of frailty is derived from studies conducted in the laboratory as well as the clinic, which have generated largely phenotypic information. Far fewer studies have uncovered biological underpinnings driving the onset and progression of frailty, but the stage is set to advance the field with preclinical and clinical assessment tools, multiomics approaches together with physiological and biochemical methodologies. In this article, we provide comprehensive coverage of topics regarding frailty assessment, preclinical models, interventions, and challenges as well as clinical frameworks and prevalence. We also identify central biological mechanisms that may be at play including mitochondrial dysfunction, epigenetic alterations, and oxidative stress that in turn, affect metabolism, stress responses, and endocrine and neuromuscular systems. We review the role of metabolic syndrome, insulin resistance and visceral obesity, focusing on glucose homeostasis, adenosine monophosphate-activated protein kinase (AMPK), mammalian target of rapamycin (mTOR), and nicotinamide adenine dinucleotide (NAD+ ) as critical players influencing the age-related loss of health. We further focus on how immunometabolic dysfunction associates with oxidative stress in promoting sarcopenia, a key contributor to slowness, weakness, and fatigue. We explore the biological mechanisms involved in stem cell exhaustion that affect regeneration and may contribute to the frailty-associated decline in resilience and adaptation to stress. Together, an overview of the interplay of aging biology with genetic, lifestyle, and environmental factors that contribute to frailty, as well as potential therapeutic targets to lower risk and slow the progression of ongoing disease is covered. © 2022 American Physiological Society. Compr Physiol 12:1-46, 2022.

Associations Between Blood Pressure and Accelerated DNA Methylation Aging

Background

Individuals of the same chronological age may exhibit diverse susceptibilities to death. However, few studies have investigated the associations between blood pressure and the accelerated aging.

Methods and Results

A cross‐sectional study was conducted in 288 adults aged ≥50 years. We assessed the DNA methylation‐based measures of biological age using CpG sites on the Illumina HumanMethylationEPIC BeadChip. Epigenetic age acceleration metrics were derived by regressing residuals (ΔAge) and ratios (aging rate) of DNA methylation age on chronological age. Dose‐response relationships between blood pressure and epigenetic age acceleration were quantified using multiple linear regression and restricted cubic regression models. We found that each 10–mm Hg increase in systolic blood pressure was associated with 0.608 (95% CI, 0.231–0.984) years increase in ΔAge and 0.007 (95% CI, 0.002–0.012) increase in aging rate; meanwhile, for pulse pressure, the increase was 1.12 (95% CI, 0.625–1.61) years for ΔAge and 0.013 (95% CI, 0.007–0.020) for aging rate. Subgroup analysis showed that the significant associations of systolic blood pressure and pulse pressure with epigenetic age acceleration appeared to be limited to women, although interactions between blood pressure and sex were not significant (P values for interaction >0.05). The combination of women and hypertension was associated with a much higher increase in ΔAge (β [95% CI], 4.05 [1.07–7.02]) and aging rate (β [95% CI], 0.047 [0.008–0.087]), compared with male participants without hypertension.

Conclusions

Our findings suggested that high systolic blood pressure and pulse pressure were associated with the epigenetic age acceleration, providing important clues for relationships between blood pressure and epigenetic aging.

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.

Cardiovascular risk in the elderly population of Spain. The EPICARDIAN risk score

BACKGROUND AND OBJECTIVES

Cardiovascular risk estimation in people over 70 years of age is problematic. Most scores have been created based on cohorts of middle-aged people, with an underrepresentation of older adults. The predictive power of classical cardiovascular risk factors declines with age. The aim of this work is to develop a specific score for estimating cardiovascular risk among the elderly population in Spain.

METHODS

This work is a population-based cohort established in 1995.

SETTING

Three geographical areas of Spain (Madrid, Ávila, and Lugo).

PARTICIPANTS

3,729 people older than 64 years with no cardiovascular diseases (CVD) at baseline.

MEASUREMENTS

Suspected fatal and nonfatal CVD (both coronary heart disease and stroke) were investigated annually and confirmed using the WHO-MONICA criteria. All participants were followed-up on until occurrence of a first CVD event, until death, or until December 31, 2015.

RESULTS

Age was the strongest predictor of CVD at 10 years in both men and women. In men, variables associated with CVD were high blood pressure treatment (HR: 1.35; 95% CI: 1.067-1.710), diabetes (HR: 1.359; 95% CI: 0.997-1.852), and smoking (HR: 1.207; 95% CI: 0.945-1.541) and in women, the variables were smoking (HR: 1.881; 95% CI: 1.356-2.609) and diabetes (HR: 1.285; 95% CI: 0.967-1.707). Total cholesterol did not increase the risk of CVD in men or women. However, total cholesterol levels >200 mg/dL were inversely associated with 10-year risk of CVD in men and women.

CONCLUSIONS

In elderly Spanish men, total CVD at 10 years is significantly increased by age, diabetes, and antihypertensive treatment and in elderly Spanish women by diabetes and smoking. Total cholesterol levels did not increase the risk of CVD, particularly in males.

Hypertension in older persons: why one size does not fit all

Over recent years, managing hypertension in older people has gained increasing attention, with particular reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g. patients with disability, cognitive impairment, and poor physical performance. Consequently, one size doesn't fit all and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. This review illustrates the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.

Association of Cardiovascular Risk Factors and APOE Polymorphism with Mortality in the Oldest Old: A 21-Year Cohort Study

BACKGROUND

Knowledge of environmental and genetic factors for healthy aging in elderly people is controversial. In addition to this evidence, few studies have been designed for this population.

OBJECTIVES

To investigate the relationship between the most frequent apolipoprotein E (APOE) genotypes and mortality in very elderly individuals living in a community and to evaluate survival according to cardiovascular risk factors.

METHODS

A sample of 74 elderly individuals aged ≥ 80 years, from the Veranópolis Project cohort, was selected for APOE genotyping. At baseline, anthropometric variables, glucose and lipid levels, blood pressure, and lifestyle variables (smoking, alcohol consumption, and physical activity) were collected. The Bayer Activities of Daily Living Scale was applied to their caregivers. Total study follow-up was 21 years. Two-sided p < 0.05 was considered statistically significant.

RESULTS

There was no association between APOE genotypes and mortality. However, the risk of death in elderly smokers was 2.30 times higher (hazard ratio [HR], 95% CI 1.01 to 5.24); in individuals with diabetes, it was 3.95 times higher (HR, 95% CI 1.27 to 12.30) than in individuals without diabetes. Subjects who practiced vigorous physical activity had a 51% reduction in risk of death (HR = 0.49, 95% CI 0.27 to 0.88). For an increase of 1 mmHg in systolic blood pressure, there was a 2% reduction (HR = 0.98, 95% CI 0.97 to 0.99) in risk of death.

CONCLUSION

In this sample population, APOE genotypes were not associated with mortality. However, classic cardiovascular risk factors may be important for overall mortality in the very elderly.

Prognostic Value of a Riser Pattern of Nighttime Blood Pressure in Very Elderly Adults of ≥80 Years: A General Practice-Based Prospective SEARCH Study

BACKGROUND

We examined our hypothesis that participants with higher mean nighttime blood pressure (BP) levels and/or those with a riser BP pattern, both measured by ambulatory blood pressure (BP) monitoring (ABPM), would show higher risk for cardiovascular disease (CVD) events compared to those with normal nighttime BP levels or a normal dipper BP pattern of circadian BP rhythm, even in very elderly participants in a general practice population.

METHODS

This prospective observational study enrolled 485 very elderly outpatients of ≥80 years (mean age: 83.2 ± 3.3 years; 44.7% male; 89.3% using antihypertensive medications). The prevalences of extreme dipper, dipper, nondipper, and riser status were 15.5%, 38.6%, 32.2%, and 13.8%, respectively.

RESULTS

During a mean follow-up of 3.9 years (1,734 person-years), 41 CVD events occurred. The participants with a riser pattern (higher nighttime systolic BP [SBP] than daytime SBP) showed a significantly higher risk for CVD events with adjustment for covariates: hazard ratio (HR), 2.61; 95% confidence interval (CI), 1.03-6.62. Even after adjusting for covariates and mean nighttime SBP level, the CVD risks in participants with a riser pattern remained significant: HR, 3.11; 95% CI, 1.10-8.88. On the other hand, all BP variables showed no significant risks for CVD events. In addition, when we divided study participants into quartiles by their ambulatory BP levels, none of the ambulatory BP variables showed a J- or U-shaped relationship with CVD event risk.

CONCLUSIONS

In very elderly general practice outpatients, a riser BP pattern was significantly associated with CVD events independently of mean nighttime BP.

High blood pressure in dementia: How low can we go?

Hypertension is an important public health concern. The prevalence keeps increasing, and it is a risk factor for several adverse health outcomes including a decline in cognitive function. Recent data also show that the prevalence of hypertension and age-related dementia is rising in Asian countries, including in the oldest old group. This study aims to discuss possible treatments for high blood pressure in the elderly and propose an optimal target for BP relative to cognitive outcomes. This review discusses several studies on related blood pressure treatments that remain controversial and the consequences if the treatment target is too low or aggressive. Longitudinal, cross-sectional, and RCT studies were included in this review. An optimum systolic blood pressure of 120-130 mm Hg is recommended, especially in nondiabetic hypertensive patients with significant risk factors. In the oldest old group of patients, hypertension might have a protective effect. The use of calcium channel blockers (CCB) and angiotensin receptor blocker (ARB) is independently associated with a decreased risk of dementia in older people. However, personalized care for patients with hypertension, especially for patients who are frail or very old, is encouraged.

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients

Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

Hypertension Management in the Elderly: What is the Optimal Target Blood Pressure?

Hypertension is a common disease in the elderly associated with significant morbidity and mortality. Due to the complexity of this population, the optimal target of blood pressure (BP) control is still controversial. In this article, we conduct a literature review of trials published in English in the last 10 years which were specifically designed to study the efficacy and safety of various BP targets in patients who are 70 years or older. Using these criteria, we found that the benefits in the positive studies were demonstrated even with a minimal BP control (systolic BP [SBP] <150 mmHg) and continued to be reported for a SBP <120 mmHg. On the other hand, keeping SBP <140 mmHg seemed to be safely achieved in elderly patients. Although the safety of lowering SBP to <120 mmHg is debated, Systolic Blood Pressure Intervention Trial study has shown no increased risk of falls, fractures, or kidney failure in elderly patients with SBP lower than this threshold. While the recent guidelines recommended to keep BP <130/80 mmHg in the elderly, more individualized approach should be considered to achieve this goal in order to avoid undesirable complications. Furthermore, further studies are required to evaluate BP target in very old patients or those with multiple comorbidities.

Frailty in Chinese older adults with hypertension: Prevalence, associated factors, and prediction for long-term mortality

Hypertension and frailty are associated and often coexist in older adults. Few studies have examined the association between hypertension and frailty in Chinese population. We explored the prevalence of and the factors associated with frailty as well as whether frailty could identify patients at risk of adverse outcomes among older adults with hypertension. Data were from the Beijing Longitudinal Study of Aging. A total of 1111 hypertensive participants aged ≥60 years old who completed the comprehensive geriatrics assessment were included. All participants were followed up for 8 years. The total number of deaths was 604. Frailty was assessed by the 68-item frailty index. Stepwise forward logistic regression was used to explore the association between the associated factors and frailty in hypertensive participants. The prediction for mortality was assessed using the adjusted Cox proportional hazards model. Two hundred and eighteen older adults were determined as frail (prevalence rate: 19.6%). Frail older adults with hypertension had worse physical performance, worse psychological, and social function, as well as worse lifestyle habits, compared to nonfrail older adults with hypertension. Chair stand test failure, balance test failure, fracture, disability, depression, and physical frailty measured with modified frailty phenotype were independently associated with frailty. Frailty was associated with a higher 8-year mortality, hazard ratio (HR) = 3.40, adjusted for age and sex, HR = 2.61. Frailty is associated with poorer physical function and higher mortality in community-dwelling hypertensive older adults in China. These findings emphasize the importance and need for frailty intervention and prevention in older adults with hypertension.

Revisiting the association of blood pressure with mortality in oldest old people in China: community based, longitudinal prospective study

OBJECTIVE

To examine the associations of blood pressure with all cause mortality and cause specific mortality at three years among oldest old people in China.

DESIGN

Community based, longitudinal prospective study.

SETTING

2011 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey, conducted in 22 Chinese provinces.

PARTICIPANTS

4658 oldest old individuals (mean age 92.1 years).

MAIN OUTCOME MEASURES

All cause mortality and cause specific mortality assessed at three year follow-up.

RESULTS

1997 deaths were recorded at three year follow-up. U shaped associations of mortality with systolic blood pressure, mean arterial pressure, and pulse pressure were identified; values of 143.5 mm Hg, 101 mm Hg, and 66 mm Hg conferred the minimum mortality risk, respectively. After adjustment for covariates, the U shaped association remained only for systolic blood pressure (minimum mortality risk at 129 mm Hg). Compared with a systolic blood pressure value of 129 mm Hg, risk of all cause mortality decreased for values lower than 107 mm Hg (from 1.47 (95% confidence interval 1.01 to 2.17) to 1.08 (1.01 to 1.17)), and increased for values greater than 154 mm Hg (from 1.08 (1.01 to 1.17) to 1.27 (1.02 to 1.58)). In the cause specific analysis, compared with a middle range of systolic blood pressure (107-154 mm Hg), higher values (>154 mm Hg) were associated with a higher risk of cardiovascular mortality (adjusted hazard ratio 1.51 (95% confidence interval 1.12 to 2.02)); lower values (<107 mm Hg) were associated with a higher risk of non-cardiovascular mortality (1.58 (1.26 to 1.98)). The U shaped associations remained in sensitivity and subgroup analyses.

CONCLUSIONS

This study indicates a U shaped association between systolic blood pressure and all cause mortality at three years among oldest old people in China. This association could be explained by the finding that higher systolic blood pressure predicted a higher risk of death from cardiovascular disease, and that lower systolic blood pressure predicted a higher risk of death from non-cardiovascular causes. These results emphasise the importance of revisiting blood pressure management or establishing specific guidelines for management among oldest old individuals.

CAIDE Dementia Risk Score, Alzheimer and cerebrovascular pathology: a population-based autopsy study

BACKGROUND

CAIDE Dementia Risk Score is a tool for estimating dementia risk in the general population. Its longitudinal associations with Alzheimer or vascular neuropathology in the oldest old are not known.

AIM

To explore the relationship between CAIDE Dementia Risk Score at baseline and neuritic plaques, neurofibrillary tangles, cerebral infarcts and cerebral amyloid angiopathy (CAA) after up to 10-year follow-up in the Vantaa 85 +  population.

METHODS

Study population included 149 participants aged ≥85 years, without dementia at baseline, and with available clinical and autopsy data. Methenamine silver staining was used for β-amyloid and modified Bielschowsky method for neurofibrillary tangles and neuritic plaques. Macroscopic infarcts were identified from cerebral hemispheres, brainstem and cerebellum slices. Standardized methods were used to determine microscopic infarcts, CAA and α-synuclein pathologies. The CAIDE Dementia Risk Score was calculated based on scores for age, sex, BMI, total cholesterol, systolic blood pressure, physical activity and APOEε4 carrier status (range 0-18 points).

RESULTS

A CAIDE Dementia Risk Score above 11 points was associated with more cerebral infarctions up to 10 years later: OR (95% CI) was 2.10 (1.06-4.16). No associations were found with other neuropathologies.

CONCLUSION

In a population of elderly aged ≥85 years, higher CAIDE Dementia Risk Score was associated with increased risk of cerebral infarcts.

Considerations for Optimal Blood Pressure Goals in the Elderly Population: A Review of Emergent Evidence

Recent hypertension clinical trials and national guideline updates have created a debate on the most appropriate treatment goals in elderly patients with hypertension. In 2014, recommendations by the Eighth Joint National Committee allowed a more lenient goal for patients 60 years and older compared with previous guidelines. Since then, several large clinical trials and meta-analyses have added more information regarding strict versus lenient treatment goals. Most recently, the American College of Cardiology and American Heart Association Task Force published their highly anticipated hypertension guideline developed in conjunction with nine additional interdisciplinary organizations. This review discusses the culmination of emerging data to provide more insight into the treatment of hypertension in the elderly. A literature search was conducted using PubMed, the Cumulative Index of Nursing and Allied Health, the Cochrane database, and by hand-searching references from relevant articles. The following key terms were used: hypertension, blood pressure, systolic, and elderly. Available literature suggests that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension. An individualized approach is reasonable for those who are institutionalized, with high comorbidity burden, or have a short life expectancy. A diastolic blood pressure of less than 60 mm Hg should be avoided due to the potential for an increase in cardiovascular risk. The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed. Other factors important to consider may include the patient's comorbidities, frailty, as well as the patient's potential for adverse drug reactions.

Protective and Risk Factors for 5-Year Survival in the Oldest Veterans: Data from the Veterans Health Administration

OBJECTIVES

To characterize physical and mental diseases and use of healthcare services and identify factors associated with mortality in the oldest individuals using the Veterans Health Administration (VHA).

DESIGN

Retrospective study with 5-year survival follow-up.

SETTING

VHA, system-wide.

PARTICIPANTS

Veterans using the VHA aged 80 and older as of October 2008 (N = 721,588: n = 665,249 aged 80-89, n = 56,118 aged 90-99, n = 221 aged 100-115).

MEASUREMENTS

Demographic characteristics, physical and mental diseases, healthcare services, and 5-year survival were measured.

RESULTS

Accelerated failure time models identified protective and risk factors associated with mortality according to age group. During 5 years of follow-up, 44% of participants died (survival rate: 59% aged 80-89, 32% aged 90-99, 15% aged ≥100). In the multivariable model, protective effects for veterans aged 80-99 were female sex, minority race or ethnicity, being married, having certain physical and mental diagnoses (hypertension, cataract, dyslipidemia, posttraumatic stress disorder, bipolar disorder), having urgent care visits, having invasive surgery, and having few (1-3) prescriptions. Risk factors were lower VHA priority status, physical and mental conditions (diabetes mellitus, anemia, congestive heart failure, dementia, anxiety, depression, smoking, substance abuse disorder), hospital admission, and nursing home care. For those aged 100 and older, being married, smoking, hospital admission, nursing home care, invasive surgery, and prescription use were significant risk factors; only emergency department (ED) use was protective.

CONCLUSION

Although the data are limited to VHA care (thus missing Medicare services), this study shows that many veterans served by the VHA live to advanced old age despite multiple chronic conditions. Further study is needed to determine whether a comprehensive, coordinated care system like VHA is associated with greater longevity for very old persons.

Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records

BACKGROUND

Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death.

METHODS

A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death.

RESULTS

During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life.

CONCLUSIONS

A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.

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.

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.

Antihypertensive and Statin Medication Use and Motor Function in Community-Dwelling Older Adults

OBJECTIVES

To investigate whether the use of antihypertensive and statin medication in very old adults is associated with the level of motor performance.

DESIGN

Cross-sectional study.

SETTINGS

A community-based study recruited from over 40 residential facilities across the metropolitan Chicago area.

PARTICIPANTS

Community-dwelling very old adults (n = 1520; mean age 80.2; standard deviation 7.7).

MEASUREMENTS

Eleven motor performances were summarized using a composite motor score. All prescription and over the counter medications taken by participants were inspected and coded using the Medi-Span Data Base System. Demographic characteristics and medical history were obtained by means of detailed interview and medical examinations.

RESULTS

In multiple linear regression models, antihypertensive medications were associated with global motor score [β = -0.075, standard error (SE) 0.011, P < .001]. Thus, motor function in an individual with antihypertensive medication, was on average, about 7.5% lower than an age-, sex-, and education-matched individual without antihypertensive medication. The number of antihypertensive medications, which were being used had an additive effect, such that a reduction in the level of motor function was observed with each additional medication, and receiving 3 or more antihypertensive medications was associated with about a 15% reduction in the level of motor function. The association between antihypertensive medications and motor function was robust, and remained unchanged after adjusting for confounding by indication using several potentially confounding variables: smoking, hypertension, diabetes, stroke, congestive heart failure, myocardial infarction, and intermittent claudication (β = -0.05, SE 0.015, P = .001). In contrast, the use of statin medications was not related to motor function (unadjusted: β = 0.003, SE 0.015, P = .826; fully adjusted: β = 0.018, SE 0.014, P = .216).

CONCLUSIONS

The use of antihypertensive medications is associated with a lower level of motor function in very old adults. The nature of this association warrants further investigation.

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2-3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10-1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05-1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15-1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2-3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.

Blood pressure and mortality: using offspring blood pressure as an instrument for own blood pressure in the HUNT study

Given that observational associations may be inaccurate, we used offspring blood pressure (BP) to provide alternative estimates of the associations between own BP and mortality. Observational associations between BP and mortality, estimated as hazard ratios (HRs) from Cox regression, were compared to HRs obtained using offspring BP as an instrumental variable (IV) for own BP (N = 32,227 mother-offspring and 27,535 father-offspring pairs). Observationally, there were positive associations between own BP and mortality from all-causes, cardiovascular disease (CVD), coronary heart disease (CHD), stroke and diabetes. Point estimates of the associations between BP and mortality from all-causes, CVD and CHD were amplified in magnitude when using offspring BP as an IV. For example, the HR for all-cause mortality per standard deviation (SD) increase in own systolic BP (SBP) obtained in conventional observational analyses increased from 1.10 (95% CI: 1.09-1.12; P < 0.0001) to 1.31 (95% CI: 1.19-1.43; P < 0.0001). Additionally, SBP was positively associated with diabetes and cancer mortality (HRs: 2.00; 95% CI: 1.12-3.35; P = 0.02 and 1.20; 95% CI: 1.02-1.42; P = 0.03, respectively), and diastolic BP (DBP) with stroke mortality (HR: 1.30; 95% CI: 1.02-1.66; P = 0.03). Results support positive associations between BP and mortality from all-causes, CVD, and CHD, SBP on cancer mortality, and DBP on stroke mortality.

Mildly elevated blood pressure is a marker for better health status in Polish centenarians

The number of centenarians is projected to rise rapidly. However, knowledge of evidence-based health care in this group is still poor. Hypertension is the most common condition that leads to multiple organ complications, disability, and premature death. No guidelines for the management of high blood pressure (BP) in centenarians are available. We have performed a cross-sectional study to characterize clinical and functional state of Polish centenarians, with a special focus on BP. The study comprised 86 consecutive 100.9 ± 1.2 years old (mean ± SD) subjects (70 women and 16 men). The assessment included structured interview, physical examination, geriatric functional assessment, resting electrocardiography, and blood and urine sampling. The subjects were followed-up on the phone. Subjects who survived 180 days (83 %) as compared to non-survivors had higher systolic BP (SBP), diastolic BP (DPB), mean arterial pressure (MAP), pulse pressure (PP), higher mini-mental state examination, Barthel Index of Activities of Daily Living and Lawton Instrumental Activities of Daily Living Scale scores, higher serum albumin and calcium levels, and total iron-binding capacity, while lower serum creatinine, cystatin C, folate, and C-reactive protein levels. SBP ≥140 mm Hg, DBP ≥90 mm Hg, MAP ≥100 mm Hg, and PP ≥40 mm Hg were associated with higher 180-day survival probability. Results suggest that mildly elevated blood pressure is a marker for better health status in Polish centenarians.

Blood pressure, gait speed, and mortality in very old individuals: a population-based cohort study

OBJECTIVES

Clinical trials and observational studies have produced contradictory results regarding the association of blood pressure (BP) and mortality in people aged 80 years or older. Gait speed at usual pace has been shown to moderate this association in a population of noninstitutionalized people aged 65 years or older. The aims of this study were to investigate the association of BP with all-cause mortality in a representative sample of people aged 85 years or older and to assess whether gait speed moderates this association.

DESIGN, SETTING, AND PARTICIPANTS

A total of 806 participants in the population-based prospective Umeå 85+/GERDA study aged 85, 90, and 95 years or older.

MEASUREMENTS

Gait speed at usual pace was measured over 2.4 m. The main outcome was hazard ratios (HRs) for all-cause mortality according to systolic and diastolic BP categories in the total sample and in faster-walking (≥0.5 m/s, n = 312) and slower-walking (<0.5 m/s, n = 433) subcohorts; the latter also included habitually nonwalking participants. Comprehensive adjustments were made for sociodemographic and clinical characteristics associated with death.

RESULTS

Mean age and baseline systolic and diastolic BP were 89.6 ± 4.6 years, 146.8 ± 23.9 mm Hg, and 74.8 ± 11.1 mm Hg, respectively. Most (n = 561 [69%]) participants were women, 315 (39%) were care facility residents, and 566 (70%) were prescribed BP-lowering drugs. Within 5 years, 490 (61%) participants died. In the total sample and slower-walking subcohort, systolic BP appeared to be inversely associated with mortality, although not independent of adjustments. Among faster-walking participants, mortality risk after adjustment was more than 2 times higher in those with systolic BP of 140 to 149 mm Hg (HR = 2.25, 95% confidence interval [CI] = 1.03-4.94) and 165 mm Hg or higher (HR = 2.13, 95% CI = 1.01-4.49), compared with systolic BP of 126 to 139 mm Hg. Mortality risk was also independently higher in faster-walking participants with diastolic BP higher than 80 mm Hg, compared with diastolic BP of 75 to 80 mm Hg (HR = 1.76, 95% CI = 1.07-2.90).

CONCLUSION

The gait speed threshold of 0.5 m/s may be clinically useful for the distinction of very old people with and without increased all-cause mortality risk due to elevated systolic and diastolic BP.

Prognostic power of lower pulse pressure on long-term all-cause mortality in octogenarians with acute coronary syndrome: a propensity-score-matched cohort study

OBJECTIVE

The impact of lower pulse pressure (PP) on long-term all-cause mortality in the octogenarian patients with acute coronary syndrome (ACS) remains unknown. This study sought to reveal the prognostic power of lower PP in long-term all-cause mortality in the octogenarian ACS patients.

METHODS

The current study included a total of 353 consecutive ACS patients aged at least 80 years during the period of 5-year follow-up. Association between PP and long-term mortality was confirmed by sensitivity analyses such as propensity score matching and multivariate Cox analyses. The matched cohort was developed by one-to-one, nearest-neighbor propensity score matching analyses.

RESULTS

Among patients with ACS, 113 (32.1%) admissions were alive, 240 (67.9%) were dead. There was a U-shaped association of mortality rate with PP, and the mortality rate increased in patients with PP equal to or less than 50  mmHg and greater than 70  mmHg. PP equal to or less than 50  mmHg was a predictor of the mortality rate in the overall cohort [hazard ratio: 1.92, 95% confidence interval (CI): 1.08-3.43, P = 0.027] and in the matched cohort (hazard ratio: 2.67, 95% CI: 1.16-6.14, P = 0.020). Moreover, PP equal to or less than 50  mmHg was independently related to mortality rate in the subgroup with hypertension in the overall cohort (hazard ratio: 2.04, 95% CI: 1.04-4.00, P = 0.039) and in the matched cohort (hazard ratio: 2.63, 95% CI: 1.01-6.83, P = 0.048).

CONCLUSION

This study reveals a U-shaped association of mortality rate with PP in the octogenarians with ACS and demonstrates that PP equal to or less than 50  mmHg has an independent prognostic power in long-term all-cause mortality in the octogenarians with ACS as well as the subgroup with hypertension.

Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions

IMPORTANCE

Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.

OBJECTIVE

To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.

DESIGN

Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.

PARTICIPANTS AND SETTING

4,961 community-living participants with hypertension.

EXPOSURE

Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.

RESULTS

Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.

CONCLUSIONS AND RELEVANCE

In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.

A 91-year-old woman with difficult-to-control hypertension: a clinical review

IMPORTANCE

Hypertension is common among people older than 65 years, affecting nearly two-thirds of men and three-fourths of women by age 75 years. Treatment goals and medication selection for this population may differ from those for younger patients.

OBJECTIVE

To discuss the presentation, pathophysiology, and optimal treatment of hypertension among elderly persons.

EVIDENCE REVIEW

MEDLINE was searched from 1990 to 2013. A hand search of bibliographies from guidelines and review articles from 2000 to 2013 was also used to identify studies of hypertension treatment in patients older than 65 years.

FINDINGS

Hypertension in elderly people differs from that in younger people in that (1) hypertension is predominantly systolic because of vascular stiffness; (2) it is associated with reduced baroreflex sensitivity, which increases blood pressure variability and vulnerability to hypotension during common daily activities; (3) it is associated with cognitive and functional decline as well as adverse cardiovascular outcomes; and (4) hypertension may be beneficial in frail people older than 85 years. Treatment of healthy patients up to age 85 years with most antihypertensive medications reduces cardiovascular morbidity and mortality and possibly cognitive and functional decline.

CONCLUSION AND RELEVANCE

Although patients in their 90s have not been studied, any ambulatory and independent patient older than 80 years should have multiple blood pressure measurements taken during their usual daily activities, and if these show persistent hypertension, these patients should be treated judiciously.

Blood pressure trends and mortality: the Leiden 85-plus Study

OBJECTIVE

To evaluate the independent contributions of both the trend in SBP and the SBP value at age 90 to the prediction of mortality in nonagenarians.

METHODS

The trend in SBP between 85 and 90 years and SBP at age 90 years were assessed in a population-based sample of 271 participants (74 men and 197 women) aged 90 years of the Leiden 85-plus Study, an observational population-based prospective follow-up study (started 1997). Primary endpoint, followed up over 5 years (median 3.6 years), was all-cause mortality.

RESULTS

A decreasing trend in SBP between 85 and 90 years (decline ≥2.9 mmHg/year) was associated with increased mortality compared to an average SBP trend (hazard ratio 1.45, 95% confidence interval 1.02-2.06), independent of SBP at age 90. The effect was stronger in institutionalized participants compared to those living independently [hazard ratio 1.87 (1.10-3.19) and hazard ratio 1.30 (0.81-2.09)]. After analysis with a fully adjusted model, the estimate approached unity [hazard ratio 1.08 (0.60-1.86)]. Overall, 90-year-old participants with SBP of 150 mmHg or less had a 1.62 times increased mortality risk compared to those with SBP more than 150 mmHg (1.21-2.20), independent of the SBP trend in preceding years. This applied to those with and without antihypertensive drugs and those with and without history of cardiovascular disease or noncardiovascular disease. In the fully adjusted model, the estimate was 1.47 (0.90-2.40).

CONCLUSION

In very old age, both decreasing trend in SBP over the previous 5 years and the current SBP value independently contribute to prediction of all-cause mortality. Therefore, in individual patients, all available preceding SBP measurements should be taken into account.

Dementia in the oldest old: a multi-factorial and growing public health issue

The population of oldest old, or people aged 85 and older, is growing rapidly. A better understanding of dementia in this population is thus of increasing national and global importance. In this review, we describe the major epidemiological studies, prevalence, clinical presentation, neuropathological and imaging features, risk factors, and treatment of dementia in the oldest old. Prevalence estimates for dementia among those aged 85+ ranges from 18 to 38%. The most common clinical syndromes are Alzheimer's dementia, vascular dementia, and mixed dementia from multiple etiologies. The rate of progression appears to be slower than in the younger old. Single neuropathological entities such as Alzheimer's dementia and Lewy body pathology appear to have declining relevance to cognitive decline, while mixed pathology with Alzheimer's disease, vascular disease (especially cortical microinfarcts), and hippocampal sclerosis appear to have increasing relevance. Neuroimaging data are sparse. Risk factors for dementia in the oldest old include a low level of education, poor mid-life general health, low level of physical activity, depression, and delirium, whereas apolipoprotein E genotype, late-life hypertension, hyperlipidemia, and elevated peripheral inflammatory markers appear to have less relevance. Treatment approaches require further study, but the oldest old may be more prone to negative side effects compared with younger patients and targeted therapies may be less efficacious since single pathologies are less frequent. We also highlight the limitations and challenges of research in this area, including the difficulty of defining functional decline, a necessary component for a dementia diagnosis, the lack of normative neuropsychological data, and other shortcomings inherent in existing diagnostic criteria. In summary, our understanding of dementia in the oldest old has advanced dramatically in recent years, but more research is needed, particularly among varied racial, ethnic, and socioeconomic groups, and with respect to biomarkers such as neuroimaging, modifiable risk factors, and therapy.

Changing prediction of mortality by systolic blood pressure with increasing age: the Rotterdam study

There are indications that in persons of older age, systolic blood pressure (SBP) is no longer associated with mortality. This raises the question whether the predictive value of SBP changes from younger to older age groups. Analysis in the Rotterdam Study, a population-based prospective cohort study among 4,612 participants aged ≥55 years without previous cardiovascular disease and with a median follow-up of 14.9 (interquartile range, 11.1-15.8) years. Within four age groups (55-64, 65-74, 75-84, ≥85 years), the predictive value of baseline SBP for mortality was studied. From age 55 to ≥85 years, risk of all-cause mortality associated with SBP ≥160 mmHg decreased from HR 1.7 (95%CI 1.2-2.2) to HR 0.7 (95%CI 0.4-1.1), p for trend <0.001. For participants with SBP 140-159 mmHg, the risk decreased from HR 1.2 (95%CI 0.9-1.5) to HR 0.7 (95%CI 0.5-1.1), p for trend <0.001. Analyses in the 5-year age groups showed an increased risk with higher SBPs up to age 75 years. After 75 years, a trend towards SBP no longer being associated with an increased mortality risk was seen in our study. These findings need to be considered with recently reported beneficial effects of antihypertensive treatment in this age group.

Type 2 diabetes in older people; the importance of blood pressure control

Diabetes and hypertension often coexist and their coexistence substantially promote cardiovascular disease (CVD) and chronic kidney disease. Control of blood pressure to a level of 140/90 mm Hg in people with diabetes can prevent or at least delay CVD and chronic kidney disease.. In the past many society treatment guidelines have stressed tight blood pressure control (=< 130/80) for people with diabetes. But recommendations for such tight blood pressure control have not been supported by recent large randomized control trials, especially in in elderly. Here we review the recent literature regarding the benefits of blood pressure control in elderly patients with diabetics. We further focus on evidence for specific levels of blood pressure treatment goals, in this population subset..