Evidence for Age Bias Contributing to Therapeutic Inertia in Blood Pressure Management: A Secondary Analysis of SPRINT

Epidemiology of Hypertension in Older Adults

The exact definition of hypertension in older adults has changed over the decades, but the benefits of strict blood pressure control across the life span are being increasingly recognized by professional societies and guideline committees. This article discusses the prevalence of hypertension in older adults and describes the associations between hypertension and both clinical and nonclinical morbidity in that population.

Optimal Blood Pressure Targets with Age

The focus of antihypertensive therapy in older adults should be on lowering the systolic blood pressure (SBP) to the patient's "optimal" benefit-based target goal. Applying benefit-based therapy to the majority of adults aged 65 years or older who are at high cardiovascular disease or cognitive impairment risk favors an SBP goal of less than 130 mm Hg, and for some, a goal of 120 mm Hg may be considered.

Managing hypertension in older people: current concepts

Hypertension management in older people is challenging due to pathophysiological changes brought about by ageing, associated comorbidities, frailty and polypharmacy and often has a poor evidence base. This article gives an overview of these factors and related available evidence with particular attention to clinical issues and consensus guidance.

Incorporating Individual-Level Treatment Effects and Outcome Preferences Into Personalized Blood Pressure Target Recommendations

BACKGROUND

There are no shared decision-making frameworks for selecting blood pressure (BP) targets for individuals with hypertension. This study addressed whether results from the SPRINT (Systolic Blood Pressure Intervention Trial) could be tailored to individuals using predicted risks and simulated preferences.

METHODS AND RESULTS

Among 8202 SPRINT participants, Cox models were developed and internally validated to predict each individual's absolute difference in risk from intensive versus standard BP lowering for cardiovascular events, cognitive impairment, death, and serious adverse events (AEs). Individual treatment effects were combined using simulated preference weights into a net benefit, which represents a weighted sum of risk differences across outcomes. Net benefits were compared among those above versus below the median AE risk. In simulations for which cardiovascular, cognitive, and death events had much greater weight than the AEs of BP lowering, the median net benefit was 3.3 percentage points (interquartile range [IQR], 2.0-5.7), and 100% of participants had a net benefit favoring intensive BP lowering. When simulating benefits and harms to have similar weights, the median net benefit was 0.8 percentage points (IQR, 0.2-2.2), and 87% had a positive net benefit. Compared with participants at lower risk of AEs from BP lowering, those at higher risk had a greater net benefit from intensive BP lowering despite experiencing more AEs (P<0.001 in both simulations).

CONCLUSIONS

Most SPRINT participants had a predicted net benefit that favored intensive BP lowering, but the degree of net benefit varied considerably. Tailoring BP targets using each patient's risks and preferences may provide more refined BP target recommendations.

Age and Comorbidities Are Associated With Therapeutic Inertia Among Older Adults With Uncontrolled Blood Pressure

BACKGROUND

Lack of initiation or escalation of blood pressure (BP) lowering medication when BP is uncontrolled, termed therapeutic inertia (TI), increases with age and may be influenced by comorbidities.

METHODS

We examined the association of age and comorbidities with TI in 22,665 visits with a systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg among 7,415 adults age ≥65 years receiving care in clinics that implemented a hypertension quality improvement program. Generalized linear mixed models were used to determine the association of comorbidity number with TI by age group (65-74 and ≥75 years) after covariate adjustment.

RESULTS

Baseline mean age was 75.0 years (SD 7.8); 41.4% were male. TI occurred in 79.0% and 83.7% of clinic visits in age groups 65-74 and ≥75 years, respectively. In age group 65-74 years, prevalence ratio of TI with 2, 3-4, and ≥5 comorbidities compared with zero comorbidities was 1.07 (95% confidence interval [CI]: 1.04, 1.12), 1.08 (95% CI: 1.05, 1.12), and 1.15 (95% CI: 1.10, 1.20), respectively. The number of comorbidities was not associated with TI prevalence in age group ≥75 years. After implementation of the improvement program, TI declined from 80.3% to 77.2% in age group 65-74 years and from 85.0% to 82.0% in age group ≥75 years (P < 0.001 for both groups).

CONCLUSIONS

TI was common among older adults but not associated with comorbidities after age ≥75 years. A hypertension improvement program had limited impact on TI in older patients.

Therapeutic inertia

Therapeutic inertia, sometimes referred to as clinical inertia, has been defined as failure to initiate or intensify therapy when therapeutic goals are not reached. Lack of initiation or intensification of treatment according to clinical guidelines has been linked to suboptimal control of a range of chronic conditions. Clinician factors contributing to therapeutic inertia include knowledge gaps; discomfort with uncertainty about the diagnosis, therapeutic target, or evidence; concerns about the safety of treatment intensification; and time constraints. Patient characteristics that may be associated with therapeutic inertia include male sex, older age, lower life expectancy, multiple comorbidities and clinical parameters that are close to target. There may be reasons other than therapeutic inertia that explain apparent undertreatment. Apparent inertia in prescribing may be accompanied by appropriate actions, such as provision of lifestyle advice or interventions to promote adherence to existing medication. Some patients choose not to intensify treatment. Interventions to reduce therapeutic inertia include access to evidence-based treatment guidelines and point-of-care tools, preferably integrated with clinical record systems; clinician education including educational visits; reminders; clinical audits with feedback and reflection on practice; shared decision-making; prompting by patients; and ambulatory or home monitoring (e.g. ambulatory blood pressure monitoring).