GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review

PURPOSE OF REVIEW

To summarise the evidence regarding which patients might benefit from deprescribing antihypertensive medications.

RECENT FINDINGS

Older patients with frailty, multi-morbidity and subsequent polypharmacy are at higher risk of adverse events from antihypertensive treatment, and therefore may benefit from antihypertensive deprescribing. It is possible to examine an individual's risk of these adverse events, and use this to identify those people where the benefits of treatment may be outweighed by the harms. While such patients might be considered for deprescribing, the long-term effects of this treatment strategy remain unclear. Evidence now exists to support identification of those who are at risk of adverse events from antihypertensive treatment. These patients could be targeted for deprescribing interventions, although the long-term benefits and harms of this approach are unclear.

PERSPECTIVES

Randomised controlled trials are still needed to examine the long-term effects of deprescribing in high-risk patients with frailty and multi-morbidity.

How do primary care clinicians approach the management of frailty? A qualitative interview study

BACKGROUND

Around 15% of adults aged over 65 live with moderate or severe frailty. Contractual requirements for management of frailty are minimal and neither incentivised nor reinforced. Previous research has shown frailty identification in primary care is ad hoc and opportunistic, but there has been little focus on the challenges of frailty management, particularly within the context of recent introduction of primary care networks and an expanding allied health professional workforce.

AIM

Explore the views of primary care clinicians in England on the management of frailty.

DESIGN AND SETTING

Semi-structured interviews were conducted with clinicians across England, including general practitioners (GPs), physician associates, nurse practitioners, paramedics and clinical pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

RESULTS

A total of 31 clinicians participated. Frailty management was viewed as complex and outside of clinical guidelines with medication optimisation highlighted as a key example. Senior clinicians, particularly experienced GPs, were more comfortable with managing risk. Relational care was important in prioritising patient wishes and autonomy, for instance to remain at home despite deteriorations in health. In settings where more formalised multidisciplinary frailty services had been established this was viewed as successful by clinicians involved.

CONCLUSION

Primary care clinicians perceive frailty as best managed through trusted relationships with patients, and with support from experienced clinicians. New multidisciplinary working in primary care could enhance frailty services, but must keep continuity in mind. There is a lack of evidence or guidance for specific interventions or management approaches.

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

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

Hypertension treatment in the oldest-old: focus group interviews with Swedish general practitioners

OBJECTIVE

This study explored the considerations and experiences of Swedish General Practitioners (GPs) of hypertension treatment in patients 80 years and above.

DESIGN

Qualitative design with focus group interviews. Data were analysed by qualitative content analysis.

SETTING

Primary health care centres (PHCCs), both rural and urban, in the Region of Västra Götaland, Sweden.

SUBJECTS

GPs and GP trainees working at PHCCs in 2019 and 2020. Five focus group interviews with 24 physicians were performed.

MAIN OUTCOME MEASURES

Considerations and experiences of hypertension treatment in the oldest-old.

RESULTS

Eighteen GPs and six GP trainees participated in the study. The latent content was formulated in a theme: 'The physician's decision-making in the treatment of hypertension in the oldest-old implies the inclusion of both medical and humanistic considerations.' The manifest content constituted three main categories: 'The patient characteristics' included medical condition, behavioural factors and daily life. 'The physician's role' described the GP as a professional and her/his experienced support. 'The treatment decision' considered these categories and involved risk-benefit balancing and communication. For the future, the participants proposed better guidelines for the oldest-old multimorbid patients, increased teamwork, continuous cooperation with nurses and better cooperation with hospital physicians.

CONCLUSION

Hypertension care for the oldest-old was experienced as complicated by GPs, due to the need of balancing medical and humanistic considerations. The GP's clinical experience and the received support were of importance when making the treatment decision based on risk-benefit balancing and communication with the patient.Key pointsGPs experienced the task of caring for the oldest-old patients with hypertension as complicated.Patient factors like multimorbidity, polypharmacy, behavioural factors and the patient's condition of daily life were identified.Clinical experience and the experienced support at the PHCC were discussed as important for the GPs' treatment decision.Treatment decisions for the oldest-old patients with hypertension were based on risk-benefit balancing and communication with the patients.