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Hypertension in older adults: What is the target blood pressure?

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Favorable outcomes in the oldest subgroup

The oldest patients in the SPRINT trial tolerated the intensive treatment as well as the youngest. 2,4

Exploratory analysis of the subgroup of patients age 75 and older, who constituted 28% of the patients in the trial, demonstrated significant benefit from intensive treatment. In this subgroup, 27 patients needed to be treated aggressively (compared with standard treatment) to prevent 1 cardiovascular event, and 41 needed to be treated intensively to prevent 1 death. 4 The lower numbers needing to be treated in the older subgroup than in the overall trial reflect the higher absolute risk in this older population.

Serious adverse events were more common with intensive treatment than with standard treatment in the subgroup of older patients who were frail. 4 Emergency department visits or serious adverse events were more likely when gait speed (a measure of frailty) was missing from the medical record in the intensive treatment group compared with the standard treatment group. Hyponatremia (serum sodium level < 130 mmol/L) was more likely in the intensively treated group than in the standard treatment group. Although the rate of falls was higher in the oldest subgroup than in the overall SPRINT population, within this subgroup the rate of injurious falls resulting in an emergency department visit was lower with intensive treatment than with standard treatment (11.6% vs 14.1%, P = .04). 4

Most of the oldest patients scored below the nominal cutoff for normal (26 points) 5 on the 30-point Montreal Cognitive Assessment, and about one-quarter scored below 19, which may be consistent with a major neurocognitive disorder. 6

The SPRINT investigators validated a frailty scale in the study patients and found that the most frail benefited from intensive blood pressure control, as did the slowest walkers.

SPRINT results do not apply to very frail, sick patients

For older patients with hypertension, a high burden of comorbidity, and a limited life expectancy, the 2017 guidelines defer treatment decisions to clinical judgment and patient preference.

There have been no randomized trials of blood pressure management for older adults with substantial comorbidities or dementia. The “frail” older adults in the SPRINT trial were still living in the community, without dementia. The intensively treated frail older adults had more serious adverse events than with standard treatment. Those who were documented as being unable to walk at the time of enrollment also had more serious adverse events. Institutionalized older adults and nonambulatory adults in the community would likely have even higher rates of serious adverse events with intensive treatment than the SPRINT patients, and there is concern for excessive adverse effects from intensive blood pressure control in more debilitated older patients.

DOES TREATING HIGH BLOOD PRESSURE PREVENT FRAILTY OR DEMENTIA?

Aging without frailty is an important goal of geriatric care and is likely related to cardiovascular health. 7 An older adult who becomes slower physically or mentally, with diminished strength and energy, is less likely to be able to live independently.

Would treating systolic blood pressure to a target of 120 to 130 mm Hg reduce the risk of prefrailty or frailty? Unfortunately, the 3-year SPRINT follow-up of the adults age 75 and older did not show any effect of intensive treatment on gait speed or mobility limitation. 8 It is possible that the early termination of the study limited outcomes.

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