Promoting higher blood pressure targets for frail older adults: A consensus guideline from Canada

CURRENT HYPERTENSION GUIDELINES

Current guidelines make reference to the elderly, but we found none that made specific recommendations for the frail elderly.

JNC 8

In December 2013, members of the Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) released new recommendations.³² One significant revision was to support higher blood pressure targets for older adults (age 60 and older). Whereas JNC 7 stated that lowering blood pressure below 140/90 mm Hg reduced cardiovascular complications,³³ JNC 8 now acknowledges that there is no strong evidence to support blood pressure targets below 150/90 mm Hg for hypertensive persons without kidney disease or diabetes age 60 and older. Thus, in the general population age 60 and older, JNC 8 recommends starting antihypertensive treatment when blood pressure is 150/90 mm Hg or higher, and treating to a goal blood pressure of less than 150/90 mm Hg. JNC 8 makes no recommendation about how to adjust blood pressure targets for frailty or how to measure blood pressure.

American College of Cardiology and American Heart Association

In 2011, the American College of Cardiology and American Heart Association published a consensus document on the management of hypertension in the elderly.⁹

They acknowledged that the generally recommended blood pressure goal of lower than 140/90 mm Hg in uncomplicated elderly patients is based on expert opinion rather than on data from randomized controlled trials, but nevertheless recommended a target systolic pressure lower than 140 mm Hg for older adults, except for octogenarians.

For those over age 80, systolic levels of 140 to 145 mm Hg can be acceptable if tolerated and if the patient does not experience orthostasis when standing. Systolic pressure lower than 130 mm Hg and diastolic pressures lower than 65 mm Hg should be avoided in this age group.

The document acknowledges that systolic pressure may have to remain above 150 mm Hg if there is no response to four “well-selected drugs” or if there are unacceptable side effects. In these cases, the lowest “safely achieved” systolic blood pressure should be the goal.

Canadian Hypertension Education Program

The 2014 Canadian Hypertension Education Program (CHEP) report makes several recommendations for the “very elderly,” a group they define as over the age of 80. The CHEP website and resources include the following recommendations¹⁰:

• For the very elderly without diabetes or target-organ damage, drug therapy should be initiated when systolic blood pressure is higher than 160 mm Hg to reach a systolic blood pressure target lower than 150 mm Hg. This is a grade C level recommendation, indicating that it is based on low-quality trials, unvalidated surrogate outcomes, or results from nonrandomized observational studies.
• For the very elderly with macrovascular target-organ damage, antihypertensive therapy should be considered if systolic blood pressure readings average 140 mm Hg or higher (grade D for 140 to 160 mm Hg; grade A for higher than 160 mm Hg), although caution should be exercised in elderly patients who are frail. (Grade D recommendations are the weakest, as they are based on low-powered, imprecise studies or expert opinion, whereas grade A recommendations are based on the strongest evidence from high-quality randomized clinical trials.)
• Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based on an individualized risk-benefit analysis.

The European Society of Hypertension and European Society of Cardiology

The 2013 guidelines from the European Society of Hypertension and the European Society of Cardiology¹¹ recommend that for elderly patients under age 80, antihypertensive treatment may be considered at systolic values higher than 140 mm Hg and aimed at values lower than 140 mm Hg if the patient is fit and treatment is well tolerated.

For those over age 80 with an initial systolic pressure of 160 mm Hg or higher, the guidelines recommend lowering systolic pressure to between 150 and 140 mm Hg, provided the patient is in good physical and mental condition. In frail elderly patients, they recommend leaving decisions on antihypertensive therapy to the treating physician, based on monitoring of the clinical effects of treatment.¹¹

The ADS/PATH guidelines

When finalizing our recommendations,¹ we considered the characteristics of frailty and the following key points from the evidence:

• Although evidence from drug treatment trials indicates that there is benefit in treating healthy older adults who have hypertension, the benefit of treating frail older adults is unknown.
• Major trials enrolled elderly patients only if they had systolic blood pressures of at least 160 mm Hg. Therefore, evidence supports initiating pharmacotherapy at a systolic pressure of 160 mm Hg or higher.
• No evidence from randomized controlled trials supports a systolic target lower than 140 mm Hg in the elderly, and there is some evidence that such a target does not benefit.
• The benefit of adding a third medication to lower blood pressure has not been studied.
• Frailty makes the potential benefits of strict blood pressure targets even less certain and increases the possibility of harm from adverse drug events.
• The only study of very old adults, HYVET,⁴⁴ enrolled relatively healthy older adults and few with orthostasis, while excluding those with a standing systolic blood pressure lower than 140 mm Hg.

OUR RECOMMENDATIONS

Based on the above, we advise against unnecessarily strict targets and recommend stopping antihypertensive medications that are used for the sole purpose of keeping the systolic blood pressure below 140 mm Hg. Our guidelines are unique in that they focus equally on when to stop and when to start medications. We concluded that without evidence of definitive benefit, “less is more” with frailty.⁵⁵ We believe that if physicians and health professionals understand the limitations of the evidence, they can be more confident in stopping medications that lower blood pressure to an unnecessarily low level.

We recommend the following (Table 4):

Before treating

• Carefully review the risks and the potential but unproven benefits of treatment.
• To avoid overtreatment, treatment decisions should be based on blood pressure measurements in the seated (not supine) position, while also considering the presence of orthostasis.
• To evaluate orthostasis, measure blood pressure in the supine position, then immediately on standing, and again after 2 minutes. Ask the patient if he or she feels light-headed or dizzy when standing.

Stop treatment

• If the seated systolic blood pressure is less than 140 mm Hg, medications can be tapered and discontinued to achieve the targets described below.
• Before discontinuation, consider whether the medications are treating additional conditions such as rate control for atrial fibrillation or symptomatic management of heart failure.
• It is uncertain whether to discontinue treatment when there is a history of stroke. Consider that treatment with two medications resulted in an absolute risk reduction for disabling stroke of 1.64% over approximately 4 years for adults with previous stroke and a mean age of 64,⁵⁷ an effect that may be more prominent at higher systolic pressures.

Start treatment

• Consider starting treatment when systolic pressure is 160 mm Hg or higher.
• Aim for a seated systolic pressure between 140 and 160 mm Hg if there are no adverse effects from treatment that affect quality of life.
• If there is symptomatic orthostasis or if standing systolic pressure is lower than 140 mm Hg, the target seated systolic pressure can be adjusted upwards.
• In the severely frail nearing the end of life, a target systolic pressure of 160 to 190 mm Hg is reasonable.
• The blood pressure target is the same in people with diabetes.
• In general, use no more than two medications.

Dissemination and implementation

The ADS/PATH guideline is intended for use by physicians and other health professionals (eg, pharmacists and nurses) who care for frail older adults or who work in long-term care facilities. Since creating our guideline, we have disseminated it to physicians, pharmacists, and other health professionals through academic detailing, large conferences, and interactive webinars.

While we do not have objective evidence of practice change, our evaluation data found that 34% of 403 family physicians who received academic detailing indicated that the guideline would change their practice, while 36% stated that the guideline confirmed their practice, an indication that family physicians are sensitive to the needs of the frail elderly.

Because health professionals may be wary of stopping medications and not meeting recommended targets, there may be barriers to adopting this guideline. However, our experience with the PATH program indicates that these barriers can be overcome using effective communication strategies between health professionals and consumers.

AN APPROACH APPROPRIATE TO FRAILTY

There is no direct evidence for systolic blood pressure targets in the frail elderly, so we applied evidence from the nonfrail elderly. Our recommendations differ somewhat from those of other groups, which recommend targets below 140 to 150 mm Hg for older adults, although some do advise caution in the elderly for whom a substantial fall in blood pressure might be poorly tolerated. Despite these messages, we believe that clearer guidance is needed to direct health practitioners toward models that acknowledge that frail patients are in a precarious balance of health and may be harmed by treatments that strive to lower blood pressure to unproven targets. For this reason, our guideline clearly indicates when to decrease or stop drug treatment.

After physicians and health professionals examine the evidence and more fully understand the benefits and harms of treating frail older adults, we are confident that they will be more comfortable stopping medications that lower blood pressure to an unnecessarily low level and instead use an approach that is more appropriate to frailty. We hope clinicians can use this guideline with the same enthusiasm applied to other guidelines, and we welcome discussion.

Acknowledgments: We would like to thank and acknowledge Tanya MacLeod and Kathryn Yuill for their review of and advice about the manuscript.