Level of Frailty Dictates Hypertension Treatment

By Jaimie Lazare

A study reports that hypertension in frail older patients is linked to lower mortality risk.

The Joint National Committee’s most recent recommendations for treating hypertension emphasized that systolic blood pressure higher than 140 mm Hg is a greater risk factor for cardiovascular disease, not diastolic blood pressure, and should be the focus of treatment in patients over the age of 50.

An observational study published in the Annals of Internal Medicine explored blood pressure in elderly patients. In the study, Odden and colleagues used walking speed as a measure of frailty to assess the association between blood pressure and mortality in older adults. Among study participants with high blood pressure who were unable to complete the walking test, identified as the frail group, high blood pressure was associated with lower mortality.

James T. Pacala, MD, president of the American Geriatrics Society and an associate professor and associate head of the department of family medicine and community health at the University of Minnesota Medical School, says The Joint Commission is preparing to release the JNC8 in 2013 (10 years after the current recommendations were published), which will include recommendations for the treatment of hypertension in older adults.

“You can apply a blanket recommendation to reduce blood pressure below 140/90 in the vast majority of middle-aged people. But in older adults, this approach toward treatment may not work, particularly as your elder patients cross that threshold from having several chronic illnesses that are relatively independent of each other to a health and functional state of increased complexity and frailty,” Pacala explains.

“As older people begin running into more health problems, the transition toward frailty is often unrecognized in medicine. Physicians continue to treat their elder patients the same way they treat everyone else: If blood pressure is too high, lower it; if heart rates are too fast or too slow, adjust it; if ejection fraction is poor, prescribe drugs to help the heart pump better,” Pacala continues. “These corrective measures work in older people with fewer comorbidities. Although conventional treatments may work for younger and healthier folks, these treatments don’t work in older adults when they develop this health and functional state of frailty.”

James Goodwin, MD, a professor of internal medicine in the division of geriatric medicine at the University of Texas Medical Branch in Galveston, says gait speed is a good indicator of older adults’ frailty because it integrates brain, neurologic, and musculoskeletal function, which basically encompasses what physicians are observing when they identify a patient as being frail.

Goodwin says over the past 30 years large observational studies have reported that hypertension is a good prognosticator among people over the age of 85, and the study by Odden and colleagues allows physicians to look at hypertension as frailty based rather than age based.

“People who are extremely frail and unable to walk, no matter their age, are the ones in whom high blood pressure is a good prognostic sign. Conversely, if your patient is an 88-year-old with good gait speed, then he has the same relationship to high blood pressure that we all do. Because people are so different from each other, having an age cutoff doesn’t make a lot of sense, which is why we should discuss the physiologic condition of the person and not their age in terms of disease,” Goodwin says.

The reasons certain study participants couldn’t or didn’t complete the walk were varied, and the nonwalkers made up the smallest of the three groups in the study. “The small cell size of this group results in a loss of some statistical certainty; however, things appear to go in the direction that you would expect because in the healthiest group lower blood pressure seems to be protective,” Pacala says. “In the slower walking group—which had significantly more comorbidities—there was no association between blood pressure and mortality.

In the smallest group that didn’t complete the test, a closer look shows that this group had comparable measured comorbidity rates to the slower walkers. It’s unclear whether this small subset of older adults is somehow distinct and frailer than the slow walkers. What’s really intriguing is that in the nonwalking—and possibly more frail—group, lower blood pressure was associated with mortality, and high blood pressure appeared to be protective.”

Insights Into Measuring Blood Pressure
The justification for treating high blood pressure is not to make the patient feel better but to reduce the patient’s risk of experiencing a heart attack or stroke, Goodwin says. “Frail older people don’t handle medicines very well. Antihypertensive medications can make their blood pressure drop too much when they stand up and increase their risk of falling, which will only exacerbate their frailty,” he explains.

It’s important for the treatment approach regarding frail older adults’ hypertension to change. “Systems are used to looking at numbers such as cholesterol and blood pressures and manipulating those numbers with drugs. The frail older person is at risk for other problems such as falling and breaking a hip, which may lead to a loss of function and independence,” Goodwin says. “The most important issues to address in your frail older patients are to help them to maintain their weight, to increase or retain their muscle mass, and to prolong their independence. So treating blood pressure in the frail older adult is very pragmatic. Because everyone is different, clinicians must focus on coming up with the best decision for their frail older adult patients that will allow them to maintain their independence.”

An article published in the Journal of the American Geriatrics Society(JAGS) offers a blueprint on how to approach complex older adults with multiple chronic illnesses. “The JAGS report casts a spotlight on this very highly complex group of older adults, and it will hopefully heighten the awareness that this is a distinct group of patients for whom conventional treatments may not work well,” Pacala says. “I think that’s an important advance, and we need to keep working in that regard because it’s these patients that the current medical care system ill serves. It’s also a very resource-intensive group of patients. So we have to provide better, cost-effective care for these frail and complex older adults.”

— Jaimie Lazare is a freelance writer based in Brooklyn, New York.