Evidence-Based Practice in LTC

Identifying & Managing Hypertension in the Elderly

by Steven Levenson, MD, CMD
Multi-Facility Medical Director, Baltimore, MD
Chair, Caring's Editorial Board

Charles Crecelius, MD, PhD, CMD
Past President, Missouri Association of Long-Term Care Physicians
Medical Director, Delmar Gardens, St. Louis, MO
Member, Caring's Editorial Board

About This Series: Over the years, certain practices have become common in nursing home care nationwide. Consultants, management, and surveyors offer multiple opinions and conflicting advice that may confuse staff and practitioners and result in over- or under-treatment. Various sources, including the Centers for Medicare and Medicaid Services, are advising nursing home staff to refer to "best practices." Yet only some of these practices reflect reliable evidence. Other habitual approaches are problematic and should change. Often, "best practices" is erroneously interpreted to mean that there is a single best treatment, when in reality there may be "better" and "worse" practices. This series will review common practices in nursing homes, comparing habitual to desired approaches, and may recommend important changes.

This month's column addresses the issue of identifying and managing hypertension.

Common Practices

In nursing homes, blood pressure (BP) measurements are often irregular and decisions regarding treatment are often inconsistent. Some nursing staff measure blood pressure only as part of monthly vital signs, regardless of the presence or absence of cardiovascular disease or medications. Others take BP measurements more frequently, with or without any particular pattern. Nurses often call physicians for isolated BP elevations, and physicians often change antihypertensive medication doses or add medications based on isolated readings. They may treat the "numbers" without necessarily evaluating the context of a patient's condition, prognosis, and goals.

BP measurements are often not standardized. Important details--such as when during the day BP is measured, whether the BP is taken while the resident is supine or standing, and any inconsistencies in cuff and arm size--are rarely noted. Staff rarely appear to understand or apply relevant principles such as auscultatory gap, pulsus paradoxus, and Osler's sign.

Signs and symptoms of orthostatic hypotension, which may occur upon standing or transfer, may not be sought or their importance may not be recognized, even when someone falls repeatedly. Postprandial hypotension may not be recognized despite its frequency in older populations.

Some practitioners do not follow commonly recognized approaches to evaluating and managing elevated blood pressure. Both under- and overtreatment are seen. Many physicians place patients on sodium restriction despite its dubious role in the frail elder's diet in the absence of congestive heart failure. Doing this may only promote undesired weight loss or increase hydration risks.

Often, elevated blood pressures are either ignored or not rechecked, or the physician does not evaluate, discuss, or document the clinical significance, or lack thereof, of the findings. Although higher acceptable limits for treating systolic hypertension based on age may be an appropriate consideration, an appropriate rationale for treating or not treating is rarely documented.

Use of costlier, higher risk, or less proven medications is not uncommon. Re-evaluation of antihypertensive treatment regimens may never occur. The need for continuing hypertension treatment in end-stage conditions or at end of life may not be reconsidered.

Practitioners often fail to consider the impact of medication treatments on the whole patient. They may not recognize or respond appropriately to likely adverse drug reactions (ADRs) such as falling, weakness, and depression. These ADRs may be due to the antihypertensive medications alone or to their effects combined with those of medications in other categories, such as anti-Parkinson or psychoactive medications.

Physicians may use substantial doses of centrally acting alpha-adrenergic blocking agents, despite the considerable incidence of significant side effects that may impair function and quality of life. Some may refuse to adjust doses of antihypertensives despite serious ADRs, stating that the patient could suffer a stroke if any changes were made.

The Evidence

There is no clear boundary between "normal" and "abnormal" BP. Hypertension is a chronic condition. If untreated over many years, it can cause complications such as hemorrhagic stroke and congestive heart failure and, among other things, exacerbate atherosclerosis and retinopathy. However, while isolated BP elevations may warrant additional evaluation, they rarely warrant immediate interventions.

Multiple factors such as age, comorbid conditions, and the presence of other cardiovascular risk factors should be considered in deciding on whether and how quickly to treat BP elevations. As a rule, maintaining BPs within the mid-normal range is desirable. There is no clear consensus on what level of BP to begin medication treatment. In addition, in older individuals, the side effects of antihypertensive medications may be highly problematic (see box below for relevant studies).

BP Measurement

What blood pressure is normal?

Blood pressure normally varies throughout the day and with changes in position and activities. Isolated or intermittent BP elevations may be a trigger for additional evaluation, but do not necessarily require interventions any more than isolated blood sugar elevations require medication treatment for diabetes.

The Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) uses a sitting systolic BP of 140 mm Hg and diastolic BP of 90 mm Hg as the criteria for hypertension. The target range for most patients is a BP of 130/85.

Many nursing home patients have isolated systolic hypertension. Most studies related to treating hypertension in the elderly use systolic blood pressures above 160 as the diagnostic standard, and recommend treatment goals of 150-160 mm Hg or less.

Several factors influence determination of normal BP for nursing home patients. BP in older patients is likely to range more widely than in younger individuals. Older patients are also more likely to have orthostatic and post-prandial hypotension, with highest readings obtained before breakfast. It has been suggested that multiple daily BP measurements using positional measurements and readings both before and after meals would improve the accuracy of the diagnosis and treatment of hypertension in LTC.

Hypertension is best identified by taking readings while sitting, but some nursing home patients spend most or all of their time supine. Blood pressure should be recorded while sitting if possible, and it should be noted if readings are taken while the individual is supine or standing. The time of day should be noted and standardized as much as possible, at least for serial measurements of the same individual. Different BP cuff sizes should be available, and supervisors should ensure that staff use proper technique.

Estimates of orthostatic (positional) hypotension prevalence in nursing home patients vary from 32% to more than 50%. Although it is defined as a change in systolic or diastolic BP upon standing of 20 mm Hg or 10 mm Hg, respectively, its possible presence must be assessed relative to any associated symptoms, and potential risks of adverse events if orthostatic hypotension is not addressed.

Positional BPs should be checked at least initially and intermittently for patients with falls, Parkinsonian symptoms, CHF, strokes, complaints of lightheadedness ("dizziness"),and those on medications that may cause dizziness or promote orthostasis. It has been reported to occur more commonly in the early morning, and in males, patients with low body mass index, and in those with higher ADL abilities. However, significant BP drops are not necessarily detectable in individuals who fall repeatedly. Therefore, "dizziness" alone--even in the absence of positional BP changes--may indicate a risk related to BP management.

Postprandial hypotension occurs in 35% of nursing home residents. It is defined as a 20 mm Hg drop in systolic BP within two hours of eating, or a 10 mm Hg drop if the initial systolic BP is 100 or less. It results primarily from a shunting of blood to the intestines to absorb nutrients. Postprandial hypotension is more likely to be seen in patients with systolic hypertension, diabetes, renal dialysis, Parkinsonism, or other associated autonomic dysfunction.

Lightheadedness, syncope, seizures, weakness, angina, or focal neurological symptoms occurring near mealtimes should prompt BP measurements before and after eating.

Measurement and treatment of hypertension should be tailored to the characteristics and needs of individual patients. Between 32% and 44% of nursing home residents have been reported to have hypertension. There is abundant evidence for optimal diagnosis and treatment of hypertension in the younger old patient. Evidence is not as substantial for those 80 to 85 and older, who constitute 40% of nursing home residents.

BP Treatment

Numerous categories and combinations of medications are available to treat hypertension. Abundant evidence suggests that older, more simplified regimens may be the most effective.

Diuretics have been shown to normalize blood pressure and reduce morbidity and mortality both in the elderly generally and in nursing home patients. Diuretics are effective in combination with other agents, although data with calcium channel blockers (CCBs) are not as favorable as others.

Angiotensin-converting enzyme (ACE) inhibitors by themselves may not be as effective in the elderly as diuretics or dihydropyridine CCBs. Data on the potential benefit of angiotensin-receptor blockers (ARB) in older adults, especially nursing home patients, are limited.

Beta blockers alone have not been shown to reduce most cardiovascular events in older adults. Alpha blockers may increase mortality and should be avoided as single drug therapy. Centrally acting agents have significant side effects and should not be used as first line therapy.

The presence of comorbid diseases is relevant to medication selection. For instance, ACE inhibitors should be considered in patients with congestive heart failure. Thiazide diuretics are helpful in managing BP in individuals with osteoporosis because they increase renal calcium retention. The presence of coronary artery disease and arrhythmias may make CCBs or beta-blockers more relevant. Diabetics may benefit from use of ACE inhibitors or ARBs for prevention of renal disease.

Regardless of which medications are chosen, potential side effects should be considered and addressed when they occur. Documentation should at least occasionally explain the rationale for the choice of medications and possible future modifications.

How important is aggressive BP control in the very old? Most considerations of hypertension-associated risk in the very old are extrapolated from studies in younger patients. Several studies have actually shown a negative correlation between hypertension and mortality in the elderly. But other studies suggest that excess mortality from lower BPs is due to poorer health and comorbid conditions, and not because of the effects of lowering blood pressure.

Although the European Working Party on High Blood Pressure study found little or no benefit for total and cardiovascular objectives in those greater than 80 years old, the Systolic Hypertension in the Elderly Program study showed reduction in strokes and CHF episodes with treatment of systolic hypertension for those over the age of 80.

Over-treatment of BP may increase risk of side effects and adverse medication interactions. It can also promote falls, immobility, stroke, myocardial ischemia, and hepatic and renal insufficiency. Studies in elderly patients in general showed successful discontinuation in 41%-55% patients in short-term (less than one year) studies and from 16%-29% patients in long-term studies. Predictors of successful withdrawal may include lower body mass index, lower systolic blood pressure during treatment, and less electrocardiographic evidence of left ventricular hypertrophy. There are no relevant studies just in nursing home patients.

Conclusions

Overall, treating hypertension in the elderly is desirable, at least up to the age of 85. Isolated systolic as well as diastolic or combined hypertension should be treated in an effort to reduce morbidity and mortality.

However, hypertension is primarily a chronic, not an acute condition. It rarely warrants immediate interventions based on isolated results. Nursing homes should adopt policies that focus on a "three-dimensional" approach, emphasizing measuring and evaluating BPs over time and making or adjusting interventions based on each patient's "big picture." This is especially important in nursing home residents older than 80 to 85.

An individualized approach should consider comorbid conditions, risks of serious adverse drug reactions in those taking large doses or multiple medications, and treatment goals. Too much treatment can create greater short-term risks than the risks posed by a less-than-fully controlled BP.

Physicians should evaluate patients who have labile or poorly controlled BPs despite treatment with several categories of medications before continuing to increase doses or add more medications. Sometimes, other medications that the patient takes may counteract or exacerbate the effects of BP medications, or vice-versa.

Moreover, the body's natural attempts to compensate for imbalances may come into play when too much treatment results in hypotension, just as excessive treatment of hyperglycemia can lead to hypoglycemia that stimulates compensatory mechanisms that lead to even more hyperglycemia. And, in many patients, development of serious comorbid conditions may make the goal of tight BP control a moot point.

Those who obtain, document, report, and respond to BP measurements should understand more about the topic. Nursing homes should have policies and procedures that control the documentation and reporting of BP results to physicians, so that there is not undue pressure to react excessively to fluctuations and elevations.

BP may drop or increase in various acute illnesses. Speculation in the medical record by nurses, physicians, and nursing home surveyors about elevated BPs as the cause rather than the result of a change in condition should be strongly discouraged, as it may be mistaken.

BP should be measured carefully, by properly trained staff at consistent times. The significance of orthostatic and post-prandial effects on BP management should be acknowledged. Potential medication side effects should be sought routinely--for example, significant orthostatic hypotension in individuals taking both anti-Parkinson medications and antihypertensives.

With some exceptions, reassessment of hypertension therapy, with attempts to gradually reduce or withdraw antihypertensive therapy, should be done periodically. A trial of a gradual, at least partial, tapering of doses or reduction of the total number of BP medications can generally be attempted without exposing most patients to acute cardiac and neurological injury. It should be possible to identify those relatively few patients for whom attempted adjustments are contraindicated.

Proper monitoring over time after tapering should readily identify individuals for whom lower doses are problematic. The fact that a few individuals may need to resume or increase doses after a tapering attempt should not obscure the likelihood that many individuals may do as well or better with less medication and lower doses. As with other medications, we won't know if less will work unless we try.

The opinions expressed in this column are those of the authors and do not necessarily reflect those of the American Medical Directors Association.

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