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Reducing Antihypertensive Medication Use in Nursing Home Patients

Reducing Antihypertensive Medication Use in Nursing Home Patients Of the 1.5 million nursing home residents, about 40% are aged 85 years or older, and a similar percentage have hypertension. The rates of incorrect diagnoses from the "white coat" effect and from errors in blood pressure evaluation are as frequent in older persons as in younger persons. The benefits of antihypertensive treatment and the risks of lowering blood pressures in the very old (≥85 years) are uncertain. Elderly patients experience adverse effects from drug treatment that are unique to their age group and that complicate management problems associated with polypharmacy and multiple comorbid conditions. Trials to withdraw or lower the dosage of antihypertensive medications have been successful in up to 40% of elderly persons when combined with salt restriction and weight loss, but such studies are lacking in nursing home patients. The management of hypertension should be reevaluated in nursing home patients.Pharmacological therapy reduces risks for complications of hypertension (stroke, congestive heart failure, renal failure, and mortality) in youngand elderlypatients. Although there is strong evidence of benefit from drug treatment for most patients, several areas of uncertainty remain. Among these are rates of diagnostic accuracy, risks, and benefits of therapy in the very old (≥85 years) and in those either with multiple comorbid conditions or living in long-term institutional settings such as nursing homes. Although much of the content of this review pertains to all elderly patients, we focus on those residing in nursing homes. These patients have many comorbid conditions for which they take multiple medications. They are at increased risk for adverse drug reactions, and changes resulting from management modifications can be observed and continuously monitored.HYPERTENSION IN NURSING HOME PATIENTSForty percent of the approximately 1.5 million nursing homes residents are aged 85 years or older,and between 32% and 44% have hypertension.To our knowledge, there have been few hypertension studies in nursing home patients. The prevalence of hypertension reported as only 14.0% in the 1985 National Nursing Home Surveyis considerably lower than the rate of 54.9% for noninstitutionalized persons aged 65 to 74 yearsand the rates of 34.0% (men) and 50.0% (women) for those aged 85 years and older.Using a database of almost 300 000 nursing home patients in 5 US states, Gambassi et alreport hypertension in 32%, with the highest prevalence among African Americans and women. Seventy percent receive antihypertensive medications. This percentage decreases with increasing age (≥85 years: odds ratio, 0.85; 95% confidence interval [CI&rsqb;, 0.81-0.89). Recorded blood pressure readings were unavailable in this study, and the extent of blood pressure control is unknown. Data from 2 cross-sectional studies are similar. In a survey of 617 patients in 17 Texas nursing homes,and in oneof 804 patients in 3 New York nursing homes, rates of hypertension were reported as 40% and 44%, respectively. Studies that use higher blood pressures to define hypertension (systolic blood pressure, ≥160 mm Hg) report rates that vary from 15% to 44%.Multiple comorbid conditions are the rule, and complicate therapy for hypertension. Gambassi et alreport that 67% of patients had 3 or more and 25% had 6 or more; Trilling et alreport an average of 5 per patient. The most common long-term problems are ischemic heart disease, 32% to 39%; cerebrovascular disease, 26% to 30%; anemia, 20%; depression, 17% to 20%; arthritis, 15% to 36%; and diabetes, 15% to 27%.Rates of dementia range from 36% to 43%.Polypharmacy also complicates therapy in hypertensive nursing home patients. Avorn and Gurwitzreport an average of 7.2 prescribed medications daily; Beers et al,8.1; and Trilling et al,8.7. In the latter report, the number of daily medications is 9.4 for patients with hypertension and 8.0 for those who are normotensive. The distribution of antihypertensive medications is as follows: calcium channel blockers, 26% to 30%; diuretics, 25% to 28%; angiotensin-converting enzyme inhibitors, 22% to 27%; β-blockers, 8%; and α-blockers, 5.3%.These data on calcium channel blockers are similar to those reported by othersand mirror the distribution in the general geriatric population, in whom they are the most commonly prescribed antihypertensive medications.The number of hypertensive nursing home patients who do not receive antihypertensive medications varies from 24% to 30%.Blood pressure control (<140/90 mm Hg) is excellent, achieved in 88.8% of patients taking medication.Perhaps the amount of time spent in bed contributes to the high rate of successful blood pressure control. Of those treated, 54.0% to 58.7% receive 1 and 32.7% receive 2 drugs.ACCURACY OF DIAGNOSISIncorrect technique for blood pressure measurement might result in incorrect diagnoses. Using a trained physician as the reference standard, Stoneking et alfound that nursing home staff significantly underestimated systolic blood pressure and overestimated diastolic blood pressure, resulting in the misclassification of hypertension in 21% of patients. An additional source of error is falsely elevated blood pressure readings from "white coat hypertension." In a study of 50 untreated patients with hypertension aged 70 years and older (mean ± SD, 79 ± 6 years), 9 (18%) were classified as having white coat hypertension and an additional 13 (26%) as having an intermediate hypertension between normal and abnormal.Findings in younger persons are similarand, together with other studies,suggest that some patients with hypertension might be normotensive. Although it is likely that the hypertension was present for most nursing home residents before admission, studiesof hypertension in nursing home patients do not report rates of new diagnoses following admission. The extrapolation of findings in an ambulatory setting to nursing homes is questionable, because blood pressure measurements taken at the bedside might not be subject to the white coat effect. The issue is germane because some investigatorssuggest that white coat hypertension might not be benign and could cause cardiovascular abnormalities that include stiffness, loss of compliance, and elasticity of cardiac muscle. Although there is little evidence from longitudinal studiesthat this group of patients is at increased risk for cardiovascular morbidity or mortality, the prognosis is uncertain and continued monitoring is indicated.If the diagnosis of hypertension is in doubt, ambulatory blood pressure measurements (automated multiple blood pressure readings during a 24-hour period), although expensive, could help resolve the problem. Correlation between office and ambulatory blood pressure readings is poor even when measurements from as many as 6 office visits are averaged.Ambulatory blood pressure readings predict cardiac size and function better than office blood pressure determinations.Adjustment of antihypertensive medication using ambulatory blood pressure readings results in less intensive treatment, while maintaining good control of blood pressure and improved well-being, when compared with adjustments based on office measurements.CARDIOVASCULAR RISKS FROM HYPERTENSION IN THE VERY OLDThe cardiovascular risks in the very old (≥85 years) from uncontrolled hypertension are uncertain.Bulpitt and Fletcherreport a negative relation between hypertension and mortality in men older than 75 years and in women older than 85 years, with hypertensive persons living longer. In a study of 795 community-dwelling men and women aged 75 years and older, a decrease of 5 mm Hg or greater in diastolic blood pressure in men was associated with an increased all-cause mortality (relative risk, 2.33; 95% CI, 1.39-3.91) and cardiovascular mortality (relative risk, 3.13; 95% CI, 1.47-6.66). Men taking antihypertensive medication whose diastolic blood pressure decreased had a higher risk of mortality (relative risk, 12.33; 95% CI, 2.73-55.72) when compared with treated men whose diastolic blood pressure did not decrease.Using data from the Framingham study, D'Agostino et alfound that, independent of antihypertensive treatment, low diastolic blood pressures were associated with increased cardiovascular deaths in persons with a history of myocardial infarction, but increased systolic blood pressures caused a small but statistically significant increase in cardiovascular disease. Other investigators interpret these relations differently. The National Institute on Aging-Sponsored Established Populations for Epidemiologic Studies in the Elderlyconcludes that excess mortality in elderly persons with a lower blood pressure might in part be due to comorbid conditions and suggests that there is no consistent relation between diastolic pressure and mortality. In a community study of 835 people older than 85 years, Boshuizen et alconclude that the relation between low blood pressure and increased mortality is caused by poor health and not by the blood pressure levels.None of the randomized treatment trials of elderly patientsenrolled enough patients aged 85 years and older to provide a definitive answer about the value of drug therapy in this age group. The studyby the European Working Party on High Blood Pressure in the Elderly found that treatment conferred little or no benefit for persons older than 80 years. Subsequent subgroup analyses of data from that study for the group aged 80 years and older showed no treatment benefit for total and cardiovascular mortality but suggest that treatment "probably still prevented cardiovascular complications, stroke and cardiac end points."(p1686) Subgroup analyses of the treated group aged 80 years and older compared with the placebo group in the Systolic Hypertension in the Elderly Program showed a reduction in episodes of congestive heart failure and strokes.Data from observational studies and clinical trials fail to define the benefits and risks of treating hypertension in the very old. Definitive answers could be forthcoming from the ongoing Hypertension in the Very Elderly Trial.This is an open study, however, and it is unlikely that nursing home patients are included; patients confined to bed and those with dementia are excluded.RISKS OF PHARMA http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Family Medicine American Medical Association

Reducing Antihypertensive Medication Use in Nursing Home Patients

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American Medical Association
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Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
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1063-3987
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1063-3987
DOI
10-1001/pubs.Arch Fam Med.-ISSN-1063-3987-9-4-fcr9019
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Abstract

Of the 1.5 million nursing home residents, about 40% are aged 85 years or older, and a similar percentage have hypertension. The rates of incorrect diagnoses from the "white coat" effect and from errors in blood pressure evaluation are as frequent in older persons as in younger persons. The benefits of antihypertensive treatment and the risks of lowering blood pressures in the very old (≥85 years) are uncertain. Elderly patients experience adverse effects from drug treatment that are unique to their age group and that complicate management problems associated with polypharmacy and multiple comorbid conditions. Trials to withdraw or lower the dosage of antihypertensive medications have been successful in up to 40% of elderly persons when combined with salt restriction and weight loss, but such studies are lacking in nursing home patients. The management of hypertension should be reevaluated in nursing home patients.Pharmacological therapy reduces risks for complications of hypertension (stroke, congestive heart failure, renal failure, and mortality) in youngand elderlypatients. Although there is strong evidence of benefit from drug treatment for most patients, several areas of uncertainty remain. Among these are rates of diagnostic accuracy, risks, and benefits of therapy in the very old (≥85 years) and in those either with multiple comorbid conditions or living in long-term institutional settings such as nursing homes. Although much of the content of this review pertains to all elderly patients, we focus on those residing in nursing homes. These patients have many comorbid conditions for which they take multiple medications. They are at increased risk for adverse drug reactions, and changes resulting from management modifications can be observed and continuously monitored.HYPERTENSION IN NURSING HOME PATIENTSForty percent of the approximately 1.5 million nursing homes residents are aged 85 years or older,and between 32% and 44% have hypertension.To our knowledge, there have been few hypertension studies in nursing home patients. The prevalence of hypertension reported as only 14.0% in the 1985 National Nursing Home Surveyis considerably lower than the rate of 54.9% for noninstitutionalized persons aged 65 to 74 yearsand the rates of 34.0% (men) and 50.0% (women) for those aged 85 years and older.Using a database of almost 300 000 nursing home patients in 5 US states, Gambassi et alreport hypertension in 32%, with the highest prevalence among African Americans and women. Seventy percent receive antihypertensive medications. This percentage decreases with increasing age (≥85 years: odds ratio, 0.85; 95% confidence interval [CI&rsqb;, 0.81-0.89). Recorded blood pressure readings were unavailable in this study, and the extent of blood pressure control is unknown. Data from 2 cross-sectional studies are similar. In a survey of 617 patients in 17 Texas nursing homes,and in oneof 804 patients in 3 New York nursing homes, rates of hypertension were reported as 40% and 44%, respectively. Studies that use higher blood pressures to define hypertension (systolic blood pressure, ≥160 mm Hg) report rates that vary from 15% to 44%.Multiple comorbid conditions are the rule, and complicate therapy for hypertension. Gambassi et alreport that 67% of patients had 3 or more and 25% had 6 or more; Trilling et alreport an average of 5 per patient. The most common long-term problems are ischemic heart disease, 32% to 39%; cerebrovascular disease, 26% to 30%; anemia, 20%; depression, 17% to 20%; arthritis, 15% to 36%; and diabetes, 15% to 27%.Rates of dementia range from 36% to 43%.Polypharmacy also complicates therapy in hypertensive nursing home patients. Avorn and Gurwitzreport an average of 7.2 prescribed medications daily; Beers et al,8.1; and Trilling et al,8.7. In the latter report, the number of daily medications is 9.4 for patients with hypertension and 8.0 for those who are normotensive. The distribution of antihypertensive medications is as follows: calcium channel blockers, 26% to 30%; diuretics, 25% to 28%; angiotensin-converting enzyme inhibitors, 22% to 27%; β-blockers, 8%; and α-blockers, 5.3%.These data on calcium channel blockers are similar to those reported by othersand mirror the distribution in the general geriatric population, in whom they are the most commonly prescribed antihypertensive medications.The number of hypertensive nursing home patients who do not receive antihypertensive medications varies from 24% to 30%.Blood pressure control (<140/90 mm Hg) is excellent, achieved in 88.8% of patients taking medication.Perhaps the amount of time spent in bed contributes to the high rate of successful blood pressure control. Of those treated, 54.0% to 58.7% receive 1 and 32.7% receive 2 drugs.ACCURACY OF DIAGNOSISIncorrect technique for blood pressure measurement might result in incorrect diagnoses. Using a trained physician as the reference standard, Stoneking et alfound that nursing home staff significantly underestimated systolic blood pressure and overestimated diastolic blood pressure, resulting in the misclassification of hypertension in 21% of patients. An additional source of error is falsely elevated blood pressure readings from "white coat hypertension." In a study of 50 untreated patients with hypertension aged 70 years and older (mean ± SD, 79 ± 6 years), 9 (18%) were classified as having white coat hypertension and an additional 13 (26%) as having an intermediate hypertension between normal and abnormal.Findings in younger persons are similarand, together with other studies,suggest that some patients with hypertension might be normotensive. Although it is likely that the hypertension was present for most nursing home residents before admission, studiesof hypertension in nursing home patients do not report rates of new diagnoses following admission. The extrapolation of findings in an ambulatory setting to nursing homes is questionable, because blood pressure measurements taken at the bedside might not be subject to the white coat effect. The issue is germane because some investigatorssuggest that white coat hypertension might not be benign and could cause cardiovascular abnormalities that include stiffness, loss of compliance, and elasticity of cardiac muscle. Although there is little evidence from longitudinal studiesthat this group of patients is at increased risk for cardiovascular morbidity or mortality, the prognosis is uncertain and continued monitoring is indicated.If the diagnosis of hypertension is in doubt, ambulatory blood pressure measurements (automated multiple blood pressure readings during a 24-hour period), although expensive, could help resolve the problem. Correlation between office and ambulatory blood pressure readings is poor even when measurements from as many as 6 office visits are averaged.Ambulatory blood pressure readings predict cardiac size and function better than office blood pressure determinations.Adjustment of antihypertensive medication using ambulatory blood pressure readings results in less intensive treatment, while maintaining good control of blood pressure and improved well-being, when compared with adjustments based on office measurements.CARDIOVASCULAR RISKS FROM HYPERTENSION IN THE VERY OLDThe cardiovascular risks in the very old (≥85 years) from uncontrolled hypertension are uncertain.Bulpitt and Fletcherreport a negative relation between hypertension and mortality in men older than 75 years and in women older than 85 years, with hypertensive persons living longer. In a study of 795 community-dwelling men and women aged 75 years and older, a decrease of 5 mm Hg or greater in diastolic blood pressure in men was associated with an increased all-cause mortality (relative risk, 2.33; 95% CI, 1.39-3.91) and cardiovascular mortality (relative risk, 3.13; 95% CI, 1.47-6.66). Men taking antihypertensive medication whose diastolic blood pressure decreased had a higher risk of mortality (relative risk, 12.33; 95% CI, 2.73-55.72) when compared with treated men whose diastolic blood pressure did not decrease.Using data from the Framingham study, D'Agostino et alfound that, independent of antihypertensive treatment, low diastolic blood pressures were associated with increased cardiovascular deaths in persons with a history of myocardial infarction, but increased systolic blood pressures caused a small but statistically significant increase in cardiovascular disease. Other investigators interpret these relations differently. The National Institute on Aging-Sponsored Established Populations for Epidemiologic Studies in the Elderlyconcludes that excess mortality in elderly persons with a lower blood pressure might in part be due to comorbid conditions and suggests that there is no consistent relation between diastolic pressure and mortality. In a community study of 835 people older than 85 years, Boshuizen et alconclude that the relation between low blood pressure and increased mortality is caused by poor health and not by the blood pressure levels.None of the randomized treatment trials of elderly patientsenrolled enough patients aged 85 years and older to provide a definitive answer about the value of drug therapy in this age group. The studyby the European Working Party on High Blood Pressure in the Elderly found that treatment conferred little or no benefit for persons older than 80 years. Subsequent subgroup analyses of data from that study for the group aged 80 years and older showed no treatment benefit for total and cardiovascular mortality but suggest that treatment "probably still prevented cardiovascular complications, stroke and cardiac end points."(p1686) Subgroup analyses of the treated group aged 80 years and older compared with the placebo group in the Systolic Hypertension in the Elderly Program showed a reduction in episodes of congestive heart failure and strokes.Data from observational studies and clinical trials fail to define the benefits and risks of treating hypertension in the very old. Definitive answers could be forthcoming from the ongoing Hypertension in the Very Elderly Trial.This is an open study, however, and it is unlikely that nursing home patients are included; patients confined to bed and those with dementia are excluded.RISKS OF PHARMA

Journal

Archives of Family MedicineAmerican Medical Association

Published: Apr 1, 2000

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