Bruce M. is an 82-year-old patient with moderate dementia (Mini-Mental State Examination score of 12), recently admitted to long-term care following surgery for a hip fracture 6 weeks ago. Other relevant medical history includes coronary artery disease (myocardial infarction [MI] 10 years ago treated with angioplasty and stent), long-standing hypertension, stage 3 chronic kidney disease (estimated glomerular filtration rate of 40 mL/min), and benign prostatic hypertrophy. Medications include 10 mg of ramipril daily, 25 mg of hydrochlorothiazide daily, 50 mg of metoprolol twice daily, 10 mg of rosuvastatin daily, 81 mg of acetylsalicylic acid daily, 0.4 mg of controlled-release tamsulosin daily, 70 mg and 5600 IU of alendronate–vitamin D weekly, and 1000 mg of acetaminophen 3 times daily. The bisphosphonate–vitamin D pill and acetaminophen are the only new medications since his hip fracture.
The nursing staff report that Bruce appears to be light-headed and unsteady when he stands up to move with his walker. They are concerned that he will fall. Clinical data from the past week show blood pressure (BP) readings ranging from 130/84 to 118/60 mm Hg and a regular pulse of 54 to 70 beats/min. Apart from cognitive impairment and evidence of recent hip surgery, findings of his clinical examination are unremarkable, with no signs of heart failure and only a 5–mm Hg postural BP drop.
As the family physician providing ongoing care to Bruce, would you consider any changes in his medical management?
Bringing evidence to practice
Blood pressure targets in the elderly
Recent changes in the recommendations for BP targets in older adults have been the subject of considerable discussion. Variation among guidelines has resulted from evidence that aggressive BP lowering in older adults might lack benefit while increasing adverse event risk (Table 1).1–3 The Canadian Hypertension Education Program has proposed a revision of the recommendation for those older than 80 years of age with isolated systolic hypertension:
In the very elderly (age 80 years and older), who do not have diabetes or target organ damage, the [systolic BP] threshold for initiating drug therapy is ≥ 160 mm Hg and the BP target is < 150 mm Hg (Grade C).4
One trial (Hypertension in the Very Elderly Trial) has looked specifically at those aged 80 and older (Table 2).5 Although guidelines differ somewhat, BP targets are more aggressive for those with diabetes (Table 3).4–9 Individualize BP targets in older adults based on their frailty, comorbidities, life expectancy, and tolerability to medications.
Diastolic BP is also important. Recent guidelines caution against lowering diastolic BP to below 60 or 65 mm Hg when isolated systolic hypertension and established coronary artery disease are present, owing to concerns about myocardial ischemia.4,10 Diastolic BP below 65 mm Hg has been associated with an increased risk of stroke and cardiovascular events.11
Hypertension treat-to-target randomized controlled trials (mean age > 70 y)
Hypertension trials in the very elderly (age ≥ 80 y)
Comparison of guidelines for BP targets: BP targets in older adults should be individualized based on a person’s frailty, comorbid conditions, and tolerability of the medications and adverse effects. The optimal target for BP remains undetermined. Benefits of treatment including reduction in heart failure and death from stroke or any cause in people > 80 y (mean 84 y) have been demonstrated with a target SBP < 150 mm Hg.5
Pharmacotherapy considerations for hypertension in the elderly
β-Blockers are not necessarily indicated indefinitely following MI.12 Evidence is lacking to support use of β-blockers for more than 3 years after MI, unless there are other compelling indications (eg, heart failure, stable angina, atrial fibrillation).13 They are a less effective antihypertensive option in older adults. If a decision is made to discontinue a β-blocker, it is important to taper the dose gradually, by 25% to 50% every 1 to 2 weeks, to minimize withdrawal symptoms (eg, reflex tachycardia, angina, anxiety, and general malaise).
When combined with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), thiazide diuretics are often synergistic and lower doses are often effective.14 Many combination products (ACEI or ARB combined with thiazide diuretics) are available to lessen the pill burden for those who are stable on such 2-drug regimens.
Thiazide diuretics might lose their effectiveness in those with impaired renal function (creatinine clearance < 30 mL/min). Use in combination with furosemide is effective in those with a greater degree of chronic kidney disease.
Better trial evidence for benefit of thiazide diuretics has been shown with chlorthalidone and indapamide as opposed to hydrochlorothiazide.5,11,15 Chlorthalidone is about 1.5 to 2 times more potent at the same dose (in milligrams) as hydrochlorothiazide. Some would consider a switch to chlorthalidone; however, the availability of only a single scored 50-mg strength tablet is inconvenient if the lower 12.5-mg dose is needed.
Ramipril is often given at 10 mg daily as a result of the HOPE (Heart Outcomes Prevention Evaluation) trial.16 The HOPE trial compared 10 mg of ramipril daily at bedtime with placebo in a population at high cardiovascular risk (average age 55). This higher dose might be preferred if there is another compelling indication (eg, heart failure). However, a lower dose is more suitable for those experiencing falls, dizziness, or other possible adverse events.
Thiazides, ACEIs, ARBs, and calcium channel blockers are all reasonable options for older adults. All of these, and especially diuretics, can cause orthostatic hypotension. Caution is required with calcium channel blockers, as pedal edema is a common complaint, often unnecessarily treated with furosemide, leading to a “prescribing cascade.”
α-Blockers (also used for benign prostatic hypertrophy) might be particularly problematic in causing orthostatic hypotension.17,18 (See the RxFiles Q&A on Orthostatic Hypotension available from CFPlus.*)18
Nonhypertension-related options for those with recent history or risk of falls and fractures
Assess for and consider the deprescribing of other possible medications that can increase fall risk (eg, antipsychotics, sedatives, benign prostatic hypertrophy treatment, antihyperglycemics).19 Both the Beers and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) screening criteria are useful in identifying potentially problematic medications in the elderly.20,21
Implement nondrug measures to decrease the risk of falling (eg, removing area rugs, keeping walking area free of obstacles, ensuring adequate lighting, providing assistive devices for walking and transferring).
Ensure adequate vitamin D supplementation (eg, 800 to 2000 IU daily).22
Ensure adequate total calcium intake (1200 mg elemental calcium daily) from diet and supplements.22
Consider the role of a bisphosphonate for fracture prevention in high-risk individuals.22
Consider if hip protectors might be indicated to reduce fracture risk.23,24
Back to our case
Metoprolol was tapered from 50 mg twice daily to 25 mg twice daily for 2 weeks, with plans for a further reduction to 12.5 mg twice daily after an additional 2 weeks. Bruce was monitored for any symptoms of withdrawal such as reflex tachycardia or angina.
Hydrochlorothiazide was reduced to 12.5 mg daily and ramipril was reduced to 5 mg daily, with plans to reassess and switch to a combination product after 4 to 8 weeks if his BP were stable. A goal is set to avoid symptoms of hypotension, such as light-headedness, while managing hypertension with a target BP of below 150/90 mm Hg.
Tamsulosin was continued because Bruce’s family perceived it to be valuable; however, if Bruce continues to have light-headedness, it might be discontinued.
Further relaxing of BP targets and reduction in antihypertensive medication use might be considered if Bruce continues to have symptoms of hypotension or adverse effects from antihypertensive medications. Patient safety, quality of life, life expectancy, time-to-benefit from therapy, and overall pill burden are valid considerations in contextualizing guideline recommendations in older adults with increasing frailty. It is important to be alert for, and avoid, a potential prescribing cascade where a drug is added to counteract or treat the side effect of another drug.
Footnotes
This article is eligible for Mainpro-M1 credits.
To earn credits, go to www.cfp.ca and click on the Mainpro link.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mai 2014 à la page e254.
↵* The RxFiles Q&A on Orthostatic Hypotension is available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.
Competing interests
RxFiles and contributing authors do not have any commercial competing interests. RxFiles Academic Detailing Program is funded through a grant from Saskatchewan Health to Saskatoon Health Region; additional “not for profit; not for loss” revenue is obtained from sales of books and online subscriptions.
- Copyright© the College of Family Physicians of Canada
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