Blood pressure targets in the very old

Evidence review

Program objective

Balancing competing benefits and harms of elevated BP is therefore a challenge in the older elderly population, especially for those with mild elevations in BP or comorbidities, or for those who are frail. In view of this, we set out to gain consensus within our team on appropriate BP targets and target ranges in our very old, often frail GDH patients and to develop a tool that we could use to ensure that targets were individualized and used to guide interventions for hypertension management in this population. Ultimately, we hoped that using this tool would assist in reducing the use of medications known to increase BP and in increasing or decreasing doses of antihypertensive medications to maintain BP within an individualized optimal range.

Program description

Following the literature review and over the course of several meetings, the 3 GDH physicians and the pharmacist developed and achieved consensus on a draft set of BP targets and target ranges for those 80 years of age or older (eg, BP target < 150/80 mm Hg for those without comorbidities) and those 85 years of age or older. Input was provided by the GDH team nurses, as well as by 2 local external specialists known to the GDH physicians (ie, a cardiologist and a geriatrician) who informally reviewed the tool, commented on the team’s conclusions, and recommended adjustments be made for lower BP targets for patients with diabetes or those with kidney disease. The resulting tool included a series of instructions to follow as a patient progressed in the GDH program. A current version of the tool can be found at CFPlus.^*

Laminated copies of the tool were posted in high-traffic areas (ie, the charting room and the “chart cart” used during daily care-planning rounds) to ensure it was readily accessible for physicians and nursing staff who routinely monitored patients’ BP measurements. The team decided the tool should be used for the following circumstances:

• identifying and documenting a patient’s target BP during goal-setting rounds;

• documenting a patient’s BP measurements (from twice weekly measurements) during midpoint-review rounds;

• adjusting nonpharmacologic and pharmacotherapeutic management strategies for hypertension (typically after 5 to 7 readings, unless systolic BP is < 100 mm Hg, in which case 1 to 3 readings might suffice); and

• communicating the target BP, as well as the progress toward it, to patients (through medication charts given to patients seen by the team’s pharmacist) and to primary care providers (through GDH discharge summaries including a rationale for the BP target range).

We conducted an audit of the first 10 weeks (July 1 to September 15, 2011) of the tool’s use in the GDH. The objectives of the audit were to determine the following:

• if the tool was being used to consistently document target BP in patient care plans and medication charts;

• whether the BP target was being communicated to family physicians on discharge;

• whether the tool was being used to guide pharmacologic and nonpharmacologic changes to achieve BP targets; and

• whether users perceived the tool to be helpful.

An audit form was developed and used by a co-op pharmacy student to screen patients for eligibility (eg, preexisting diagnosis of hypertension) and capture relevant data. A guided small group discussion was held with 3 GDH physicians, the pharmacist, a nurse, and a local family physician to informally gather thoughts about whether the tool was allowing BP targets to be identified and communicated clearly. The group also discussed general barriers and perceived benefits of the tool.

Program evaluation

The results of the chart audit are outlined in Figure 1. We were not able to ascertain whether establishing a BP target was responsible for individual pharmacologic and nonpharmacologic interventions that occurred, as prescribers rarely re-stated the BP target when documenting rationale for interventions in the progress notes.

• Download figure
• Open in new tab

Figure 1.

Results of the chart audit used to screen patients for eligibility

BP—blood pressure.

Overall, the GDH physicians and staff found the BP target tool to be extremely useful in establishing consistent practices among the physicians and increasing prescriber confidence in reducing or stopping antihypertensive medications. All participants agreed that the 2011 Canadian Hypertension Education Program (CHEP)¹ guidelines were well known and adhered to; however, their applicability to patients older than 80 years of age, or those who were frail, was much less clear.

In order to reduce confusion, provide education, and improve primary care providers’ future adherence to the BP targets, it was suggested during the group feedback discussion that a standardized letter describing common issues and relevant literature surrounding hypertension management in the very old, in addition to stating the patient’s BP target, be attached to the discharge summary. It was also suggested that a similar letter be sent to the primary care provider after the first care-planning round in order to minimize the potential for conflicting hypertension management strategies between the GDH and the primary care provider during the course of the patient’s admission. While these suggestions were not subsequently incorporated into the process, the physicians have started including a paragraph in their discharge summaries outlining the rationale for the individualized BP targets. To improve continuity of care among health care providers and to foster patient self-management, it was suggested that the patients’ BP targets be written on all antihypertensive prescriptions and prescription labels.

Finally, it was suggested that the tool be simplified for easier use (eg, revising the tool’s BP target to a single target instead of 2 targets for patients with diabetes).