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Blood Pressure Drugs & the Elderly - 3

Summary:


  • If you are elderly - you made it! That means you have enjoyed a long life.

  • Lowering blood pressure in the elderly has little impact on vascular mortality.

  • The risk of an adverse event can be reduced by taking better care of your teeth and gums.

  • Finding studies to support eliminating blood pressure meds are hard to find.


 

Here are two case studies.


  1. My own father was on blood pressure medications and had dementia. In his state he needed adequate blood pressure to support his deteriorating brain. One night he got out to use the bathroom. In his confusion, he took a "right" at the top of the stairs rather than a "left" into the bathroom. He fell down the stairs and slammed his head into the door at the bottom. My mother had managed to care for him at home, but after this fall, his confusion and violence increased dramatically. She had no choice but to put him in a care facility (VA). He was dead in 1 month.

  2. A client had diabetes as was put on what I call the circle of drugs, statins, insulin, metformin, and blood pressure medications. He told me he didn't even have high blood pressure. However, these scripts are the standard of care that protects doctors. We eventually got him off all the drugs. This took 9 months. When he had his next checkup with his on-site clinic doctor (who I at one point respected) he was put back on all meds because his A1C was "high." However, his glucose, fasting insulin, lipids, and triglycerides all were significantly reduced and he was no longer considered diabetic. I recommended he no longer use the on-site doctor and switch to Dr. Austin, which he did. My wellness contract with the company was NOT renewed. An insider told me that the reason was my referral of participants away from the on-site clinic.


Summary of the cases:

  1. Dad's confusion was exacerbated by the BP meds, leading to his sudden death.

  2. The client did NOT have high blood pressure but was put on the drug anyway. (Why did he cede to this recommendation - doctors put pressure on patients to take polypharma). He retired shortly thereafter and kept in touch with me. His daily state of wellbeing significantly improved off of the polypharma.


 

The elderly make up of majority of the population on BP drugs. However, they are ubiquitous across all ages. Here are a couple of studies that suggest the elderly are NOT in need of BP drugs most of the time.



Key results

  • We found that stopping antihypertensive medications is possible in older adults.

  • Most of the older people in the discontinuation groups did not need to restart their medication.


We found low certainty of evidence that stopping antihypertensive medication increased blood pressure by a small amount.


We found low or very low certainty of evidence that stopping blood pressure medications did not increase the risk of having a heart attack, stroke, hospitalization, or death.


We found very low certainty of evidence that stopping blood pressure medications did not increase the risk of adverse events and may resolve side effects, but this was not reported well, and so we were unable to draw conclusions.


Certainty of the evidence

We rated the certainty of the evidence using four levels: very low, low, moderate, or high. High certainty evidence means that we are very confident in the results. Very low certainty evidence means that we are very uncertain about the results. We judged the certainty of evidence as very low and low.


Conclusion

It may be safe to stop antihypertensive medications in older people who are taking the medication for high blood pressure or primary prevention of heart disease.

 

Have you had any concerns about an older person falling, or being at risk for a broken hip?


A new clinical research study relevant to millions of older adults was just featured in the news.


The study, completed by a team of geriatrics researchers at Yale, found that in older adults aged 70 or older, taking blood pressure medication was linked to a higher risk of serious falls. (Serious falls as in, falls that caused an ER visit for a fracture, a dislocated joint, or a brain bleed. Serious stuff indeed!)


So, if the person you care for has a diagnosis of hypertension, and if you’ve had any concerns regarding falls or near-falls, these study results should be of interest to you.

In this post, I’ll review the key results of this study. Then I’ll tell you what I think are the most important practical take-aways for family caregivers.


This post will also include some practical tips to help you minimize the risk of your loved one experiencing a serious fall.


Key results of the high blood pressure medications and falls study.


One of the many good things about the study is that it used the Medicare records of a “real-world” group of 4961 people aged 70 or older.  (This is important because many clinical trials of BP medication are done with patients recruited specifically for the study; there are advantages to this but it means that often patients in clinical trials are healthier than the aging adults that you and I are caring for.)


To be included in this “real-world” study, the patients had to have a diagosis of high blood pressure, they had to be living at home or in assisted-living, and they had to be in Medicare fee-for-service (no Medicare Advantage patients).

The researchers then examined three years worth of these patients’ Medicare records. Here’s what they found:

  • Overall, 9% of these older people experienced a serious fall injury.

  • When people were classified based on how much BP medication they were taking, the percentages of aging adults having a serious fall within 3 years were:

  • No medication: 7.5%

  • Moderate-intensity BP medication: 9.8%

  • High-intensity BP medication: 8.2%


Next the researchers used some statistical adjustments, to compare older adults with similar levels of illness burden. (It’s important to do this adjustment, because otherwise it could be that some people have no BP medication because they are so sick and frail that doctors have stopped their medications.) In this adjusted group, the percentages of older adults having a serious fall over 3 years were:

  • No medication: 7.1%

  • Moderate-intensity BP medication: 8.6%

  • High-intensity BP medication: 8.5%


The researchers also found that in those people who’d had a serious fall injury within the previous year, being on BP medication was linked to an especially high chance of another serious fall.


What you should take away from this study

I consider this study very important, because most clinical research focuses on benefits of medication, rather than studying the potential harms and downsides of medication. It’s probably not a coincidence that the main author is a geriatrician; we tend to feel that a little goes a long way when it comes to medications in aging adults!


Key take-aways for family caregivers:

  • Serious falls are a fair possibility in all older adults aged 70+. Over 3 years, 9% of these Medicare patients had a fall involving a fracture, a dislocation, or a brain bleed. It’s probably reasonable for you to assume that your loved one has at least a roughly 10% chance of a serious fall within a few years. This risk is higher if your loved one has already had a serious fall.

  • Consider learning practical approaches to reducing fall risk in your loved one. Along with learning to be careful with medications, there is lots more that you can do! Visit our fall prevention topic page to see all our articles on this topic.

  • Consider a plan or system to call for help in the event of a fall. This is especially important for those independent older adults who live alone! Last year I saw a patient who lay at home with a broken hip for 2 days before he was found 🙁

  • Home sensors and/or a personal emergency response system can help alert a care circle when an older person falls.


  • Being on blood pressure (BP) medication raises the risk of a serious fall. This doesn’t mean your loved one shouldn’t take any medication for high BP. But it does mean that you should be thoughtful about weighing the benefits and the risks, and you probably want to aim for the lowest doses possible.  In my experience, regular doctors tend to not think of the risks of BP medications in aging adults. So here are some specific things YOU can do:

  • Be careful if your loved one’s BP is often below the new recommended target of 150/90. Read “What the New Blood Pressure Guidelines Mean for Older Adults” for more info.

  • Ask the doctors to help you understand how much benefit to expect from the BP treatment. Note that often the expected chance of benefit (e.g. avoiding a stroke or heart attack) is about the same as the risk of harm that was found in this research study.


Lewis: Don't expect an answer other than "take the damn BP meds and stop bothering me!"


  • Seniors who’ve had a previous serious fall are at extra high risk. Be extra careful about blood pressure and over-treatment if your loved one has already had a serious fall. These are the older adults for whom it’s most important to make sure that they aren’t on more medication than is absolutely necessary.

  • Know that in general, the most benefit from treating high blood pressure in seniors comes from getting a systolic blood pressure (SBP; that’s the top number that a monitor reports) from 170 or higher, down to 140s-150s.

  • Once elderly people are treated to a SBP below 140, the chance of harm can easily become bigger than the chance of benefit.

  • Get a home blood pressure machine if you’re concerned about falls and your loved one is on medication. Don’t just leave it to the doctors to monitor things and take action. When properly done, home BP measurements can be more accurate than occasional office measurements, and can lead to better care.




 

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