There has been a ton of talk about the need to deprescribe medications in older adults. Many of these medications are associated with significant risk with very little benefit. The Bruyere team have developed some great deprescribing guidelines for:
- Proton pump inhibitors
- Antihyperglycemic agents
- Antipsychotic agents
- Benzodiazepine receptor agonists
- Cholinesterase inhibitors and memantine
These guideline are all free online at their website: Deprescribe.org. These guidelines are excellent and there are multiple videos that demonstrate how they can be integrated.
What about Antihypertensive Medications?
In older versions of the Hypertension Canada guidelines recommended that older adults have a systolic blood pressure target of < 150 mmHg. This has changed in the latest version of the guidelines which promote the same blood pressure targets for older adults as for younger adults. They state:
- “Consistent with the changes made to section II (Indications for drug therapy for adults with hypertension without compelling indications for specific agents), we have removed the previous guidelines for different BP goals for the elderly. Evidence suggests that older patients with hypertension similarly benefit from intensive BP reduction as younger adults.”`
They now recommend for most older adults to have a blood pressure target of <140/90 mmHg.
Lower BP may be Better for People over 80 years?
The Systolic Blood Pressure Intervention Trial (SPRINT) trial set a blood pressure target of a systolic blood pressure of < 120 mmHg versus a standard target of < 140/90 mmHg. A new sub-analysis of the SPRINT trial evaluated the effects of this lower target in people 80 years of age and older. The study can be found at:
This trial demonstrated some key advantages with this lower blood pressure target (SBP<120 mmHg):
- 44% risk reduction in cardiovascular events (hazard ratio [HR] = .66; 95%confidence interval [CI] = .49-.90)
- 33% risk reduction in mortality (HR = .67; 95%CI = .48-.93)
- 30% risk reduction in mild cognitive impairment (HR = .70; 95% CI = .51-.96)
They found some interesting facts that may help for selecting this lower target:
- The patients with higher cognitive function (measured by Montreal Cognitive Assessment -MOCA) derived a significant benefit for the composite of CVD and mortality
- The benefits were less appreciable in people with more significant cognitive impairment
- Gait speed (a measure of frailty) did not effect the treatment effect
- Lower BP did not increase the rate of injurous falls
- There was a higher rate of acute kidney injury and decline in renal function (≥ 30% decrease in eGFR)
What does this mean for practice?
- The benefits of lower blood pressure continues in older adluts
- Lower blood pressure has multiple benefits on CV outcomes and cognitive impairment.
- The benefits are most seen in patients without significant cognitive impairment.
- Frailty does not seem to influence the results
- Falls did not increase in the group with lower BP
- Renal function should be monitored regularly with the intensive targets
Fundamentally, if you have an older adult who has good cognitive function a blood pressure target of a systolic blood pressure < 120 mmHg may lower his/her risk of serious adverse outcomes