My Dad has lived with us for two years ever since Mom died. He’s 87 now and has become more and more disabled due to recurrent strokes. Is there a better way to control his hypertension? He’s on 3 medicines and his blood pressure is still over 160. His doctor is suggesting another medicine. I’m very worried because he needs help walking. His pressure drops below 95 when he stands up. He gets dizzy and he falls a lot. I think it’s because of his meds.
What is the best blood pressure for this person? The above situation is common and challenging. In my last post I discussed the benefits of treating hypertension in seniors. But treatment can also cause problems. In some patients medicines are added but the hypertension persists. Also, the blood pressure can fall dramatically when a person stands up (orthostatic hypotension).
The treatment of hypertension in patients like this is controversial. Physicians disagree on approaches. In the worst-case scenario different doctors start, stop and restart medicines. (Does this sound familiar?)
Physicians disagree because there are three problems, not one. Providers differ on which problem is the most important. The problems are:
- Hypertension increases the risk of disease, disability, and death.
- Orthostatic hypotension also increases the risk of disease, disability, and death. Medicines can increase the risk of hypotension and other adverse effects.
- The man described is frail. Few studies explore the risks and benefits in these patients.
Problem 1: Hypertension
Why is it important to treat?
Isolated systolic hypertension is the most common type of hypertension among seniors. It means a systolic pressure of at least 160 mm with a normal or low diastolic blood pressure less than 80 mm. As discussed in the last post, isolated systolic hypertension is harmful at all ages. This includes people age 85 and over. Medications lower the blood pressure. The risk of stroke, cardiovascular disease, and death decreases. Some experts recommend a systolic blood pressure less than 140 mm.
Problem 2: Orthostatic Hypotension
How serious of a problem is it?
Orthostatic hypotension means that the systolic blood pressure falls by 20 or more points when a person stands up. In the man described the fall in blood pressure is severe, falling below 100 mm. The patient feels lightheaded when he stands up due to the fall in pressure. This increases his risk for falling. Orthostatic hypotension is linked to cognitive decline, stroke, and death.
Orthostatic hypotension occurs for several reasons. Diabetics often have difficulty maintaining blood pressure when standing. The circulatory system does not adjust to the change in position. This is also true of people with neurologic diseases such as Parkinson’s.
In seniors, the major arteries are stiff. The vessels do not expand when blood is pushed through. When the heart relaxes between beats, the vessels do not compress. The result is both elevated systolic pressure and depressed diastolic pressure. The problem is worse when a person stands up. Blood vessels do not adjust to the change in position and the pressure falls. Orthostatic hypotension occurs in 20% of seniors with hypertension. My expertise is in the care of frail elderly patients. In these patients the problem is even more common. There are severe drops in blood pressure when standing up.
In the man described, medicines are used to control his hypertension. They are also likely to contribute to orthostatic hypotension. More medicine may control his blood pressure better but make his hypotension worse. Less medicine may improve his hypotension but make his hypertension more severe.
Problem 3: Frailty
What difference does that make?
Most seniors become frail late in life. The body does not defend itself well when an adverse event or illness occurs. At this point in life, many medications have less benefit and more risk. Drug studies rarely involve these people. Will more medicine stabilize an already damaged circulatory system? Or will the medicine result in more harm than good?
Disease management recommendations change. An example of this is Diabetes. Tight control of diabetes does not improve nor prolong life in these patients. There is wide consensus that seniors are often overtreated. The result is an increased risk of low blood sugars.
In a future post I will discuss frailty. We can do our best to delay it. But it is a chapter in life that most seniors will face. In frailty it is more important than ever to care for the person as well as the disease.
A standing blood pressure of 95 mm systolic is unacceptable in a frail elderly person. What happens next?
Some providers emphasize the benefit of treating systolic hypertension. They prefer continuing or adding medicine. They are likely to recommend other measures to manage the drop in blood pressure. Other providers emphasize the harm of hypotension. They are likely to recommend a trial of less medication. The systolic blood pressure is allowed to remain above 160 mm.
The right answer for this older man starts with the question: What matters to him and to loved ones? We do not know that better blood pressure control will prolong life. When patients are frail, they are prone to many end-of-life events. Optimal control of blood pressure is unlikely to be the key factor. What matters most in the time that is left? Here is a partial list of factors to consider:
- A lower blood pressure may reduce the risk of another stroke. This could be important to a person who is still able to walk with help. Another stroke may result in inability to walk and/or nursing home placement.
- Orthostatic hypotension has an impact on daily life. A person with recurrent falls is at high risk in any social situation or in traveling. Are outings important in the quality of life?
- Polypharmacy means that a patient is taking many medicines regularly. Medicines can result in adverse side effects, drug interactions and loss of appetite.
In otherwise healthy older adults, a systolic blood pressure below 160 mm is important.
In frail elderly patients the target systolic blood pressure is much more controversial.
The combination of systolic hypertension and orthostatic hypotension is common among older adults.
There is no clear best way to manage a patient such as the one described. A decision should be based on what matters most to him and to loved ones.
See these sites for more information:
Please let me know if you have questions.
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.