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Care of the Aging Patient: From Evidence to Action
July 14, 2015

Polypharmacy in the Aging PatientManagement of Hypertension in Octogenarians

Author Affiliations
  • 1Department of Geriatrics and FHU-CARTAGE, CHU de Nancy, Université de Lorraine, Nancy, France
  • 2Centre d’Investigations Cliniques Plurithématique 1433-Inserm CHU de Nancy, Université de Loraine, Nancy, France
  • 3INI-CRCT (F-CRIN network), Nancy, France
  • 4Geriatria ed Accettazione Geriatrica d’Urgenza, IRCCS-INRCA, Ancona, Italy
  • 5Department of Internal Medicine and Geriatrics, Jagiellonian University, Cracow, Poland
  • 6Brighton and Sussex Medical School, Brighton, United Kingdom
  • 7Department of Geriatrics, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
  • 8Institute of Health Sciences/Geriatrics, University of Oulu, Oulu, Finland
  • 9Department of Geriatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
JAMA. 2015;314(2):170-180. doi:10.1001/jama.2015.7517
Abstract

Importance  Hypertension treatment is beneficial for most hypertensive patients. The benefits for patients who are very old and frail, especially those taking numerous medications, are less certain.

Objective  To provide recommendations for the evaluation and treatment of hypertension among patients aged 80 years and older.

Evidence Acquisition  MEDLINE, PubMed Central, and the Cochrane Database of Systematic Reviews were searched from inception through April 2015, with an emphasis on 2010-2015. Manual cross-referencing of review articles and meta-analyses was also performed to identify randomized controlled trials (RCTs) examining antihypertensive use in octogenarians. The search strategy included the following Medical Subject Headings: hypertension or high blood pressure and trials and oldest old or very old or very elderly.

Findings  Six post hoc analyses of the previously published Hypertension in the Very Elderly Trial (HYVET) met the inclusion criteria. In the only placebo-controlled RCT on hypertension management in patients older than 80 years (HYVET; N = 3845), the treatment was associated with lower total mortality and key cardiovascular end points but the effect on stroke (fatal and nonfatal), which was the primary outcome, failed to reach the significance level (P = .06). Post hoc analyses of HYVET suggested that active hypertension treatment in very elderly patients was beneficial by reducing blood pressure in individuals with white coat hypertension, showed moderate benefits of the active treatment for cognition, a possible effect for fractures prevention, and sustained differences in reductions of total mortality and cardiovascular mortality in those receiving active treatment. However, patients were community dwelling and less disabled than individuals of the same age in general.

Conclusions and Relevance  Hypertensive patients who are healthy, functionally independent, and aged 80 years and older should be treated according to current recommendations for people older than 65 years. There is insufficient evidence regarding the benefits of hypertension treatment for frail polymedicated octogenarians, for whom treatment should be individualized.

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