One of my patients, a woman in her late 80s, has required 4 drugs at high doses for many years to keep her systolic blood pressure under 160 mm Hg. Over a 3-month period earlier this year, she went from 4 drugs to 1, with her systolic blood pressure now under 140 mm Hg. She and her family are ecstatic; I, less so.
It has been known for many years that decreasing blood pressure in the elderly is a bad sign, unless related to more aggressive treatment.1 Decreases in blood pressure are a component of the so-called terminal decline, a constellation of signs and symptoms including decreases in activity, weight, cognition, and psychological outlook that often occur in the year or 2 before death, particularly death in very old age.2 Of these, blood pressure is the most noticeable, because it is numerical, frequently measured, and valued by patients and physicians. Weight loss is also a bad sign.3 We have all encountered octogenarian patients proud of finally shedding that excess 20 pounds after 50 years of failed attempts. Once again, not a good sign.