Feature Article
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The Prevalence and Treatment of Hypertension in Long-Term Care Settings: Implications for Quality of Care of the Frail Elderly This article reviews findings regarding the prevalence of hypertension and correlates of treatment among older nursing home residents and presents comparable data for a large sample of chronic hospital patients in the province of Ontario, Canada. Data from both populations suggest that those most vulnerable to potential undertreatment may include the very elderly, women, and those with cognitive and/or functional limitations. Low-dose thiazide diuretics appear to represent the preferred antihypertensive therapy for the frail elderly in long-term care. However, alternative therapy may be warranted for those who have a contraindication or are at greatest risk for experiencing adverse effects from diuretic therapy. Further research is needed to examine the relative benefits and risks of antihypertensive treatment in long-term care settings. (Annals of Long-Term Care: Clinical Care and Aging 2000;8[11]:31-36)
Background Hypertension is common in older individuals1,2 and is an important risk factor for cardiovascular morbidity and mortality.3,4 The treatment of hypertension in the elderly has been shown to be beneficial in a number of trials. These large randomized controlled trials, however, have included relatively healthy older individuals, generally between the ages of 60 and 84 years.5 The generalizability of recommendations regarding select antihypertensive agents for frail seniors and those older than 84 years of age is uncertain. In particular, little has been reported on hypertension in nursing home residents. Age-based exclusions in clinical trials of drug and other therapies for heart disease have resulted in an underrepresentation of older persons (women in particular) in research, and thus, a lack of evidence regarding the benefits and risks of such therapies among this population.6
The specific prevalence of hypertension among nursing home residents depends on how hypertension is defined. A recent study found that 29% of older nursing home residents (mean age, 84 years) had at least one elevated systolic blood pressure recording during a given day.7 On average, the highest blood pressure readings occurred before breakfast. Another study found that 32% of nursing home residents (mean age, 82.7 years) had a diagnosis of hypertension.8 A third study found that 44.2% of nursing home residents had either a diagnosis of hypertension or an elevated blood pressure when measured.9 Hypertension is seemingly more common among female nursing home residents than among male residents.7,8
Hypertensive nursing home residents typically have a number of comorbidities and consume multiple medications.7-9 Specifically, data suggest that approximately 65% of nursing home residents with hypertension have more than three comorbid medical conditions.8 Frequent comorbid conditions that may modify preferred therapy include coronary heart disease, congestive heart failure, cerebrovascular disease, diabetes, renal disease, dementia, and obstructive airway disease.7-9 Orthostatic hypotension is more common among hypertensive residents.7 Hypertensive residents of nursing homes typically are taking more than five medications daily.8,9 Studies to date have not clearly indicated whether hypertensive residents have a worse or a better prognosis than normotensive long-term care residents.
Among seniors, those residing in a nursing home and suffering from a severe dementia appear to be at greater risk for not receiving treatment for hypertension.10 Within nursing homes, it has been found that the relative odds of receiving treatment for hypertension are decreased with increases in age and the presence of severe impairments of physical and/or cognitive functioning. The consequences of this potential undertreatment are unknown because the relative benefits and risks of therapy have not been accurately determined. Increasing severity of dementia is associated with lower blood pressure, suggesting that there may be less need for therapy in residents with severe dementia.11
The most commonly prescribed agents for the treatment of hypertension in nursing home residents are calcium channel blockers, diuretics, and angiotensin-converting enzyme (ACE) inhibitors.7-9 One descriptive study suggested that diuretic use alone, or in combination with other agents, was more likely to be associated with normalized blood pressures and that successful antihypertensive therapy was associated with a lower prevalence of orthostatic hypotension.7
Therapy should be cautious and individualized, based on a consideration of the resident's concurrent diseases.5,12 Table I shows a summary of the influence of comorbidity on the choice of antihypertensive therapy derived from the 1999 Canadian Recommendations for the Management of Hypertension.5 Similar guidelines for the treatment of hypertensive patients with comorbid conditions are provided in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI).13 For older patients (60+) with uncomplicated hypertension, the Canadian guidelines recommend low-dose thiazide diuretics or long-acting dihydropyridine calcium channel blockers as preferred therapy. Although the JNC VI guidelines recommend thiazide diuretics or beta blockers in combination with thiazide diuretics as preferred agents for older hypertensive persons, the report also states that long-acting dihydropyridine calcium channel blockers may be considered in this population. A reasonable first-line drug for the treatment of uncomplicated hypertension in long-term care settings would be a low-dose thiazide diuretic.
Although diuretics are recommended as the preferred therapy for older hypertensive persons, it is also important to consider the potential risks of diuretic use in this population. Common adverse reactions that may lead to the withdrawal of diuretic therapy include dehydration, orthostatic hypotension, and electrolyte abnormalities.14 Dehydration is common among nursing home residents.15 If diuretics are used, the resident's fluid balance should be monitored carefully. Orthostatic hypotension occurs in more than half of frail, older nursing home residents16 and is a risk factor for both syncope and falls.17 When assessing orthostatic hypotension, drug therapy should always be reviewed as a potential contributing risk factor. Diuretics and other antihypertensives can cause or worsen postural drops in blood pressure. Supine and standing blood pressures should be routinely obtained in nursing home residents being treated for hypertension.
Interestingly, recent data suggest that diuretic therapy does not necessarily increase the risk of orthostatic hypotension16 or falls18 among nursing home residents. Among some diuretic users, there may be an increased risk of fluid and electrolyte abnormalities. Thus, pertinent laboratory tests such as serum potassium, glucose, creatinine, and urea assays should be done periodically when using a diuretic, especially in frail seniors, those with suspected or confirmed renal insufficiency, diabetics, and those who have previously developed electrolyte abnormalities. Less common adverse effects of diuretics leading to withdrawal would include urinary incontinence, gout, and glucose intolerance.14
Hypertension and Treatment in Chronic Care One of the most informative investigations of hypertension and treatment among U.S. nursing home residents to date is the study conducted by Gambassi et al,8 based on the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database. One component of SAGE is a computerized database comprised of longitudinal data on approximately 400,000 nursing home residents derived from the Minimum Data Set (MDS) instrument. The MDS, which forms part of the Resident Assessment Instrument,19 provides a standardized and comprehensive assessment of residents' functional, health, and psychosocial characteristics and has been federally mandated for use among all nursing homes in the United States for the last decade. Since July 1996, the MDS (version 2.0) has also been mandated for all patients occupying a chronic hospital bed in the province of Ontario, Canada.
We examined data available from the initial MDS 2.0 assessment for all chronic hospital patients age 65 years and above in Ontario (n = 23,655) between 1996 and 1998. Residents of chronic care hospitals in Canada would be comparable to those found in U.S. skilled nursing facilities. Our intent was to examine the consistency of findings regarding the prevalence of hypertension and correlates of treatment relative to those reported for nursing home residents in the SAGE database. Preliminary findings are presented in Table II and Figures 1 and 2. The mean age of the sample was 80.7 years (SD, 7.7), and 59.0% were women. Approximately 22% of the sample had an active diagnosis of hypertension, a value lower than that reported by the SAGE investigators, and about 29% were receiving diuretics.
Unfortunately, data regarding other antihypertensive drug use are not currently available since the Ontario MDS database, unlike the SAGE program, has not yet been linked to computerized drug data. A diagnosis of hypertension was more common among women and those aged 75-84 years (Figure 1). Diuretic use increased with age and, with the exception of those aged 85 years and above, was higher among women than men.
Comparable to the SAGE findings, our data showed a relatively high prevalence of comorbid conditions and polypharmacy (mean number of medications per resident, 7.7) among chronic care hospital patients, especially among hypertensive subjects (Table II). Among the total sample, the most common conditions included stroke (28%), heart disease and other cardiovascular conditions, dementia (26%), depression (21%), and diabetes (18%). With the exception of COPD, dementia, and depression, the chronic conditions listed in Table II were significantly more common among patients with hypertension.
Interestingly, as has been reported elsewhere, treatment with diuretics declined significantly with increasing cognitive impairment among patients with hypertension or congestive heart failure (Figure 2). Undertreatment of chronic heart failure with ACE inhibitors in nursing home patients has been found by other researchers.20 Although our finding appears to suggest potential treatment bias among older patients with moderate to severe cognitive impairment, the direction of this association is unclear, given the cross-sectional nature of our data. Preliminary data also suggest that diuretic use in older hypertensive patients may reduce the risk of dementia and cognitive decline.21 In any case, such findings as ours support the need for further large-scale longitudinal investigations among older persons (including those in long-term or chronic care settings) to examine the associations between hypertension, select therapeutic agents, and cognitive as well as other health outcomes.
Summary Preliminary results indicate that hypertension may be undertreated in the frail elderly. Such findings are of particular concern for older residents of nursing homes and chronic care hospitals. Other investigators have raised concern about the potential underuse of cardiac medications in the nursing home setting. Those most vulnerable to possible undertreatment may be the very elderly, women, and those with cognitive and/or functional impairments—that is, those typically underrepresented in randomized clinical trials of antihypertensive drugs.
Since effective and safe treatment with the various antihypertensive agents is often influenced by the presence of comorbid conditions, clinical decisions regarding treatment and ongoing management in older hypertensive patients should be individualized and cautious. We feel that, if pharmacologic therapy is deemed necessary, the drug of choice for older hypertensive patients in long-term care facilities is a low-dose thiazide diuretic. Research is urgently needed on hypertension and its treatment in this unique and vulnerable population.
Acknowledgments Dr. Maxwell's work is funded by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research, and she is a Fellow with the Institute of Health Economics in Edmonton, Alberta. Dr. Hogan is the holder of the Brenda Strafford Chair in Geriatric Medicine, University of Calgary. The Chair provides financial support to Drs. Maxwell and Hogan. Financial support has been provided to Dr. Hirdes by the Providence Centre Foundation.
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Drs. Maxwell and Hogan are with the Departments of Community Health Sciences and Medicine of the University of Calgary, Calgary, Alberta, Canada; Dr. Hogan is also with the Department of Clinical Neurosciences. Dr. Hirdes is with the Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario, Canada, and Director of the Canadian Collaborating Centre-interRAI, Providence Centre, Toronto, Ontario. Address for correspondence: Dr. Colleen Maxwell, Community Health Sciences, University of Calgary, Heritage Medical Research Bldg, 3330 Hospital Dr NW, Calgary, Alberta, Canada T2N 4N1. E-mail: maxwell@ucalgary.ca.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 11 - November 2000 |