COMMENTARY

Hypertension in Frail, Elderly Patients: Treating the Individual, not the Stereotype

Henry R. Black, MD; Barry J. Materson, MD, MBA

Disclosures

May 10, 2016

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Editor's Note:
In this latest discussion in the Black on Cardiology series, Henry R. Black, MD, speaks with Barry J. Materson, MD, MBA, a nephrologist, American Society of Hypertension-certified specialist in clinical hypertension, and senior professor of medicine at the University of Miami.

Dr Black: Hi. I'm Dr Henry Black, an adjunct professor of medicine at the Langone New York University School of Medicine. I'm here today with my friend, Dr Barry Materson. Barry, welcome.

Dr Materson: Thank you very much, Henry. I'm a senior professor of medicine at the University of Miami Miller School of Medicine. Today, we are going to talk about hypertension in the frail elderly.

Defining Frailty

Dr Black: What do you mean by "frail"?

Dr Materson: That's an interesting question. The answer is that nobody has agreed upon a definition as yet. There is actually an international meeting planned to try and answer this question.

For the clinician, though, the important thing is the 5-point definition elaborated by Fried and colleagues[1] that [identifies it as] unintentional weight loss of 10% or more in the past year, self-reported exhaustion, weakness as measured by grip strength, low physical activity, and slow walking speed. I'll describe those in greater detail momentarily. However, it's a syndrome, and an individual is deemed frail if three out of the five elements are present.

Our gerontologists at the University of Miami use a frailty score developed by Morley and colleagues,[2] which was published in the Journal of Nutritional Health and Aging in 2012. This is a 5-item questionnaire based on the work of Fried and colleagues, but offers a little more detail. For example:

  1. To determine fatigue, patients should be asked how much of the time during the past 4 weeks they have felt tired.

  2. For resistance, ask the individual whether they have any difficulty walking up 10 steps without using any aids.

  3. For ambulation, ask whether the patient has any difficulty walking several hundred yards without aids.

  4. For illnesses, ask whether a doctor has ever told the patient that one of numerous disorders is present: hypertension, diabetes, cancer, chronic lung disease, heart attack, heart failure, angina, asthma, arthritis, stroke, or kidney disease. Remember, you need three out of five, so that question is probably going to get everybody.

  5. And finally, for weight loss, ask, "Have you lost more than 10 pounds in the past year without trying to do so?"

That generates a score, which any clinician can do in his or her office. Our gerontologists have actually reduced this, based on Morley and colleagues' work, to a simple questionnaire that can be filled out and scored.

One of the other assessments for frailty is gait testing, which a clinician can very easily do in his or her office. Find a corridor where the patient is not going to get trampled, and mark off 20 feet with tape at both ends—preferably bright-colored tape that the patient is not going to miss. Have the patient walk at their usual speed, and time it with a stopwatch. Everybody's smartphone has a stopwatch; even my "dumb phone" has one. You can time it that way. If it takes more than 7.5 seconds to walk that 20 feet, then your patient may very well be frail.

This has importance clinically, because the healthy (also termed "robust") elderly actually did very well. Clinical trialists, like Henry and I, have to use cut-offs in order to make statistical sense out of the trials. The general terms used to describe those 60-79 years of age is "elderly," and those 80 years and above are termed "very old." A lot of people listening to this are probably already angry, but those are the definitions.

The government uses all kinds of definitions for the elderly—especially the Internal Revenue Service, who require that an individual take a minimum distribution at age 70.5 years. An employer may use chronological age for pension plans and things like that. The clinician should not use the chronological age of the patient as the sole determinant of what they are going to do with patients, because robust patients, irrespective of their age, are likely to do quite well.

Pivotal Trials

Dr Materson: The Hypertension in the Very Elderly Trial[3] has been criticized because only approximately 80 out of the [almost 4000] patients were Western European, with the rest Eastern European and Chinese; however, [these patients] are all human. The results were very good in terms of lowering blood pressure and very effective in terms of reducing the adverse effects of hypertension, with which we are all familiar.

The Systolic Blood Pressure Intervention Trial[4] (SPRINT) subdivided their population and looked at those 75 years and older, and also showed benefit from reducing blood pressure, even to the lower tier of a systolic pressure of ≤ 120 mm Hg.

You have to be very careful, because SPRINT and all of these clinical studies deal with patients who were healthy enough to come to the clinic. They are not being wheeled in on stretchers or coming by ambulance.

The other thing to consider with SPRINT is that blood pressure was determined in a way that probably very few of us use. The patient was put in a room alone—there are no observers— and they were hooked up to an automated device; seated properly; and positioned properly according to the American Heart Association and Seventh Report of the Joint National Committee (JNC 7) criteria, with their back supported, feet on the floor, and so forth. The machine then measured sequential blood pressures. We do not generally do that with our patients, so you have to keep in mind that the SPRINT investigators used a much more ideal system.

What happens with people who are definably frail? For example, those in nursing homes do not do well when you lower their blood pressure, especially if you treat them with combination medications. Any combination medication ought to be used very carefully in nursing home patients or very frail patients. As many of you know, I've been a champion of combination medications—but not in this group, because if you lower the blood pressure too much, they do get into difficulty.

Community-based frail people are a somewhat different story. You can treat them, but you need to be very careful and you need to individualize that treatment. People worry about orthostatic hypotension from the antihypertensive drugs, but that's not really the problem. The problem is the psychotropic drugs that many of these people take. Psychotropic drugs definitely are associated with a risk for orthostatic hypotension and falls.

Individualizing Treatment Options

Dr Black: One of the things I didn't hear you mention was the issue of depression. Many of the things that people seem to have sound like depression. Do we use the same criteria for depression in frail elderly or older people as we would use in younger people?

Dr Materson: I'm hardly an expert in that field, and so I don't even treat these patients for depression. I refer them on to our psychiatrists or psychologists and let them treat with the drugs that may be needed. Then I work around those drugs with the antihypertensives that the patients need.

Yes, many of the patients whom I have seen are depressed; however, what is much more common is anxiety. I see a huge amount of anxiety-driven blood pressure elevation, which does not respond to treatment with antihypertensive drugs. These people need anxiolytic drugs, and psychiatrists and psychologists who are familiar with that can be very helpful in the care of your patients.

Dr Black: Do you see any particular pharmacologic or nonpharmacologic approaches to this problem in the frail elderly, or are we just going to have to use what we have and do so correctly?

Dr Materson: We need to use what we have correctly. There have been some studies that have suggested that certain drugs are "matchable" to certain groups of people. I'm not going to try to replicate that information here, because I do not know whether any of that is going to stand up on further investigation.

The point is that diuretics are amazingly helpful in this population, but have to be used carefully. Again, if you are going to combine them with another drug, caution is indicated to avoid orthostatic hypotension, hypokalemia, and hyponatremia, which are all a risk in these patients. Usually these complications do not occur with a low dose, and they are not terribly common. Calcium antagonists are very helpful. Beta-blockers generally are not, but there are patients who have atrial fibrillation who may benefit from the heart rate-slowing effects of anti–beta-adrenergic agents.

The choices have to be very carefully individualized. There is no single drug that is going to solve this problem for everyone.

Promoting Independent Living

Dr Black: If you are taking care of a patient whom you suspect ought to be called "frail," do you recommend that they go to an extended care facility or move out of their home if they live by themselves?

Dr Materson: No, because this has to be individualized. One of the things that I have been involved with that is quite interesting is a project based out of Seaside, Florida. It [promotes] living in home with grace and encouraging people to refit their homes (changing the size of entryways, putting up rails, safety bathtubs and showers, toilets reconfigured), so that they can remain there. Survey data show that about 70% of people who are aging wish to remain in the house in which they are living[5]; they don't want to move out. It depends on the extended care facility, because some people are very happy there and some people are not. Again, you must individualize that very carefully with the patient, the patient's family, and the patient's primary care physician.

Dr Black: What I think you are saying is that the majority of individuals who fit into this category, who are living by themselves at home, can stay there if they make some important adjustments to their physical space. Do I have that right?

Dr Materson: That is correct. The statistics show that this population is growing hugely and rapidly, and we are going to have a lot more people in this situation. Most of them are pretty robust. They may have the usual diseases that all of us see, but that does not mean they are necessarily bound for nursing homes, extended care facilities, or any kind of special assisted living facilities. So we shouldn't condemn them to that.

I recently did a preoperative exam on a 91-year-old patient coming to surgery for the first time in his life. This man was extraordinarily healthy except for the relatively minor bit of surgery that he had to have. Another 91-year-old patient was running 10 miles a day and complained he wanted a cardiac cath (catheterization) because he was finding he could only run 8 miles a day. He actually found somebody that did a cardiac cath on him, and his coronaries were quite clean. If some of you caught the news, there was a 106-year-old lady who was dancing about in the White House just a few days ago.

There are many examples of functioning elderly who have the ability to do their activities of daily living, have their cognitive skills, are able to take the medications that they need, can follow directions, and keep their appointments. In those people, we have to appreciate that even though they cross this mark of 80 years, we do not stop treating them if the treatment at age 79 and nine-tenths years is successful.

Dr Black: You have hit on a very important topic, one that is going to get more and more important as we all collectively age. Hopefully, we can age gracefully and be robust as long as possible.

Barry, I'd like to thank you very much. It's been a pleasure as usual to talk with you.

Dr Materson: Thank you, Henry.

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