High blood pressure and its treatment in the very old: balancing benefits and risks

Abstract

The combined processes of ageing, multimorbidity, and concomitant polypharmacy challenge us not so much regarding whether to treat high blood pressure in the very old, but rather how strictly it should be treated. This thesis investigates the benefits and risks associated with high blood pressure and its treatment in the very old, including whether an elevation in blood pressure by discontinuing antihypertensive treatment has any beneficial effects on older adults with physical and cognitive impairments. The results in this thesis confirm that low blood pressure in the very old is a marker of decreased life expectancy, particularly among those with physical and cognitive impairments. However, in nursing home residents with dementia, the elevation of blood pressure following the discontinuation of antihypertensive treatment was associated with an increased risk of adverse outcomes and an implausible chance of any health gain. Therefore, we strongly advise against the proactive discontinuation of antihypertensive treatment in older adults with dementia and consider this a reactive strategy to an adverse clinical trigger. Since nursing home residents with dementia represent only a subset of the heterogeneous population of frail older adults, further research will need to clarify who may benefit from more relaxed blood pressure targets.