Date of Award

7-20-2023

Document Type

Dissertation

Degree Name

Doctor of Medical Science (DMSc)

Department

Department of Physician Assistant Medicine

First Advisor

Asa Di Carlo, PA-S

Second Advisor

Elizabeth Uptown, PA-C

Third Advisor

Justin Gambini, DMSc, PA-C, DFAAPA

Abstract

PURPOSE:

The primary purpose of this paper is to review the current available evidence on benefits and risks of intensive blood pressure control (< 120 mmHg systolic) in the greater than 75-year-old population. The secondary purpose will focus on discussion of general recommendations for blood pressure treatment in non-diabetics in this population.

METHOD:

A PubMed and NEJM literature search was directed towards search terms: hypertension, intensive, standard, older, and elderly, as well as search terms surrounding risk: adverse event, fall, fracture, syncope, AKI, and mortality. Fourteen articles are used for the basis of this paper, six of which are large scale RCTs.

RESULTS:

Though there has been a general lack of consensus on appropriate hypertensive management in the elderly, data has increasingly shown that lower blood pressure goals continue to demonstrate benefits on cardiovascular and cerebrovascular morbidity and mortality, as well as all-cause mortality in populations greater than 75 years old. However, with intensive management comes the concern for risk of morbidity from falls, syncope, AKI, cognitive decline and other laboratory aberrations, which impact patients of this population more severely. These risks are proven to be present with all levels of blood pressure management, and when comparing standard to intensive blood pressure goals, neither the frequency nor the severity of these risks seem to rise with more aggressive treatment. Simply, the intensive blood pressure target demonstrates continued benefits across a spectrum of morbidity and mortality causes, while the frequency of adverse events appears to plateau early. However, most of the trials focused on this cohort excluded some major comorbidities, including diabetes, prior stroke, and residence in a care facility. Intensive blood pressure targets are appropriate for ambulatory patients over the age of 75, but discussion of the risks and benefits should be weighed on a case-by-case basis and tailored to individual patient comorbidities and values.

CONCLUSION: Overall, intensive blood pressure management should be considered in patients greater than 75 years old in order to mitigate morbidity and mortality associated with hypertension. Shared decision-making conversations and recommendations should be made with patients individually based on comorbidities, symptoms, and personal values.

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