Polypharmacy in the Aging Patient: Management of Hypertension in Octogenarians

IMPORTANCE: Hypertension treatment is beneficial for most hypertensive patients. The benefits for patients who are very old and frail, especially those taking numerous medications, are less certain. OBJECTIVE: To provide recommendations for the evaluation and treatment of hypertension among patients aged 80 years and older. EVIDENCE ACQUISITION: MEDLINE, PubMed Central, and the Cochrane Database of Systematic Reviews were searched from inception through April 2015, with an emphasis on 2010-2015. Manual cross-referencing of review articles and meta-analyses was also performed to identify randomized controlled trials (RCTs) examining antihypertensive use in octogenarians. The search strategy included the following Medical Subject Headings: hypertension or high blood pressure and trials and oldest old or very old or very elderly. FINDINGS: Six post hoc analyses of the previously published Hypertension in the Very Elderly Trial (HYVET) met the inclusion criteria. In the only placebo-controlled RCT on hypertension management in patients older than 80 years (HYVET; N = 3845), the treatment was associated with lower total mortality and key cardiovascular end points but the effect on stroke (fatal and nonfatal), which was the primary outcome, failed to reach the significance level (P = .06). Post hoc analyses of HYVET suggested that active hypertension treatment in very elderly patients was beneficial by reducing blood pressure in individuals with white coat hypertension, showed moderate benefits of the active treatment for cognition, a possible effect for fractures prevention, and sustained differences in reductions of total mortality and cardiovascular mortality in those receiving active treatment. However, patients were community dwelling and less disabled than individuals of the same age in general. CONCLUSIONS AND RELEVANCE: Hypertensive patients who are healthy, functionally independent, and aged 80 years and older should be treated according to current recommendations for people older than 65 years. There is insufficient evidence regarding the benefits of hypertension treatment for frail polymedicated octogenarians, for whom treatment should be individualized.