Frailty and hypertension | Right Decisions

The aim to control blood pressure to lower than 140/90mmHg is associated with a significant reduction in composite cardiovascular outcomes.^100,101 The evidence was reviewed for tight blood pressure control in older adults living with frailty and hypertension, considering if treatment aimed at reducing BP to less than 140/90mmHg will:

reduce the risk of mortality?
reduce the risk of cardiovascular outcomes?
increase adverse events?

From the review of guidelines available, (one of mixed quality and one of high quality), there is advice regarding detection, monitoring, and treatment of hypertension, however levels of frailty were not considered.^100,101 Independence, frailty, and comorbidities will all influence treatment decisions, especially in older (>65 years) and very old (>80 years) people.

Lowering systolic blood pressure to less than 140mmHg in older people with primary hypertension without T2DM, is associated with both benefits and harms. While reducing mortality and cardiovascular events, a systolic blood pressure below 120mmHg is associated with greater risk of harms, including injury from falls and acute kidney injury, particularly for those with frailty.

NICE hypertension guidelines recommend checking for postural hypotension people with hypertension and:¹⁰¹

type 2 diabetes or
symptoms of postural hypotension or
aged 80 and over

In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.

NICE list blood pressure targets to be considered for people over the age of 80 (use clinical judgement for people with frailty or multimorbidity) (see the table below)¹⁰¹

Clinic blood pressure targets for people aged 80 and over (use clinical judgement for people with frailty or multimorbidity)

Person aged 80 and over with:	Clinic blood pressure target	Source
hypertension (with or without type 2 diabetes) or type 1 diabetes (regardless of albumin to creatinine ratio)	Below 150/90	Recommendation 1.4.21 NICE's guideline on type 1 diabetes in adults (recommendation 1.13.8)
chronic kidney disease plus albumin to creatinine ratio less than 70 mg/mmol	Below 140/90	NICE's guideline on chronic kidney disease (recommendation 1.6.1)
chronic kidney disease plus albumin to creatinine ratio of 70 mg/mmol or more	Below 130/80	NICE's guideline on chronic kidney disease (recommendation 1.6.2)

Please note that the above table may need to be scrolled horizontally or vertically in order to view all information, depending on your device.

There is a lack of evidence for intensive blood pressure targets in people with frailty and for those over the age of 80 years. It is noted that people who are frail have increased risk of adverse events and less time to gain benefits from long-term rigid BP control. The list below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Recommendation when managing frailty and hypertension

1 - Good practice point

Antihypertensive medications can reduce the risk of mortality, stroke, and heart failure in older adults. Because biological rather than chronological age can determine tolerability of, and likely benefit from medications, these individuals should not be denied treatment, or have it withdrawn simply on the basis of their chronological age. A person-centred approach should be considered.

2- Good practice point

Prescribers and people over 65 years of age with frailty may want to discuss the tolerability of, and benefits from, antihypertensive medication taking into consideration a person’s level of frailty, postural hypotension and independence.

3 - Conditional recommendation

A general treatment target of systolic blood pressure (SBP) below 140 mmHg, and diastolic blood pressure (DBP) below 80 mmHg is recommended for adults under 80 years with or without T2DM. For those over 65 years of age with frailty, this might not be achievable. While a higher target is acceptable, if lower blood pressure is sought, a slower timeline for reductions will be required in frail old or very old patients; it is important to recognise that this might not be achievable as the risk of harm may outweigh the benefits.

4 - Good practice point

BP targets should be balanced with the greater risk of harms, falls and acute kidney injury.