Yearly Archives: 2019

Blood Pressure Control for People Aged 80 and Older: What’s the Right Target?

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Journal of the American Geriatrics Society Research Summary

The number of people who are 80-years-old and older is on the rise, and will account for nearly 10 percent of the whole U.S. population by 2050. Since the lifetime chance for developing high blood pressure is at least 70 percent by age 80, more and more people will be at risk for the health problems that high blood pressure can cause.

High blood pressure, or hypertension, is sometimes called the “silent killer” because it produces few, if any, symptoms. In fact, you might not even realize you have high blood pressure. But if it’s not treated, this condition can lead to heart attacks, strokes, kidney disease, and other serious problems, including a risk for dementia.

The 2017 American College of Cardiology and American Heart Association blood pressure guidelines recommend that most people aged 65 or older maintain their systolic blood pressure (the first number in a blood pressure reading) at less than 130 mmHg. But, people 80 years or older often also have multiple chronic health conditions, can be frail, take several medicines, and could have cognitive problems. Because of this, it’s still unclear whether the risks and benefits of lowering systolic blood pressure to less than 130 mm Hg are the same for people aged 80 years and older as they are for people aged 65 to 80.

Given this knowledge gap, a team of researchers focused on this group of older adults within a large randomized trial called the Systolic Blood Pressure Intervention Trial (SPRINT). They published their findings in the Journal of the American Geriatrics Society. In their analysis of SPRINT data, the researchers focused on people aged 80 and older, who had reported heart disease events (such as heart attacks or strokes), changes in kidney function, cognitive impairment, quality of life, or death. The researchers also explored whether impairments in cognitive or physical function had any effect on intensive blood pressure control.

The analysis included 1,167 participants. Most were around 84 years old, and about 3 percent were 90 or older. Their baseline systolic blood pressure was around 142 mmHg. Most of the participants had at least three chronic health conditions. More than half were taking at least five medications and about 27 percent had a history of heart disease.

The participants were randomly assigned to one of two groups. One group received “intensive” treatment targeting to lower their blood pressure to less than 120 mmHg. The other group received treatment to target lowering their blood pressure to less than 140 mmHg.

The people who received treatment to lower their blood pressure to less than 120 mmHg experienced a lower risk for heart disease events, as well as less risk for mild cognitive impairment and death from all causes. However, people in this group also experienced an increased risk of small, but meaningful, declines in kidney function as well as hospitalizations for short term kidney damage (from which most people recovered). Attempting to lower systolic blood pressure to less than 120 mmHg did not increase the risk for injury-causing falls. This is important, since falls raise the risk for death in older adults and low blood pressure can result in falls.

While the rate of developing dementia was similar in the two groups, participants in the intensive 120 mmHg group were 28 percent less likely to develop mild cognitive impairment.

The researchers also reported that people with better cognitive function (remembering, thinking, and making decisions) at the beginning of the study benefited the most from intensive blood pressure control. They also experienced less heart disease and fewer deaths. This same benefit was not seen in participants who had poorer cognitive function at the beginning of the study. However, there was not strong evidence of intensive blood pressure control having a harmful impact on death rates or developing heart disease for those with poorer cognitive function.

The researchers concluded that, for adults aged 80 years or older, intensively controlling systolic blood pressure to less than 120 mmHg lowers the risk of heart attacks, stroke, death, and mild cognitive impairment, but increases the risk of declines in kidney function. Benefits related to the risk for heart disease and death were highest in people with higher cognitive performance at the beginning of the trial.

This summary is from “Intensive versus Standard Blood Pressure Control in Adults 80 years or Older: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial.” It appears online ahead of print in the December 2019 issue of the Journal of the American Geriatrics Society. The study authors are  Nicholas M. Pajewski, PhD; Dan R. Berlowitz, MD, MPH; Adam P. Bress, PharmD; Kathryn E. Callahan, MD; Alfred K. Cheung, MD; Larry J. Fine, MD; Sarah A. Gaussoin, MS; Karen C. Johnson, MD, MPH; Jordan King, PharmD; Dalane W. Kitzman, MD; John B. Kostis, MD; Alan J. Lerner, MD; Cora E. Lewis, MD, MSPH; Suzanne Oparil, MD; Mahboob Rahman, MD; David M. Reboussin, PhD; Michael V. Rocco, MD; Joni K. Snyder, RN; Carolyn Still, PhD; Mark A. Supiano, MD; Virginia G. Wadley, PhD; Paul K. Whelton, MD; Jackson T. Wright Jr., MD, PhD; and Jeff D. Williamson, MD, MHS.

 

 

New Study Suggests Cautions About Antipsychotic Medications for Hospitalized Older Adults

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Journal of the American Geriatrics Society Research Summary

Delirium (sudden confusion or a rapid change in mental state) remains a serious challenge for our health care system. Delirium affects 15 to 26 percent of hospitalized older adults and can be particularly problematic because those experiencing the condition may interfere with medical care or directly harm themselves or others. Besides behavioral therapy and physical restraints, antipsychotic medicines are among the few therapeutic options healthcare providers can use to ease delirium and protect patients and caregivers—but antipsychotics also come with risks of their own.

To learn more about the effect of antipsychotic medicines on older hospitalized patients, a research team created a study published in the Journal of the American Geriatrics Society. This study included information from hospitalized patients at a large academic medical center in Boston.

The researchers looked specifically at death or non-fatal cardiopulmonary arrest (heart attack) during hospitalization.

The researchers learned that adults taking “first-generation” or “typical” antipsychotic medications (medicines first developed around the 1950s) were significantly more likely to experience death or cardiopulmonary arrest, compared to people who did not take those drugs. Taking “atypical” or “second-generation” antipsychotics (so named because they were developed later) raised the risk for death or cardiopulmonary arrest only for people aged 65 or older.

In the past, other studies have suggested that typical antipsychotic medications could cause sudden death, and that atypical antipsychotics could raise peoples’ risks for falls, pneumonia and death. What’s more, another large study also suggested that both types of antipsychotic medicines posed a risk for fatal heart attacks.

Despite these known risks, atypical antipsychotics are often prescribed for people in the hospital. One recent study of patients at Beth Israel Deaconess Medical Center in Boston found that antipsychotics were prescribed for nine percent of all adults who were hospitalized for non-psychiatric causes.  Another large recent study found that using antipsychotics to prevent or treat delirium did not lower the risk for death, did not lessen the severity of delirium or shorten its duration, and did not shorten the time people spent in the intensive care unit (ICU) or their hospital length of stay.

“Delirium is common in older hospitalized patients and difficult to treat, but antipsychotic medications should be used with caution regardless of age,” said the authors.

This summary is from “Antipsychotics and the Risk of Mortality or Cardiopulmonary Arrest in Hospitalized Adults.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Matthew Basciotta, MD; Wenxiao Zhou, MS; Long Ngo, PhD; Michael Donnino, MD; Edward R. Marcantonio, MD, MSc; and Shoshana J. Herzig, MD, MPH.

 

Aerobic Exercise and Heart-Healthy Diet May Slow Development of Memory Problems

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Journal of the American Geriatrics Society Research Summary

Cognitive impairment without dementia (CIND), or mild cognitive impairment, is a condition that affects your memory and may put you at risk for Alzheimer’s disease and dementia. According to the U.S. National Library for Medicine, signs of mild cognitive impairment may include frequently losing things, forgetting to go to events and appointments, and having more trouble coming up with words than other people of your age.

Sine experts believe that risk factors for heart disease also are risk factors for dementia and late-life cognitive decline and dementia. Recently, researchers examined two potential ways to slow the development of CIND based on what we know about preventing heart disease. They published the results of their study in the Journal of the American Geriatrics Society.

The research team had a theory: That the healthy lifestyle behaviors that slow the development of heart disease could reduce heart disease risk and also slow cognitive decline in older adults with CIND. These behaviors include regular exercise and a heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet.

In order to investigate their theory, the researchers designed a study titled “Exercise and NutritionaL Interventions for coGnitive and Cardiovascular HealTh EnhaNcement” (or ENLIGHTEN for short). The goal of the study was to examine the effects of aerobic exercise (sometimes known as “cardio” or “cardiovascular” exercise because it involves activities that increase the circulation of oxygen through the blood) and the DASH diet on cognitive functioning in older adults with CIND.

The ENLIGHTEN study examined 160 adults 55-years-old or older. The study participants were older adults who didn’t exercise and had memory problems, difficulty thinking, and making decisions. They also had at least one additional risk factor for heart disease, such as high blood pressure (also known as hypertension), high cholesterol, diabetes, or other chronic conditions.

Participants took a number of tests to measure their heart disease risk factors and cognitive ability. Researchers also assessed participants’ dietary habits and ability to perform daily activities. The participants were then randomly assigned to one of four groups: a group doing aerobic exercise alone, a group following the DASH diet alone, a group doing aerobic exercise and following the DASH diet combined, or a group receiving standard health education.

People in the exercise group did 35 minutes of moderate intensity aerobic exercise (including walking or stationary biking) three times per week for six months. They were supervised for three months and then exercised unsupervised at home for three months. Participants in the exercise group did not receive any counseling in the DASH diet and were encouraged to follow their usual diets for six months.

People in the DASH eating plan group received instruction about how to meet DASH guidelines in a series of weekly sessions for three months and then bi-weekly for the remaining three months. Participants in the DASH group were asked not to engage in regular exercise until the completion of the six-month study.

People in the exercise and DASH group followed the exercise and DASH programs for six months. The participants who were enrolled in the health education group received weekly educational phone calls for three months and then bi-weekly calls for three months. Phone calls were conducted by a health educator on health topics related to heart disease. Participants were asked to maintain their usual dietary and exercise habits for six months until they were re-evaluated.

At the conclusion of the six-month intervention and assessment, participants were free to engage in whatever activity and dietary habits they desired, with no restrictions.

The results of the research team’s study showed that exercise improved the participants’ ability to think, remember, and make decisions compared to non-exercisers, and that combining exercise with the DASH diet improved the ability to think, remember, and make decisions, compared to people who didn’t exercise or follow the diet—even though they didn’t perfectly follow the programs they were assigned to during the six-month interventions.

The researchers concluded that their findings are promising proof that improved ability to think, remember, and make decisions can last one year after completing a six-month exercise intervention. They suggested that further studies would be needed to learn more.

This summary is from “Longer Term Effects of Diet and Exercise on Neurocognition: One Year Follow-Up of the ENLIGHTEN Trial.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are: James A. Blumenthal, PhD; Patrick J. Smith, PhD; Stephanie Mabe, MS; Alan Hinderliter, MD; Kathleen Welsh-Bohmer, PhD; Jeffrey N. Browndyke, PhD; P. Murali Doraiswamy, MBBS, FRCP; Pao-Hwa Lin, PhD; William E. Kraus, MD; James R. Burke, MD; and Andrew Sherwood, PhD.

Geriatricians, Internists, and Cardiologists Surveyed About Deprescribing

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Journal of the American Geriatrics Society Research Summary

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As you grow older, you’re more likely to develop health conditions that require taking multiple medications—some of which you may take for a long time. Many older people also take over-the-counter (or “OTC”) medications, vitamins, or supplements as part of routine care. As a result, older adults have a higher risk of overmedication, also known as “polypharmacy”—the medical term for taking four or more medications at the same time. Polypharmacy can increase your chances of unwanted reactions (also called “adverse drug reactions”) due to medications taken on their own or together.

To address this increasingly common problem, healthcare providers are focusing on how to reduce the number of medicines older adults are using through a practice called “deprescribing,” which is when health professionals work with patients to decide to stop the use of one or more medications for which the benefits no longer outweigh the potential harms.

Getting both patients and health professionals on board with deprescribing can be key to its success, however. In order to learn more about physicians’ attitudes and approaches to deprescribing medications for older adults, a team of researchers designed a survey. They published their investigation in the Journal of the American Geriatrics Society. Continue reading →

For Older Adults, Newer Hepatitis C Treatments are Safe and Effective

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Journal of the American Geriatrics Society Research Summary

Viral hepatitis is a disease that causes inflammation of the liver. There are three viruses responsible for most cases of the disease: hepatitis A, B, and C. Hepatitis A is typically caused by consuming contaminated food or water.  Hepatitis B and C usually occur when someone comes in contact with infected bodily fluids, such as blood. The severity of hepatitis can range from a mild illness lasting a few weeks to a serious, lifelong illness.

In 2016, there were an estimated 2.4 million people living with hepatitis C, one of the more severe forms of the disease, in the United States. A hepatitis C infection can be particularly serious for older adults, since many don’t seek treatment until the condition is in advanced stages. What’s more, hepatitis C is considered harder to treat for older people who have lived with the condition for a long time compared to younger people are.  Treatment is often unsuccessful, too, because many of the common treatment options aren’t easy for older adults to tolerate or may no longer be effective as our body changes with age.

Thankfully, newer treatments known as interferon-free direct-acting antivirals offer a promising approach to addressing hepatitis C.  These medications offer cure rates of more than 90 percent in clinical trials and in real life, but they haven’t been studied extensively for older adults. A team of researchers studied this issue and published their findings in the Journal of the American Geriatrics Society. The researchers examined how well people older than 65 tolerated interferon-free direct-acting antivirals compared with younger patients. Continue reading →