Abstract
Abstract Optimizing of polypharmacy in the elderly patient presenting with falls requires making judgement calls between stopping or reducing anti-hypertensives with the increased risk of stroke and cardiovascular disease versus continuing the medications with the consequent orthostatic hypotension, electrolyte abnormalities and worsening of cognition due to reduced perfusion pressure in patients with dementia. The trial evidence in this cohort of patients is scant and conflicting. The Milan 75+ Cohort study published in Age and Ageing, Volume 44, Nov. 2015 by Giulia Ogliari et al showed a U shaped relationship between BP and mortality with the lowest mortality at systolic blood pressure of 165 mm Hg. The Hypertension in the Very Elderly Trial (HYVET) published in New England Journal of Medicine in March 2008 by Nigel S Beckett et al showed reduction in any cause death by 21% in the intensive treatment group, while the Cochrane Systematic Review by Vijaya M Musini et al published in 2009 showed no reduction in total mortality in the very elderly patient with increased withdrawals due to adverse effects in the treatment group. There are questions on the applicability of trial evidence with the HYVET trial having lower level of patients with diabetes and cardiovascular disease and the SPRINT trial including mainly younger patients with good baseline renal function and little cardiovascular disease. The combination of frailty showed improved outcome in HYVET but had no effect in SPRINT trial. The number needed to treat to avoid one significant event in patients with a blood pressure of >170 is 125 for death, 67 for stroke and 48 for heart failure. In this context issues such as patient preference, degree of frailty, cognitive impairment, and life expectancy have to be taken in account before deciding on the suggested treatment for the individual patient.
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