Increasing awareness on frailty in the management of hypertensive older adults.

Abstract

Frailty is a common concern in geriatric practice, which has increasingly gained attention over recent years, as the world population ages. Frailty is a multifactorial phenomenon characterized by a decline in individuals’ resilience and physiological reserve, resulting in increased vulnerability to external stressors [1]. Consequently, frail individuals are at increased risk of adverse events, including disability, hospitalization, institutionalization and mortality. The negative prognostic impact of frailty also includes a predisposition to falls, a high risk of cardiovascular events and impairment of quality of life [2]. In the literature, the reported prevalence of frailty is highly variable, ranging from 4 to 59% because of different operational definitions and measures of frailty across studies [3]. The prevalence of frailty is known to increase with advancing age and it is estimated to be around 11% in community-dwelling older people [4], while reaching more than 30 and 50% among individuals with dementia and long-term care residents, respectively [5,6]. Recently, frailty has become a matter of debate in cardiovascular literature and there is an increasing awareness that it significantly influences the outcomes of patients with cardiovascular diseases [7–9]. Consistently, frailty was shown to influence the association between blood pressure (BP) and negative health outcomes including mortality [10]. Therefore, the management of hypertension cannot disregard an accurate assessment of frailty. Frailty and hypertension frequently coexist in older people, as one out of seven hypertensive patients are frail [11]. The study by Lina et al.[12], which is published in the present issue, confirms this epidemiological relevance, reporting a 14% prevalence of frailty in hypertensive patients and a 78% prevalence of hypertension in frailer ones. In addition, the authors investigate the factors that are independently associated with frailty in older hypertensive adults, thus defining their clinical profile. The study results show that frail hypertensive patients are typically older and present with reduced physical activity, a higher white blood cell count and multimorbidity, including cardiovascular diseases, diabetes, osteoporosis, depression, cognitive impairment and hearing loss. Multimorbidity is usually associated with polypharmacy, which implies a higher risk of interactions and adverse drug reactions. Therefore, the clinical phenotype which is outlined in this study draws up the picture of a complex and highly vulnerable population. Indeed, while some clinical features denote a high cardiovascular risk and suggest potential benefits deriving from antihypertensive treatment, some others indicate a predisposition to treatment-related complications, such as syncope, falls and injuries, electrolyte imbalances and renal dysfunction. These data confirm that frail hypertensive individuals represent a totally different population from that typically included in clinical trials, where participants are usually younger and predominantly healthy, with a low risk of treatment-related adverse events [13–15]. It follows from this that the management of hypertension in frail older adults is a clinical challenge, as treatment benefits must be balanced against potential risks in the absence of strong evidence supporting clinical decisions. In this context, mainly expert opinions are available to guide therapeutic strategies, along with clinical judgment whose role is strongly emphasized by guidelines [16]. Among experts’ documents and position papers, a milestone is represented by the statement of the European Society of Hypertension (ESH) and the European Geriatric Medicine Society (EuGMS) [17]. In this document it is suggested that antihypertensive treatment in frail older adults should target a SBP ‘safety range’ of 130–150 mmHg, which probably allows to provide cardiovascular benefits while minimizing the risk of hypotension-related complications. Therefore, antihypertensive medications should be reduced or discontinued in patients with SBP less than 130 mmHg, to prevent excessive BP lowering. In addition, the document clearly highlights that frailty assessment is a fundamental prerequisite for a proper management of hypertension in older adults. The level of frailty should be carefully evaluated before treatment initiation – to identify those patients who are less likely to tolerate and benefit from BP lowering – as well as during treatment – to promptly recognize modifications in frailty status that require an adjustment of treatment strategies, including deprescribing when appropriate. The ESH/EuGMS experts propose the Fried Frailty Phenotype as a frailty assessment tool, which has a recognized predictive value and is easy and rapid to apply in routine practice [1]. As an alternative, physical performance tests such as the Short Physical Performance Battery, gait velocity and grip strength may also play a role, given their ability to predict adverse health outcomes in cardiovascular diseases including hypertension [18–20]. The assessment of frailty should represent the point of reference in the development of treatment strategies for hypertensive older people. Frailer adults should be regarded as more vulnerable individuals, for whom a more caution approach in BP lowering and a more strict treatment monitoring are advisable due to a higher risk of treatment-related complications. Conversely, adults with mild or no frailty should not be denied a more rigorous treatment approach, as they are likely to tolerate and benefit from antihypertensive therapy due to a high cardiovascular risk. Recently, a position statement by the EuGMS Special Interest Group on Cardiovascular Medicine [21] has advocated a geriatric approach to cardiovascular diseases in older patients, which implies a multidimensional and individualized diagnostic and therapeutic approach, customized to the individual's level of frailty. Given all of the above, the same approach should apply to hypertension management. The assessment of frailty should be included in the routine clinical evaluation of older hypertensive patients and differentiated BP-lowering strategies should be developed according to frailty level and biological rather than chronological age. In addition, deprescribing should be considered, when drug therapy is supposed to cause more harm than benefit. However, to optimize patients’ care in this vulnerable population, there is a need for clinical trials focusing on frailer older hypertensive adults, to guide the development of frailty-based clinical strategies. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.