What are the blood pressure (BP) goals for long-term nursing home patients?

From the Guidelines

Blood pressure goals for long-term nursing home patients should target a systolic blood pressure of less than 150 mmHg to reduce the risk for mortality, stroke, and cardiac events, as recommended by the American College of Physicians and the American Academy of Family Physicians 1.

Key Considerations

• The target blood pressure should be individualized based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient, taking into account their unique health status and preferences.
• High-quality evidence shows that treating hypertension in older adults to moderate targets (<150/90 mmHg) reduces mortality, stroke, and cardiac events, with the most consistent and greatest absolute benefit seen in trials with a higher mean systolic blood pressure at baseline (>160 mmHg) 1.
• Nonpharmacologic treatment strategies, such as lifestyle modifications (weight loss, DASH diet, increased physical activity), should be considered as the first line of therapy or used concurrently with drug therapy for most patients with hypertension, as they are associated with fewer side effects and have other positive effects.
• Effective pharmacologic options include antihypertensive medications, such as thiazide-type diuretics, ACEIs, ARBs, calcium-channel blockers, and β-blockers, with consideration of their potential adverse effects.

Monitoring and Treatment

• Clinicians should ensure accurate measurement of blood pressure before beginning or changing treatment of hypertension, using multiple readings and considering ambulatory or home monitoring.
• Treatment decisions should prioritize once-daily dosing for compliance and consider comorbidities, fall risk, cognitive status, and life expectancy.
• Regular monitoring is essential to prevent cardiovascular complications while maintaining functional status and quality of life, rather than solely focusing on achieving specific blood pressure targets.

Recent Guidelines

• The 2020 International Society of Hypertension global hypertension practice guidelines recommend reducing blood pressure by at least 20/10 mmHg, ideally to 140/90 mmHg, with individualization for elderly patients based on frailty 1. However, the American College of Physicians and the American Academy of Family Physicians' guideline from 2017 1 provides a more specific and evidence-based recommendation for older adults, prioritizing a target systolic blood pressure of less than 150 mmHg.

From the Research

BP Goals for Long-Term Nursing Home Patients

The BP goals for long-term nursing home patients can be summarized as follows:

• For patients with diabetes mellitus or chronic renal insufficiency, the goal is to lower the blood pressure to less than 130/80 mm Hg 2, 3, 4.
• For patients without diabetes mellitus or chronic renal insufficiency, the goal is to lower the blood pressure to less than 140/90 mm Hg 2, 3, 4.
• For adults aged 80 years and older, a blood pressure below 150/90 mm Hg has been recommended, with a target goal of less than 140/90 mm Hg considered in those with diabetes mellitus or chronic kidney disease 4.
• Some studies suggest that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension, with an individualized approach for those who are institutionalized, with high comorbidity burden, or have a short life expectancy 5.

Considerations for BP Goals

When determining BP goals for long-term nursing home patients, the following considerations are important:

• Comorbidities, such as diabetes mellitus or chronic renal insufficiency, which may require more aggressive blood pressure control 2, 3, 4.
• Frailty and potential for adverse drug reactions, which may require a more individualized approach 5.
• Method of blood pressure measurement, which is extremely important to consider when determining the blood pressure goal 5.
• Patient's potential for adverse events, such as cardiovascular risk, which may be increased with diastolic blood pressure less than 60 mm Hg 5.

Trends in BP Diagnosis, Treatment, and Control

Studies have shown that:

• The age-standardized prevalence of hypertension diagnosis at admission to nursing homes has increased over time 6.
• Rates of BP treatment and control among residents with hypertension at admission have remained high, but have declined slightly over time 6.
• Certain populations, such as those with a history of diabetes, stroke, and renal disease, are less likely to have an average BP <140/90 mm Hg 6.