Weighing a ‘Less is More’ Approach to Hypertension Medication in Nursing Homes

Dementia is widely recognized as the most common infirmity among residents in nursing homes. What barely registers on the radar screen of physicians, though, is the most effective treatment and management of these typically frail patients when they have comorbidities such as high blood pressure, diabetes, and dehydration.

Kenneth Boockvar, MD, MS, Professor of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, has spent the last five years of his clinical research shedding light on this critical question.

“It often boils down to a matter of intensity,” he says. “Do we really need to aggressively manage an older person with two or three drugs for hypertension when one, or perhaps none, would suffice? We’re still learning what the appropriate level is.”

Hypertension is a particular area of interest for Dr. Boockvar, who is also Associate Director of Research and Acting Director of the Geriatrics Research Education and Clinical Center at the James J. Peters VA Medical Center in the Bronx, an affiliate of the School of Medicine. For example, in a study published in the Journal of the American Geriatrics Society in 2019, Dr. Boockvar and his team found that long-term residents with hypertension did not experience significant benefits from more intense antihypertensive treatment.

The investigators found in their observational study of more than 255,000 long-term residents of U.S. nursing homes that 46 percent of those with hypertension also had dementia and moderate or severe cognitive impairment. Moreover, nearly 41 percent of this group were receiving two or more first-line antihypertensive medications. The participants in the study were long-term nursing home residents treated for hypertension during the second quarter of 2013.

The danger, as Dr. Boockvar points out, is that residents with dementia are at particularly high risk of adverse effects of antihypertensive treatment when taken with other medications that can magnify drug-drug interactions.

“There is interesting new clinical data to suggest that controlling blood pressure yields some protection against cognitive impairment,” says Dr. Boockvar, who treats older adults in addition to his ongoing research. “Even so, clinicians should prescribe antihypertensive drugs with caution. In fact, these drugs may be reasonable targets for deintensification. I’ve taken that approach with my patients and found that when I deprescribe, they often end up doing better because the medications were causing side effects like drowsiness and imbalance.”

In a related study, Dr. Boockvar reported that certain low-potency diuretics (i.e., hydrochlorothiazide) may be a medically sound first-line choice for hypertension treatment of older patients in nursing homes, despite the fact that they are less commonly prescribed by physicians out of fear they may trigger adverse events such as dehydration, orthostatic hypotension, or falls. Mount Sinai researchers found no association between the use of these diuretics and adverse events, including incontinence and hospitalization.

Dehydration and cognitive impairment in geriatric patients stricken with COVID-19 has also come under study at the Boockvar lab.

“Most studies on COVID-19 have focused on the management of hypoxemic respiratory failure from pneumonia,” he explains. “Less known are the geriatrics complications that can result, such as dehydration, delirium, and falls. There is no definitive test for dehydration, so physicians caring for these patients need to have a very low threshold for suspecting dehydration.”

Indeed, his unique findings could well serve as guidance for caregivers at nursing home facilities across the country. The message: Be prepared to administer intravenous fluids to about half of your patients affected by COVID-19.