Jenni Harrison is a Clinical Research Fellow at The University of Edinburgh. Her previous role was as an Academic Clinical Fellow in Geriatric Medicine in Leicester. She was part of the Hypertension in Dementia (HIND) Research Group at the Universities of Nottingham and Leicester. The group recently produced a New Horizons article on the management of hypertension in people with dementia. She tweets @JenniKHarrison.
In the face of uncertainty around the optimal management of hypertension in people with dementia we sought to review and summarise the available evidence. After first considering the rationale for the treatment of hypertension and possible reasons why the approach could be different for those with dementia, we structured our review around three key questions:
(1) Do people with dementia experience greater adverse effects from antihypertensive medications?
(2) Is cognitive function protected or worsened by controlling blood pressure?
(3) Are there subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful?
We examined the evidence from pharmacology, pathology, epidemiology and clinical trials. While there was a lack of direct evidence of benefit, there was also a lack of evidence of harm from treating hypertension in individuals with dementia. Like so many of the clinical questions pertinent to the practice of geriatric medicine one of our major conclusions is that we need more high quality research. Specifically:
(1) Mechanistic research to improve our understanding of hypoperfusion, orthostatic hypotension, cerebral blood flow and blood pressure variability between blood pressure and cerebral perfusion and
(2) Randomised trials to explore the feasibility, acceptability and safety of deprescribing in specific subgroups – we would encourage the inclusion of patient-centred outcomes to help provide evidence to support clinical decision-making
We offer pragmatic guidance for everyday clinical practice, including:
(1) Careful assessment of risk factors, comorbidities and greater use of ambulatory blood pressure monitoring in diagnosis
(2) Utilising complementary effects of medications where comorbidities are present
(3) Review of those with an existing diagnosis of hypertension to establish if treatment is still required as this need may change over time
and, most importantly
(4) Individualising management by actively seeking your patient’s preferences and priorities for care. There needs to be greater dialogue between all patients and their doctors around medication use and review, not limited to the treatment of hypertension. Decisions on whether to continue or stop prescribed therapies should be shared to ensure decision-making is person not practitioner-centred.
This is a complex and nuanced topic which benefits from greater understanding and exploration. The research and reviews conducted as part of the HIND project have uncovered further research questions. Our New Horizons article provided the group with an opportunity to challenge our own knowledge and practice and we invite you to do the same.
Read the full Age & Ageing Article: New horizons: the management of hypertension in people with dementia