Hypertension in Long-Term Care Center Residents

Information concerning the prevalence and management of hypertension in residents of long-term care (LTC) facilities is beginning to emerge. The prevalence of hypertension in this population ranges from approximately one-third to two-thirds. Special considerations are warranted in LTC residents with respect to making the correct diagnosis and defining the goals of therapy and its effects on quality of life. Blood pressure measurements in LTC settings may not be accurate.

Inaccuracies result from measurement errors and from the temporal variability in blood pressure, particularly in relation to meals. Blood pressure appears to be highest in the morning before breakfast. Postprandial hypotension is common among LTC residents, affecting about one-third of this population. The presence of postprandial hypotension has been associated with otherwise unexplained syncope and has been found to be a significant independent risk factor for falls, syncope, stroke, and overall mortality.

There are several factors to consider in the management of hypertension in the LTC population. First, the advanced average age and multiple comorbidities in this population raises several questions surrounding the beneficial effects of antihypertensive therapy.

The beneficial effects of treatment must be carefully balanced against the potential adverse effects of therapy, and the goals of therapy must be defined within the context of the patient's overall clinical situation. Even an intervention as seemingly innocuous as a sodium-restricted diet needs to be evaluated in the context of the high prevalence of protein-energy malnutrition among nursing home residents.

Second, the medication list of the average LTC resident includes seven medications, and most have three or more comorbid conditions. The addition of an antihypertensive medication increases the possibility of an adverse drug event in this frail, at-risk group. Third, several studies have identified antihypertensive medications, particularly vasodilators, as a risk factor for falls in this high-risk population who experience an average of two falls each year.

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Consequently, it is appropriate to assess both postural and prandial blood pressure in this population. Randomized controlled trials have not yet been conducted in the LTC population to provide clear risk-benefit evidence to support an approach to antihypertensive management. The available data suggest that diuretic therapy is effective in controlling systolic blood pressure elevations and that blood pressure reduction with diuretics lowered the prevalence of postural hypotension.

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