Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Long-term antihypertensive medication in the elderly did not decrease quality of life

ACP J Club. 1995 Mar-April;122:35. doi:10.7326/ACPJC-1995-122-2-035


Source Citation

Applegate WB, Pressel S, Wittes J, et al. Impact of the treatment of isolated systolic hypertension on behavioral variables: results from the Systolic Hypertension in the Elderly Program. Arch Intern Med. 1994 Oct 10;154:2154-60.


Abstract

Objective

To study whether long-term therapy with antihypertensive medication affects cognition, mood, activities of daily living (ADL), and leisure activities in older adults with isolated systolic hypertension.

Design

Randomized, placebo-controlled, stepped-care trial with mean follow-up of 5 years.

Setting

16 academic care centers.

Patients

4736 of 447 921 screened patients ≥ 60 years of age (mean age 72 y, 57% women, 86% white) with isolated systolic hypertension (mean systolic blood pressure [SBP] ≥ 160 mm Hg and mean diastolic blood pressure [DBP] < 90 mm Hg). Patients with serious medical conditions were excluded. Follow-up was 99.8%.

Intervention

The goal of therapy was SBP < 160 mm Hg with a reduction in SPB > 20 mm Hg. BP was monitored monthly, and drug therapy (with active drug or placebo) was adjusted in 4 consecutive steps: chlorthalidone, 12.5 mg/d; chlorthalidone, 25 mg/d; addition of atenolol, 25 mg/d, or reserpine, 0.05 mg/d; and addition of atenolol, 50 mg/d, or reserpine, 0.1 mg/d. 2365 patients received active treatment and 2371 patients received placebo. Patients with sustained SBP > 200 mm Hg or DBP > 90 mm Hg received active treatment.

Main outcome measures

12 behavioral assessment instruments were used to assess cognition, depressive symptoms, physical and social functioning, ADL, and mood or emotional state.

Main results

The groups did not differ at follow-up for global quality of life, cognitive impairment, or symptoms of depression, but the treatment group showed less deterioration in personal grooming, dressing, eating, using the toilet, walking up and down stairs, and walking half a mile. Patients in both groups showed modest decreases over time in strenuous or complex activities (e.g., active sports, physical exercise, or overnight trips).

Conclusion

Medical treatment of isolated systolic hypertension in the elderly did not cause deterioration in measures of cognition, emotional state, physical function, or leisure activities.

Source of funding: National Institutes of Health.

For article reprint: Mr. William Applegate, Department of Preventive Medicine, University of Tennessee, Memphis TN 28105, USA. FAX 336-716-2273.


Commentary

Older patients with isolated systolic hypertension (SBP > 160 mm Hg) might benefit if clinicians initiate therapy with a low-dose thiazide diuretic and add atenolol or reserpine if needed. This approach is inexpensive ($6 to $12/mo) and modestly effective in reducing strokes and cardiovascular-related morbidity and mortality; on average, it does not diminish physical, psychological, or social functioning caused by adverse drug effects.

Clinicians, however, must clearly understand the caveats of this study. The therapies initiated in the treatment and control groups were not always the same as the therapies patients were receiving when the outcomes were assessed and analyzed. When quality of life and possible adverse drug effects were assessed, only two thirds of the patients assigned to the treatment group were still being treated according to protocol and > 40% of the patients assigned to placebo had been switched to active drugs. Adverse drug effects were more common in the treatment group; significantly more patients stopped the study medications because of intolerable side effects (13% vs 7%) (1). Memory or concentration problems and sexual dysfunction were reported more frequently in the active treatment group than could be explained by chance alone. Nevertheless, adjustments in therapy apparently negated these short-term adverse effects (1).

Can these results be generalized to the average patient seen by the average clinician? The study participants were seen monthly, and they, along with their families and physicians, were probably more vigilant in identifying subtle adverse drug effects than might be expected of average patients and clinicians outside the setting of a clinical trial. Despite this concern, the final message is clear: Older patients with isolated systolic hypertension can be effectively and inexpensively treated, and, if we carefully monitor adverse drug effects, this can be done without worsening their quality of life.

Arthur T. Evans, MD
Mark E. Williams, MDUniversity of North Carolina at Chapel HillChapel Hill, North Carolina, USA


Reference

1. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-64.