Putting on the Pressure

Blood-pressure guidelines don’t allow for how old and frail my mother was

By Janice Neumann

(The Washington Post) – Last summer, during a routine visit by my 92-year-old mother to a cardiologist for a pacemaker check, her systolic blood pressure registered a dangerously high 220 over 94, a reading that sent her — and me — on a difficult journey through changing recommendations about blood pressure goals.

Her pressure had been 150 — that’s the systolic number — over 82 — that’s the diastolic number — the day before at home, where she was typically calm and relaxed with my dog lying nearby on the floor and my cat purring beside her on the couch.

Her doctor said the spike might be “white coat hypertension,” or high blood pressure in a doctor’s office caused by anxiety. He took her pressure again, saw it was still too high and said she needed to be hospitalized.

The soothing atmosphere at home was far different from that of the doctor’s office, where she was rushed into an exam room by a nurse who seemed oblivious to my mother’s difficulty walking, near blindness and hesitation at answering even simple questions.

So she was hospitalized for a day, was pumped full of medicine and had her dose of blood pressure medications increased. She left the hospital weak and dazed.

That weakness grew worse over the fall and into winter, as doctors tried to keep her blood pressure well below 150. Her cardiologist lowered her blood pressure medication in an attempt to address her weakness, but she was still on plenty. Some days, she was too weak and dizzy to get out of bed until the afternoon. When she missed a doctor’s appointment because she couldn’t muster the strength to leave the house, her cardiologist thought the problem was psychological because her blood pressure readings at home were good.

When I told doctors I thought her symptoms were from drug side effects, they paid scant attention.

By early spring, my mother was apathetic and even weaker. (She had been eating and drinking little.) During a visit to her geriatrician, her sodium level was so low that she needed to be hospitalized and pumped full of fluid. (Low sodium can cause brain damage.)

She was discharged to a rehabilitation facility with feet so swollen she could not wear shoes. She left the facility several weeks later feeling even weaker and sicker, was hospitalized again and was found to have heart failure.

In recent years, doctors have been urged to treat high blood pressure more aggressively, especially in older people. My mother’s doctors seemed intent on lowering her blood pressure despite what I thought were side effects that were diminishing her quality of life.

In 2014, the American Society of Hypertension recommended a target pressure of 140 over 90 or lower for most adults and 150 over 90 or lower for those 80 and older.

In 2015, the SPRINT: Systolic Blood Pressure Intervention Trial showed that seniors at high risk for cardiovascular events but without diabetes had lower rates of heart attack, heart failure, stroke or death when they aimed for a systolic blood pressure of less than 120 than when the target was less than 140.

That study helped lead to the guidelines — announced by the American Heart Association, the American College of Cardiology and nine other health groups in November 2017 — that put the new normal at less than 120 over 80.

Although my mother’s ordeal began in the summer of 2017, before the latest guidelines were released, many doctors were already acting on the SPRINT findings.

But in the SPRINT study, patients’ blood pressure was measured after five minutes of quiet rest, and medication dose was based on the mean of three readings. That’s much different from the rushed atmosphere my mother encountered.

That study also did not recommend a blood pressure goal for patients in nursing homes or with advanced illness and limited life expectancy. Although my mother did not meet those criteria last summer, I think her increased frailty and steep decline put her close. I think doctors should have relaxed her blood pressure target and lowered her medication dose, monitoring her closely, rather than going by blood pressure standards meant for elderly people who are healthier.

The SPRINT study also found that intensive reductions in high blood pressure increased the likelihood of abnormally low blood pressure, fainting, abnormalities of electrolytes such as sodium, potassium and calcium, and acute kidney injury or failure.

A conversation with Michael Rich, a geriatric cardiologist at Washington University School of Medicine in St. Louis, made me realize I should have insisted that doctors consider my mother’s age and quality of life.

Rich, who wrote a recent editorial in the Journal of the American Geriatrics Society on a study about some of the risks of the SPRINT blood pressure targets, said blood pressure goals could be relaxed in people with a limited life expectancy and other serious medical problems.

“Ultimately it should be a shared decision-making process where the person’s goals and preferences of how they want to spend the rest of their life becomes an important factor in how to treat their medical problems,” Rich said.

“In some people, 120 might be too low; they might be having side effects like dizziness, falls; a lot depends on the individual, and what’s too low is partly dependent on whether or not the person is having symptoms related to it.”

Medication dosages become trickier to adjust and side effects may increase as people age because “metabolism changes, and the absorption, the distribution in the body and the elimination of most drugs is affected by aging,” Rich said.

“That predisposes older individuals to higher risks for side effects from most medications,” he said. “Therefore, often doses need to be adjusted in older individuals, typically downward in order to get an equivalent effect to younger individuals without increasing side effects.”

Jeff Williamson, chief of gerontology and geriatric medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and one of the authors of the SPRINT study, stressed that, among older, independent adults, those with a systolic blood pressure lower than 130 had “the lowest risk for stroke, heart failure and heart attack — all conditions that can result in a person losing the ability to live at home.”

But Williamson also said there was some room for flexibility.

“Many patients say to me, ‘I just don’t feel well at the lower goal’ or ‘I’m having trouble getting there,’” he said.

“So we agree on a little bit higher goal for them, knowing 140 is still better than 150 in terms of reducing the risk of stroke or heart failure.”

For patients with not more than a year to live, Williamson said, he would be even less intense about blood pressure goals.

“I might say, ‘Let’s try a lower dose on this blood pressure medicine to see if you feel a little better.’ Now it’s all about quality of life and not quantity,” he said.

Leslie Kernison, who has a blog about health while aging, suggests that patients or their caregivers keep a log of how a patient feels when medications are started or changed and ask doctors about possible side effects of drugs.

“Patients should ask doctors about the benefits and risks of blood-pressure treatment,” she said. “I think most people are just not prepared to ask questions.” Kernison is a geriatrician.

Those are the conversations I wish my mother and I had had.

We finally got there — a few weeks before my mother went into cardiac arrest and died this month. By that time, a geriatric nurse practitioner who was making home visits listened to us about my mother’s symptoms and adjusted her medications accordingly.

He was satisfied when my mother’s systolic blood pressure was a little over 150.

“We’re not trying to get her blood pressure down to 120,” he said. “That would be crazy.”