Pharmacists should be aware of the potential for the over interpretation of guidance for the treatment of hypertension particularly for older, frail people who may experience harm from antihypertensive therapy, say Clare Howard and Dr Lawrence Brad

A strategy was launched last year to identify the up to 4.2 million people in England who are thought to be living with undiagnosed high blood pressure. Hypertension often has no symptoms, but if left untreated can lead to fatal heart attacks, strokes, kidney disease and vascular dementia.

With the NHS expanding blood pressure checks in community pharmacies, the national campaign is urging those aged 40 years and over to get a free blood pressure test at a participating pharmacy. This campaign is backed by British Heart Foundation, Stroke Association, Heart Research UK, Blood Pressure UK, May Measurement Month, British Society for Heart Failure, and others.

It is clearly in the public interest to have a national campaign to identify those at risk from undiagnosed or untreated hypertension. Many of those people will be older and hypertension is an important risk factor for cardiovascular disease and the benefits of treating hypertension in older people is well recognised.

However, in our role in delivering the Polypharmacy Action Learning Sets, we have started to hear about some worrying unintended consequences of what could be described as over interpretation of this policy particularly for older, frail people who may experience harm from antihypertensive therapy.

Many hypertension treatment guidelines advise using lower BP targets in those aged over 80 and highlight concerns around antihypertensive therapy in older frail people such as the risk of falls, the risk of hypotension particularly orthostatic hypotension and post-prandial hypotension. NICE guidance states that for those over 80 with multimorbidity clinical judgment should be used.

Polypharmacy and long-term conditions

The Polypharmacy Action Learning Sets (ALS) were first developed by Health Innovation Wessex (formerly Wessex Academic Health Science Network). This interactive, educational programme was developed primarily for GPs to improve their confidence to stop medicines that were no longer clinically appropriate, particularly in older people taking large number of medicines.

Since its inception, we have published an evaluation showing the impact on clinicians who attend the three half-day sessions. We have opened the training up to pharmacists and other primary care prescribers and, in response to the policy of the National Over Prescribing review report, we have been funded to scale this training up across England as part of the Health Innovation Network’s Polypharmacy Programme ‘Getting the balance right’.

To date, we have trained over 1,100 GPs and pharmacists and other prescribers involved with caring for people with multiple long-term conditions. This work has continued to be highly evaluated.

During the training, geriatricians support delegates to grow their confidence in the management of complex medication reviews, often (but not exclusively) in older people with frailty. We ask delegates to explore the personal and environmental barriers that can contribute to leaving older patients on medicines which we know may cause more harm than good.

Over 1 million people in England take 10 or more medicines for long-term conditions and almost half of them are aged 75 and over, according to NHS BSA polypharmacy prescribing comparators.

The number of older people living longer with multiple long-term conditions will continue to increase. Yet the health service often treats single organ conditions without understanding the other issues that a patient (or their carer) may be dealing with.

We promote the importance of shared decision making with the patient and encourage delegates to understand from our older patients what matters most to them, as they reach their later years when their physiological reserves to safely metabolise multiple medicines are diminished. We encourage prescribers to take a fresh look at the person in front of them and not to injudiciously apply guidance which may have been developed based on clinical evidence from much younger, fitter patients.

Might pharmacists feel pressure to prescribe?

In recent months, we have been told by some of the pharmacist delegates on the ALS programme that they are increasingly being asked to review very old, frail patients in their clinics who have had a one-off raised blood pressure reading, and that these pharmacists can sometimes feel pressure to start an antihypertensive in order to meet targets.

This could be a concerning unintended consequence of the policy to identify and treat undiagnosed hypertension.

There is now growing evidence that older people, particularly those over 80 may suffer more harm from starting antihypertensive medication.

Older people are at greater risk from the consequences of falls. It has long been established that antihypertensives can be associated with an increased risk of serious fall injuries in older adults with hypertension and multiple other conditions and that aggressive treatment of hypertension in older people may be associated with risk.

Take care when considering hypertension

Therefore, it important that sensible initiatives to identify and treat undiagnosed hypertension in people at risk from premature heart attacks and strokes are not injudiciously applied to older frail people where the benefits of therapy may be marginal or may even be harmful.

Community pharmacy and general practice could work together to ensure that there are clear, shared goals in place about who to refer and to flag where patients have received a shared decision-making consultation and where the Benefits, Risks, Alternatives and do Nothing (BRAN) were explored and agreement about next steps reached. Documentation of this in the patient’s notes are vital to ensure the whole team is aware of the patient’s wishes.

This work is NOT about denying medicines to older people simply because of their age. It is aiming to increase understanding that prescribing for older, frail people needs a different approach in order that we don’t inadvertently expose them to harm.

Before any medicine is started in an older person with frailty, the prescriber should be satisfied that they have spoken carefully to the patient (or their carer) about the benefits and risks of any treatment, the alternatives to drug therapy and that doing nothing can be the right course of action.

The prescriber should understand how many other medicines the person is already prescribed and how they are managing with multiple medicines.

An exploration of what is important to the patient is vital to true shared decision making.

Often the evidence won’t tell us exactly how to prescribe in older frail people as (even now) relatively few studies are carried out in this group. Therefore, the right course of action can be reached via an agreement between the patient and their prescriber with each bringing their knowledge, expertise and perspective to the discussion.

Large scale initiatives that can be seen to override this opportunity may cause more harm than good in vulnerable people, who deserve more from their health system.

Clare Howard FFRPS FRPharmS is the clinical lead for the Health Innovation Network Polypharmacy: Getting the Balance Right, and co-founder of the Polypharmacy Action Learning Sets. Dr Lawrence Brad is a GP and co-founder of the Polypharmacy Action Learning Sets