Optimising Blood Pressure Management in Older People Living with Frailty

Intro

Older adults with reduced physiological reserve are more vulnerable to medication related adverse effects. Hypertensive management may contribute to Orthostatic Hypotension (OH), falls and functional decline. This clinical audit aimed to assess adherence to NICE guidance recommendation regarding Lying/Standing Blood Pressure (LSBP) measurement in adults with hypertension either aged  ≥80 or with symptoms of OH and evaluate whether antihypertensive therapy was appropriately reviewed following recommendations of the British Geriatric Society Pragmatic Prescribing guidelines.

Methods 

A two-cycle retrospective study involving 100 patients discharged from five Older Persons Medicine (OPM) wards. Data collected included Clinical Frailty Score (CFS), LSBP assessment and anti-hypertensive medication pre- and post-admission. Education was provided via a multidisciplinary presentation alongside further informal discussions with nursing staff across OPM wards to address the issues with assessing LSBP such as designated timing. 

Results 

LSBP measurement had a 20% completion rate with CFS 5 = 14%, CFS 6 = 31% and CFS ≥7 = 10%. Post intervention showed a significant improvement in LSBP assessment to 56%, improving at all levels of frailty – 40%, 53% and 33% for CFS 5, 6 and ≥7 respectively. 

ACE-i/ARBs and Calcium channel blockers were more commonly deprescribed with an initial increase in beta-blocker (114%) and diuretic (108%) use, resulting in a minor increase in number of patients on no anti-hypertensive medications at discharge (107%). Cycle 2 showed an almost 200% improvement in patients being deprescribed all anti-hypertensive medications, with a decrease in medication burden among all anti-hypertensive classes. 

Conclusions 

Following the intervention, there was a significant improvement in adherence to LSBP assessment and deprescribing practices. Improving recognition of OH supports safer prescribing practice and prevents medication related harm. Further interventions should focus on multidisciplinary education and identifying system barriers to ensure consistent assessment and individualised blood pressure management in people living with frailty.