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 Nursing Home Residents Left Out of New Cholesterol, Blood Pressure Guidelines, Geriatricians Worry

New guidelines on cholesterol and high blood pressure appear to have left nursing home residents behind, two geriatricians are claiming.

Late last fall, the American College of Cardiology and the American Heart Association published new
guidelines for treating high cholesterol that, among other things, recommended increased use of statins to fight high cholesterol.

Earlier this year, the Eighth Joint National Committee for
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure released new guidelines that suggested that elderly patients might do just fine with higher-seeming blood pressure levels.

But in reviewing each of those expert panels’ findings, St. Louis University geriatricians Angela Sanford and John Morley find they don’t offer much help to the frail and elderly.

“A recent editorial in the Annals of Internal Medicine suggests that for cholesterol guidelines, ‘Godot’ has finally arrived,” Sanford and Morley say in their own editorial, published in the Journal of the American Medical Directors Association. “However, it would seem that geriatricians are still waiting for ‘Godot’ to arrive and, thus, we are provided a tabula rasa
with no recommendations for our population.”

The Joint
 Committee guidelines “are a little less age friendly,” Sanford and Morley say.

Morley is the editor of JAMDA. Sanford is his faculty colleague at Saint Louis University School of Medicine's geriatric division. 

As to the cholesterol guidelines, the “authors acknowledge that most randomized controlled trials do not include those older than 75 years of age and, therefore, research data in this population is lacking, particularly regarding the role of statins in primary preventions of CVD [cardiovascular disease],” Sanford and Morley say.

If the cholesterol guidelines are followed to the letter, the percentages of “young” old (those between 60 and 75) would leap dramatically, Sanford and Morley say.

“This is particularly troublesome, as the new guidelines could result in greater than 45 million people (one in three adults) who do not have established CVD being placed on statin therapy,” Sanford and Morley say.

The cholesterol guideline “authors clearly tried to provide evidence-based recommendations,” Sanford and Morley acknowledge; the problem is, there just don't seem to be a lot of data on the effect of statins on the frail elderly. And that’s a little worrying, Sanford and Morley say.

“A high rate of statin use has been reported in some nursing homes,” Sanford and Morley say. “Statins cause myopathy in some elderly and may be a cause of falls. In additional, statins may worsen dementia in older persons.”

Earlier this year, AMDA teamed up with Consumer Reports and the ABIM Foundation’s “Choosing Wisely” campaign to warn nursing home residents about the possible dangers of statins.

Meanwhile, it’s certainly progress that the elderly are being offered a slightly higher threshold for high blood pressure, but, overall, the new guidelines are—if anything—“a little less age friendly,” Sanford and Morley argue.

“The recommendations fail to meet a reasonable standard for persons over 80 years of age,” the editorial states. “Epidemiologic studies have suggested that persons in their eighties and beyond may do better with higher blood pressures.”

That the Joint Committee didn’t address the frail elderly is a “major flaw” in the study, Sanford and Morley claim. And their guidelines don’t “make any attempt to address the fact that most blood pressures are not appropriately measured.”

“White coat hypertension was shown to be present in 30 percent of nursing residents when 24-hour ambulatory blood pressures were measured,” Sanford and Morley say.

“White coat hypertension” refers to the (false) readings that result from patients' anxieties about being examined by doctors, or in clinical settings.

“It is recognized that some geriatric experts would support the [Joint Committee’s recommendations], but there does not appear to be much evidence to support their viewpoint,” Sanford and Morley say.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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