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Hypertension and the older patient in general practice. A comparison of process and outcome for patients on multiple therapies at two practices

Moyez Jiwa, George Freeman, Michael Gordon, Katie McGowan

Background There are now many perceived benefits of polypharmacy in the management of hypertension. With surveys reporting inadequate blood pressure control there are calls for more aggressive management particularly in relation to the older npatient. However, because of the physiological changes of ageing, the risks of polypharmacy are substantial in this group and may undermine efforts to prescribe multiple therapy.Aim To quantify and compare documented efforts to manage hypertension in patients over 75 years of age, treated with multiple agents over a three-year period at two UK general practices.Methods We conducted a retrospective review of computerised and paper medical records. Health records were examined (n = 192) for patients aged 75–80 years registered over three years at two South Yorkshire practices. Included patients had to havebeen taking therapy for high blood pressure since at least October 2000 and been managed on at least two different prescribed drugs. The most recently recorded blood pressure readings before October 2003 were noted. The number of agents and doses throughout the three-year period were recorded. Biochemical and physical side-effects recorded in the notes were included in the analysis. Therapeutic manoeuvres, patient concordance and consultations where blood pressure was taken were recorded.Results Both practices recorded similar efforts to manage hypertension in this age group. There were small differences in clinical practice, though the end-point measurement – proportion of cases with normal blood pressure after three years – was no different between the practices (42% vs. 36%). In general, concordance was noted to be greater in patients who were normotensive by the end of three years. However, logistic regression analysis fitting hypertension at the end of three years as the outcome variable, and general practitioner recording of blood pressure, number of treatment manoeuvres, number of investigations and concordance as explanatory variables failed to demonstrate that any of these factors are useful predictors of a normal blood pressure after three years (r2 = 0.09). Discussion We found that these two practices successfully treated 60% of their older hypertensive patients when using two or more classes of therapy by a defined date at the end of a three-year period. Patients who do not request repeat prescriptions for treatment are more likely to remain hypertensive.However, the data do not suggest that a greater proportion of patients prescribed more than two classes of drugs are more successfully treated than those on two, or that patients taking more classes of drugs had more side-effects.