OPtimising Treatment for MIld Systolic hypertension in the Elderly (OPTiMISE)
The aims of this study were:
- To safely reduce the amount of blood pressure medication taken by older people using self-monitoring of blood pressure.
- To see if reducing the amount of medication taken by older people results in fewer falls or other harmful events and side-effects.
- To see if reducing the number of blood pressure lowering medications can improve the quality of life of individuals entering older age.
Why is this important?
People are living longer. As a consequence, the number of people living with age-related chronic (long-term) diseases such as diabetes, kidney disease and dementia is also rising. Typically, people will have more than one age-related disease requiring treatment. We call this 'co-morbidity'. Treating patients with co-morbidity can be complex, requiring many different drugs for each condition.
Patients and carers can find this 'polypharmacy' complicated to manage and stick to. For example, correctly managing which tablets to take at what time. Polypharmacy also increases the risk of side effects, harmful drug interactions, or drugs undermining one another's therapeutic effect.
Polypharmacy can also lead to the prescription of even more drugs. For example, a doctor may not realise a patient's symptoms come from a drugs side effects or interactions, and unwittingly prescribe new drugs to counter these.
Of all the chronic conditions older patients tend to suffer from, high blood pressure is the most common. This condition increases the risk of heart attack and stroke. More than half of patients aged 80 years or older will have high blood pressure, many of which may be taking two or more different drugs to control it.
Research has shown that reducing blood pressure with medications can be beneficial. However, in older individuals, large reductions in blood pressure have been linked to an increased risk of falls which can lead to death. Falls can be especially important to older patients as they often mark the point at which they may no longer be able to live alone without specialist care.
Reducing the number of high blood pressure drugs a patient takes may be an ideal way of reducing both the increased risk of falls and death of elderly patients and polypharmacy.
The study took place in the 'real-world' setting of Primary Care (GP surgeries), where its findings will be used in routine clinical care. Participants were patients aged over 80 who had well-controlled blood pressure and took two or more blood pressure lowering drugs.
GPs, from up to 36 general practices, identified patients suitable for the study and invited them to take part. The criteria to be included will be quite broad, rather than focussing on a narrow 'ideal' subset of the population. This meant the results are as generalisable to the wider population as possible.
Patients who agreed to take part were randomly put into either the medication reduction (intervention) or usual care (control) groups.
The medication reduction group had one blood pressure lowering medication removed by their GP. They were then shown how to measure their own blood pressure at home and asked to report to their GP immediately if levels rise too high in the following weeks. Those not willing to self-monitor were asked to return to their GP for an additional safety visit after one month of medication reduction.
Safety was a crucial part of this study. Medication reduction will first be tested on a smaller number of patients to see if it is workable without risk to patients. Those individuals whose blood pressure rose beyond safe levels were put back on the medication they were originally prescribed. In these situations, medication reduction will be deemed unsuccessful, but this approach reduced the likelihood of any patient in the trial suffering adverse events as a result of medication reduction.
Over 540 patients were enrolled in the study.
Although patients and GPs knew who was and wasn't in the medication reduction group, the study was run so that those analysing the data did not. This minimised bias in interpreting the results.
The stud lasted for three months. We hoped to see less than a 10% difference in the number of patients with safe blood pressure levels at three months between the two groups.
We also looked for differences between the groups in 'adverse events' (falls, heart attacks, strokes or death), as well as quality of life using standardised surveys (EQ-5D), functional independence and frailty.
What we have found so far
The initial trial results showed that in some older people, it is possible for GPs to reduce the number of blood pressure lowering medications people take with limited impact on their blood pressure control or quality of life. The trial was conducted in 69 GP surgeries across the Midlands and South of England. A total of 569 participants aged 80 years or older with well-controlled blood pressure taking two or more antihypertensives were included in the study.
Blood pressure medications are proven to reduce a person’s risk of stroke and heart attack, but for some, they may also cause fainting and falls or kidney problems, so called ‘adverse events’. This trial shows that when someone is concerned about the risk of adverse events, it is possible to reduce the number of tablets being taken and still achieve good blood pressure control, which is important for preventing stroke.Dr James Sheppard, University of Oxford
Nearly all (98%) were living with at least 2 chronic conditions, bringing the average number of medications up to four per person. The trial showed over a period of 12 weeks, blood pressure remained well controlled (150 mm Hg or less) in 86.4% of patients in the medication reduction arm and 87.7% of patients in the usual care arm, with two thirds of those in the medication reduction group taking fewer medications at the end of the study. There were no differences in side effect, adverse events or quality of life between groups.
The trial is now in long term follow-up and aims to examine whether there were any differences between groups in hospital admissions or general health after medication reduction. This extension study (OPTiMISE-X) is funded by the British Heart Foundation.
HOW WILL THIS BENEFIT PATIENTS?
Reducing the number of drugs taken by elderly patients should make managing and complying with more complex medication schedules easier for patients and carers.
It could also result in fewer serious falls and their associated complications, such as broken bones and hospitalisation. This would have the combined effect of improving and prolonging quality of life for elderly patients, as well as freeing up NHS resources.
If this research shows blood pressure medication reduction to be effective, it could have a significant impact on future clinical guidelines and patient care. Over 1.2 million older patients throughout the UK are thought to be potentially eligible blood pressure lowering medication reduction right now. This number is expected to rise over the next 30 years as more and more people live beyond 80 years of age