Older adults accounted for over 12 million hospitalizations in 2015. During hospitalization, blood pressure (BP) may fluctuate as a result of acute illness, stress, and new medication exposures. Though the long-term benefits of strict BP control on older adults? cardiovascular risk are well established, no research has shown a short-term benefit to treating asymptomatic elevated BPs during hospitalization. Despite this evidence gap, single-center studies indicate older adults commonly receive intensive BP treatments during hospitalization for non-cardiac conditions. Older adults are at increased risk of medication-related adverse events while being treated for and recovering from acute illness, therefore, understanding the benefits and harms of intensively treating elevated BPs during hospitalization is critically important. While hospitalized for conditions unrelated to hypertension, older adults may be particularly susceptible to harms resulting from BP overtreatment, including symptomatic orthostasis, falls, and acute kidney injury. To date, prior studies have not assessed the effect of intensive inpatient BP treatment on clinical outcomes during hospitalization. The importance of addressing the knowledge gaps surrounding inpatient BP management is highlighted by prior research on inpatient blood glucose management which demonstrated that applying outpatient blood glucose treatment targets to the hospital setting results in increased risks of in-hospital hypoglycemia and mortality. The objective of this application is to characterize the epidemiology and outcomes of intensively treating elevated BPs in older adults during hospitalization. We propose a retrospective cohort study of all older adults hospitalized for non- cardiac conditions in the national Veteran?s Affairs Health System between 2013 and 2015. First, we will describe how often elevated inpatient BPs are treated intensively among hospitalized older adults and evaluate patient characteristics associated with intensive BP management. We will use log binominal or Poisson regression to obtain direct estimates of relative risks of intensive BP treatment by key patient characteristics including prior outpatient BP control, polypharmacy, multi-morbidity, dementia, and limited life expectancy. Second, we will evaluate the impact of intensive inpatient BP treatment on in-hospital clinical outcomes including potential harms (e.g. falls, acute kidney injury) and potential benefits (reduction in acute CV events). We will compare in-hospital outcomes of older adults who did and did not receive intensive BP treatment using propensity score matching to control for confounding by indication. We will conduct pre-specified subgroup analyses to determine whether patients with multi-morbidity, dementia, or limited life expectancy have increased risk of in-hospital harms. This study will fill a vital knowledge gap and provide key guidance to inform inpatient BP treatment decisions for older adults. These data will serve as the foundation for future studies to design and test a pilot intervention to guide the individualization of elevated BP treatment decisions during the peri-hospitalization period based upon older adults? likelihood to benefit and risk of adverse outcomes.
The proposed research is relevant to public health because more than 30 million older adults have hypertension and one in seven older adults are hospitalized annually. Patient-centered information on the clinical outcomes of blood pressure management during hospitalization will have broad implications for patient safety, treatment decision-making, identification of older adults at high risk for poor outcomes from overtreatment, and the development of interventions to improve chronic disease management during the peri- hospitalization period. Thus, the proposed research is directly relevant to the National Institute on Aging?s mission to promote the health and well-being of older adults.
