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Gait Speed: Comment on “Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults”

Gait Speed: Comment on “Rethinking the Association of High Blood Pressure With Mortality in... In 1988, Matilla et al1 reported that, among the very old, elevated systolic and diastolic blood pressure (BP) were associated with longer survival. The differences were not subtle. The 5-year survival of those with systolic BPs greater than 200 mm Hg were almost twice as high as those with levels of 120 to 140 mm Hg. Over the ensuing 25 years, a substantial number of population-based studies have reported the same findings: in those older than 85 years (or older than 80 years in some studies), high BP is an excellent prognostic sign.2,3 Perhaps the most rigorous assessment came from the Framingham Study, which reported that the strong positive association of BP with cardiovascular mortality was reversed between the ages of 75 and 85.4 Importantly, no population-based study has found the opposite, that high BP is a marker for bad outcomes in octogenarians. Conversely, “normal” BP is bad. Perhaps the worst sign is falling BP.5 This set of observations has been one of the best-kept secrets in medicine. In my experience, many physicians find the information offensive and its proselytizers suspect. After all, the recognition and effective treatment of hypertension has been among the greatest medical and public health accomplishments of the latter 20th century. Anyone with a message that threatens this progress might be dangerous. Why might high BP be a good sign in those older than 80 years? Diehr and colleagues6 noted that very old populations represent mixtures of those who are aging with those who are dying. They showed a steady decrease in BP in the 3 years before death in the very old. In other words, high BP is only a good sign in very old age because many of those with “normal” BP have it for bad reasons. Additional evidence for this concept comes from longitudinal studies of somewhat younger populations. Several groups reported that higher levels of systolic or diastolic BP predicted lower mortality in those older than 70 years, but this relationship was eliminated and in some cases reversed if the analyses controlled for the presence of comorbidity, level of physical functioning, and other indicators of overall health status.2 In this regard, normal levels of BP may be seen as a marker for frailty, and hypertension, a marker for robustness. Another layer of complexity is added when we consider the question of treatment of hypertension in the very old. Of the 4 early randomized trials that included subjects older than 80 years, 3 reported interactions between age and treatment, with no benefit or adverse effects of treatment in those older than 80 years.2,7 These findings were later contradicted by the results of the large Hypertension in the Very Elderly (HYVET) trial, which found lower mortality in the treatment arm in octogenarians with combined systolic and diastolic hypertension.8 The participants in HYVET were on average healthier, with fewer comorbidities, than typical community-dwelling octogenarians.9 Taking all of these studies together, I draw the following conclusions. The older the population, the smaller is the proportion of robust individuals. Many robust, very old individuals have hypertension. Antihypertensive treatment in those individuals is beneficial. Frail older individuals are less likely to have hypertension, and treating those who do may produce bad outcomes. How can we identify those “frail” individuals? Geriatricians have been struggling to identify a straightforward way to operationalize the concept of frailty into measureable variables. We know frailty when we see it, but subjective impressions are little valued in an evidence-based environment. Standardized measures of frailty have been developed, but they are better suited for research settings—not the clinic. Gait speed may be the answer. In this issue of Archives, Odden et al10 demonstrate that gait speed alone can distinguish those older subjects for whom high BP has the same significance as in younger populations vs those where hypertension is not associated with increased mortality. As in other studies of gait speed, Odden et al10 set the cutoff at 0.8 m/s, which is approximately 1.8 miles/h, or a 33-minute mile. Individuals 65 years and older who walk faster than 0.8 m/s have the expected relationship between BP and mortality. For those who walk more slowly, there is no clear relationship, and for those who were unable to complete the test, high BP predicted survival. The importance of the contribution of Odden et al10 is 2-fold, in my opinion. First, it is another demonstration of the utility of gait speed in understanding the health status of elderly individuals.11,12 The beauty of gait speed is that it is easily measureable and reproducible, and captures much of the clinical construct of frailty.11,12 As recently noted by Studenski,11 gait speed is a strong predictor of many important outcomes, including subsequent functional decline and disability, hospitalization, nursing home placement, surgical outcomes, and survival. The second important contribution by Odden et al10 is a better understanding of the complexities of BP in old age. Geriatricians are uncomfortable using age-based guidelines because heterogeneity in all physiologic processes increases with age. There is no such thing as an “average octogenarian.” Despite this appreciation, we were confronted with a set of age-based findings related to hypertension in elderly adults. Odden et al10 suggest that a simple test—as easily accomplished as recording a temperature or BP—will allow clinicians to categorize older individuals into those in whom high BP is clearly associated with bad outcomes vs those in whom the relationship is unclear or reversed. The realization of the importance of gait speed comes at the same time as increasing calls for individualizing the approach to older patients—the realization that guideline-based care is inappropriate for octogenarians, particularly when the guidelines were developed from data generated on younger populations. Among elderly adults, gait speed may evolve to become the most important of vital signs. Back to top Article Information Correspondence: Dr Goodwin, Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Rte 0177, Galveston, TX 77555 (jsgoodwi@utmb.edu). Published Online: July 16, 2012. doi:10.1001/archinternmed.2012.2642 Financial Disclosure: None reported. References 1. Mattila K, Haavisto M, Rajala S, Heikinheimo R. Blood pressure and five year survival in the very old. Br Med J (Clin Res Ed). 1988;296(6626):887-8893129061PubMedGoogle ScholarCrossref 2. Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol A Biol Sci Med Sci. 2003;58(7):653-65812865483PubMedGoogle ScholarCrossref 3. Satish S, Freeman DH Jr, Ray L, Goodwin JS. The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc. 2001;49(4):367-37411347778PubMedGoogle ScholarCrossref 4. Cupples LA, D’Agostino R. Some risk factors related to the annual incidence of cardiovascular disease and death using pooled repeated biennial measurements: Framingham Heart Study, 30-year follow-up. In: Kannel WB, Wolf PA, Garnson RJ, eds. The Framingham Study: An Epidemiological Investigation of Cardiovascular Disease, Section 34. Washington, DC: National Heart, Lung and Blood Institute, US Dept of Health and Human Services Public Health Services, National Institutes of Health; 1987. NIH publication 87-2703 5. Satish S, Zhang DD, Goodwin JS. Clinical significance of falling blood pressure among older adults. J Clin Epidemiol. 2001;54(9):961-96711520657PubMedGoogle ScholarCrossref 6. Diehr P, Williamson J, Burke GL, Psaty BM. The aging and dying processes and the health of older adults. J Clin Epidemiol. 2002;55(3):269-27811864798PubMedGoogle ScholarCrossref 7. Gueyffier F, Bulpitt C, Boissel J-P, et al; INDANA Group. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. Lancet. 1999;353(9155):793-79610459960PubMedGoogle ScholarCrossref 8. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887-189818378519PubMedGoogle ScholarCrossref 9. Abramov D, Cheng H. Controversy in treating the oldest old with hypertension: is the hypertension in the very elderly trial the final answer? J Am Geriatr Soc. 2009;57(3):570-57119278408PubMedGoogle ScholarCrossref 10. Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty [published online July 16, 2012]. Arch Intern Med. 2012;172(15):1162-1168Google Scholar 11. Studenski SA. Gait speed in hospitalized older people. Arch Intern Med. 2012;172(4):358-35922371923PubMedGoogle ScholarCrossref 12. Ostir GV, Berges I, Kuo YF, Goodwin JS, Ottenbacher KJ, Guralnik JM. Assessing gait speed in acutely ill older patients admitted to an acute care for elders hospital unit. Arch Intern Med. 2012;172(4):353-35822371922PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Gait Speed: Comment on “Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults”

Archives of Internal Medicine , Volume 172 (15) – Aug 13, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.2642
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Abstract

In 1988, Matilla et al1 reported that, among the very old, elevated systolic and diastolic blood pressure (BP) were associated with longer survival. The differences were not subtle. The 5-year survival of those with systolic BPs greater than 200 mm Hg were almost twice as high as those with levels of 120 to 140 mm Hg. Over the ensuing 25 years, a substantial number of population-based studies have reported the same findings: in those older than 85 years (or older than 80 years in some studies), high BP is an excellent prognostic sign.2,3 Perhaps the most rigorous assessment came from the Framingham Study, which reported that the strong positive association of BP with cardiovascular mortality was reversed between the ages of 75 and 85.4 Importantly, no population-based study has found the opposite, that high BP is a marker for bad outcomes in octogenarians. Conversely, “normal” BP is bad. Perhaps the worst sign is falling BP.5 This set of observations has been one of the best-kept secrets in medicine. In my experience, many physicians find the information offensive and its proselytizers suspect. After all, the recognition and effective treatment of hypertension has been among the greatest medical and public health accomplishments of the latter 20th century. Anyone with a message that threatens this progress might be dangerous. Why might high BP be a good sign in those older than 80 years? Diehr and colleagues6 noted that very old populations represent mixtures of those who are aging with those who are dying. They showed a steady decrease in BP in the 3 years before death in the very old. In other words, high BP is only a good sign in very old age because many of those with “normal” BP have it for bad reasons. Additional evidence for this concept comes from longitudinal studies of somewhat younger populations. Several groups reported that higher levels of systolic or diastolic BP predicted lower mortality in those older than 70 years, but this relationship was eliminated and in some cases reversed if the analyses controlled for the presence of comorbidity, level of physical functioning, and other indicators of overall health status.2 In this regard, normal levels of BP may be seen as a marker for frailty, and hypertension, a marker for robustness. Another layer of complexity is added when we consider the question of treatment of hypertension in the very old. Of the 4 early randomized trials that included subjects older than 80 years, 3 reported interactions between age and treatment, with no benefit or adverse effects of treatment in those older than 80 years.2,7 These findings were later contradicted by the results of the large Hypertension in the Very Elderly (HYVET) trial, which found lower mortality in the treatment arm in octogenarians with combined systolic and diastolic hypertension.8 The participants in HYVET were on average healthier, with fewer comorbidities, than typical community-dwelling octogenarians.9 Taking all of these studies together, I draw the following conclusions. The older the population, the smaller is the proportion of robust individuals. Many robust, very old individuals have hypertension. Antihypertensive treatment in those individuals is beneficial. Frail older individuals are less likely to have hypertension, and treating those who do may produce bad outcomes. How can we identify those “frail” individuals? Geriatricians have been struggling to identify a straightforward way to operationalize the concept of frailty into measureable variables. We know frailty when we see it, but subjective impressions are little valued in an evidence-based environment. Standardized measures of frailty have been developed, but they are better suited for research settings—not the clinic. Gait speed may be the answer. In this issue of Archives, Odden et al10 demonstrate that gait speed alone can distinguish those older subjects for whom high BP has the same significance as in younger populations vs those where hypertension is not associated with increased mortality. As in other studies of gait speed, Odden et al10 set the cutoff at 0.8 m/s, which is approximately 1.8 miles/h, or a 33-minute mile. Individuals 65 years and older who walk faster than 0.8 m/s have the expected relationship between BP and mortality. For those who walk more slowly, there is no clear relationship, and for those who were unable to complete the test, high BP predicted survival. The importance of the contribution of Odden et al10 is 2-fold, in my opinion. First, it is another demonstration of the utility of gait speed in understanding the health status of elderly individuals.11,12 The beauty of gait speed is that it is easily measureable and reproducible, and captures much of the clinical construct of frailty.11,12 As recently noted by Studenski,11 gait speed is a strong predictor of many important outcomes, including subsequent functional decline and disability, hospitalization, nursing home placement, surgical outcomes, and survival. The second important contribution by Odden et al10 is a better understanding of the complexities of BP in old age. Geriatricians are uncomfortable using age-based guidelines because heterogeneity in all physiologic processes increases with age. There is no such thing as an “average octogenarian.” Despite this appreciation, we were confronted with a set of age-based findings related to hypertension in elderly adults. Odden et al10 suggest that a simple test—as easily accomplished as recording a temperature or BP—will allow clinicians to categorize older individuals into those in whom high BP is clearly associated with bad outcomes vs those in whom the relationship is unclear or reversed. The realization of the importance of gait speed comes at the same time as increasing calls for individualizing the approach to older patients—the realization that guideline-based care is inappropriate for octogenarians, particularly when the guidelines were developed from data generated on younger populations. Among elderly adults, gait speed may evolve to become the most important of vital signs. Back to top Article Information Correspondence: Dr Goodwin, Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Rte 0177, Galveston, TX 77555 (jsgoodwi@utmb.edu). Published Online: July 16, 2012. doi:10.1001/archinternmed.2012.2642 Financial Disclosure: None reported. References 1. Mattila K, Haavisto M, Rajala S, Heikinheimo R. Blood pressure and five year survival in the very old. Br Med J (Clin Res Ed). 1988;296(6626):887-8893129061PubMedGoogle ScholarCrossref 2. Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol A Biol Sci Med Sci. 2003;58(7):653-65812865483PubMedGoogle ScholarCrossref 3. Satish S, Freeman DH Jr, Ray L, Goodwin JS. The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc. 2001;49(4):367-37411347778PubMedGoogle ScholarCrossref 4. Cupples LA, D’Agostino R. Some risk factors related to the annual incidence of cardiovascular disease and death using pooled repeated biennial measurements: Framingham Heart Study, 30-year follow-up. In: Kannel WB, Wolf PA, Garnson RJ, eds. The Framingham Study: An Epidemiological Investigation of Cardiovascular Disease, Section 34. Washington, DC: National Heart, Lung and Blood Institute, US Dept of Health and Human Services Public Health Services, National Institutes of Health; 1987. NIH publication 87-2703 5. Satish S, Zhang DD, Goodwin JS. Clinical significance of falling blood pressure among older adults. J Clin Epidemiol. 2001;54(9):961-96711520657PubMedGoogle ScholarCrossref 6. Diehr P, Williamson J, Burke GL, Psaty BM. The aging and dying processes and the health of older adults. J Clin Epidemiol. 2002;55(3):269-27811864798PubMedGoogle ScholarCrossref 7. Gueyffier F, Bulpitt C, Boissel J-P, et al; INDANA Group. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. Lancet. 1999;353(9155):793-79610459960PubMedGoogle ScholarCrossref 8. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887-189818378519PubMedGoogle ScholarCrossref 9. Abramov D, Cheng H. Controversy in treating the oldest old with hypertension: is the hypertension in the very elderly trial the final answer? J Am Geriatr Soc. 2009;57(3):570-57119278408PubMedGoogle ScholarCrossref 10. Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty [published online July 16, 2012]. Arch Intern Med. 2012;172(15):1162-1168Google Scholar 11. Studenski SA. Gait speed in hospitalized older people. Arch Intern Med. 2012;172(4):358-35922371923PubMedGoogle ScholarCrossref 12. Ostir GV, Berges I, Kuo YF, Goodwin JS, Ottenbacher KJ, Guralnik JM. Assessing gait speed in acutely ill older patients admitted to an acute care for elders hospital unit. Arch Intern Med. 2012;172(4):353-35822371922PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 13, 2012

Keywords: hypertension,older adult,walking speed

References