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What is the evidence for treating hypertension in older people with dementia? A Systematic Review.
L. Beishon, Dr. J. Harrison, Dr. S. Conroy Mean trial quality was high (mean Van Tulder score 13.3/16).
Hypertension is a prevalent condition in older people • All studies were RCTs and included patients with mild to(~50%), the treatment of which significantly reduces lowering • Only one study included patients from a care home setting6, the blood pressure in the frail population with concomitant majority of participants were community dwelling2-7.
dementia could worsen cognitive outcomes2, increase falls3 • There were extensive exclusion criteria for many major co-and even mortality4. Certainly, current NICE guidelines fail morbidities (E.g. Heart failure)1-7.
to discuss hypertension in patients with dementia5.
All trials reported baseline and follow up MMSE, however not allreported blood pressure changes at follow up (Table 2).
There is a paucity of research into the management ofhypertension in the frail older population with dementia.
The aim of this review is to assess this evidence gap.
Four databases were screened from inception until August2011, (Medline 1966-2011, EMBASE 1988-2011 week 41,Cochrane Library, National research register archives) withindividual search strategies and limits applied. A total of1178 abstracts were screened by one reviewer and 23 papers were selected (Figure 1). These were assessedindependently by 2 reviewers using the Van Tulder Score. 7 Table 2. Individual study characteristics1-7. *Not at follow up. ** Only in studies were suitable for inclusion (Table 1).
Ohrui6 - brain penetrating ACEi provided a lower decline inMMSE, unrelated to blood pressure lowering.
Kume7 - telmisartan conferred a positive effect on cognition overamlodipine.
Sze8 and Morich9 - beneficial effects of nimodipine on cognition,with greater effect in those with poorer cognition at baseline.
PROGRESS1 - the largest and most prominent study included inthis review. There is a clear reduction in incident dementia, butnot seen in patients with existing dementia.
Pantoni10 - some benefit of antihypertensive.
Richard11 - no statistically significant changes.
There was considerable heterogeneity between studies, makingcomparisons difficult.
The benefits seen with specific antihypertensive may not occurthrough The studies evaluated in this review had small sample sizes, theparticipants were mainly community dwelling, had limited co-morbidities and milder forms of dementia. This fails to reflect Figure 1. Flow diagram illustrating paper the frail, older population where management decisions may The outcomes studied were often limited and fail to consider thebroader issues within this area. This review emphasises the needfor further research into the frail older population.
References: 1. Tzourio 2003, Arch Intern 6. Ohrui 2004, Neurology. 63(7):1324-25.
8. Sze 1998. Acta Neurologica Scandinavica . 3. Tinetti 2003, The New England Journal 9. Morich 1996. Clinical Drug Investigation.
4. Fisher 2005, J Am Geriatr Soc.1313-20.
10. Pantoni 2005. Stroke. 36(3):619-24.
11. Richard 2009. Journal of the American Table 1. Inclusion and exclusion criteria for the review.

Source: http://www.collegeofmedicine.org.uk/sites/default/files/lucybeishon.pdf

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