There is a decrease in mean systolic BP and diastolic BP for more than a decade before death among patients who died at age 60 years or older, according to a large-scale analysis of individual patient trajectories.
The data, published in JAMA Internal Medicine, showed BP decreases were present among those not treated with antihypertensive medications, but the steepest declines were among patients with hypertension, dementia, HF and late-life weight loss.
“Observing individuals with multiple repeated BP measures over time could help clarify the causes underlying trends,” João Delgado, PhD, professor of epidemiology and public health at the Institute of Biomedical and Clinical Science at the University of Exeter Medical School, U.K., and colleagues wrote. “If increasing end-of-life disease explains BP changes, then similar downward BP trajectories should not be observed in age- and sex-matched controls who die much later.”
Using a population-based Clinical Practice Research Datalink, researchers estimated clinically measured systolic BP and diastolic BP trajectories for 20 years before death for 46,634 individuals aged 60 years or older.
Linear systolic BP trends for years 10 to 3 years before death in patients who died were compared with age- and sex-matched controls who survived at least 9 years to separate age from end-of-life associations and avoid health survivor bias, according to the study.
The researchers found that systolic and diastolic BPs were highest at 18 to 14 years before death and decreased progressively onward.
The mean changes in systolic BP from peak values were between –8.5 mm Hg (95% CI, –9.4 to –7.7) for patients dying at age 60 to 69 years to –22 mm Hg (95% CI, –22.6 to –21.4) among patients dying at age 90 years or older.
According to the study results, 64% of participants had systolic BP changes greater than –10 mm Hg.
Individuals not treated with antihypertensive medications showed decreases in systolic BP from 10 to 3 years before death, but mean yearly changes were steepest among those with hypertension (–1.58 mm Hg; 95% CI, –1.56 to –1.6 vs. –0.7 mm Hg; 95% CI, –0.65 to –0.76), dementia (–1.81 mm Hg; 95% CI, –1.77 to –1.87 vs. –1.41 mm Hg; 95% CI, –1.38 to –1.43), HF (–1.66 mm Hg; 95% CI, –1.62 to –1.69 vs. –1.37 mm Hg; 95% CI, –1.34 to –1.39) and late-life weight loss.
“Substantial BP decreases toward the end of life may have implications for treatment monitoring, and decreases in BP may also bias risk estimation and complicate trial design,” Delgado and colleagues wrote.
In an accompanying editorial, James S. Goodwin, MD, from the department of medicine at the Sealy Center on Aging at the University of Texas Medical Branch, discussed challenges for physicians treating the elderly.
“We do not much teach or study or talk about the various trajectories before death,” Goodwin wrote. “To me, that is the real value of the study by Delgado et al and of future studies using the same or similar databases. They should help us dissect out many different trajectories that end in death, to better inform physicians and their patients about what they might expect.” – by Dave Quaile
Disclosures: Delgado and Goodwin report no relevant financial disclosures.