Blood pressure behavior in the nursing home: Implications for diagnosis and treatment of hypertension

OBJECTIVES: To determine patterns of elevated blood pressure (BP) behavior, their clinical correlates, and the relationship to diagnosis and management of hypertension. DESIGN: A cross-sectional, prevalence survey. SETTING: Forty-five nursing homes owned or managed by a large national chain. PARTICIPANTS: A total of 857 older residents (mean age = 84 years). MEASUREMENTS: Supine and standing (1 and 3 minutes) BP and heart rate, taken four times in one day (before and after breakfast, and before and after lunch) by trained nurses using a random zero sphygmomanometer; medication profile; active medical diagnoses; functional status; sociodemographics. RESULTS: The prevalence of a single, elevated, supine systolic pressure (greater than or equal to 160 mm Hg) was 14.3%, and of two to four elevated measures was 14.9%. The pre-breakfast reading was consistently the highest, and mean systolic pressures decreased;after breakfast. Compared with those not treated, older residents taking antihypertensive medications had higher systolic pressures at all times and showed the same pattern of decline after breakfast. Isolated diastolic hypertension was uncommon (0.9%). Cardiovascular disease, orthostatic hypotension, diabetes, and use of angiotensin converting enzyme inhibitors or calcium channel blockers were more prevalent among older residents who had elevated pressures on multiple occasions (P < .03). Successful antihypertensive treatment was associated with a lower prevalence of orthostatic hypotension. Diuretic use was more likely to be associated with blood pressure control. CONCLUSION: The diagnosis of hypertension in frail older people would benefit from multiple, within-day measures, including postural BP, taken before and after meals. Diuretic use alone, or in conjunction with ACE inhibitors or calcium channel blockers, was more likely to be associated with normalized blood pressures.