Study: Discontinuing antihypertensive drugs not recommended in elderly with dementia in nursing home

Many elderly people have long used blood pressure-lowering medications to lower their risk of developing cardiovascular disease. But as the health of the elderly declines, the balance of pros and cons of these drugs may change. For example, the drugs, which are meant to be preventive, may do more harm than good.

Researchers at the LUMC Center for Gerontology and Geriatrics wondered: does discontinuing anti-hypertensive drugs step by step lead to less misunderstood behavior, such as aggression and apathy, and to a better quality of life? Important questions also on the minds of caregivers, the elderly and their families.

Dizziness and tendencies to fall

Professor in Primary Care Medicine Jacobijn Gussekloo of the Department of Public Health and Primary Care is the project leader of the study: “From observations, we knew that vulnerable elderly people taking blood pressure lowering drugs can have dizziness and tendencies to fall, possibly because the body does not get enough oxygen everywhere due to low blood pressure. Also, elderly people with dementia show so-called neuropsychiatric symptoms, such as aggression and apathy, possibly because the brain starts working differently due to too low blood pressure.”

GP and co-project leader Rosalinde Poortvliet adds: “The main question was whether there is a causal relationship: are these symptoms a direct result of the blood pressure-lowering drugs, or are there other effects? That had never been properly investigated before. For example, it could also be that the combination with other drugs is causing the side effects.”

Not previously studied

The study builds on an earlier LUMC study of stopping blood pressure-lowering drugs in people over 75 living at home with mild cognitive decline, such as memory loss and concentration problems. That group was found to have no disadvantages but also no benefits from discontinuing blood pressure-lowering drugs.

In this study, researchers focused on older people with dementia living in nursing homes, a group of older people with frail health. Participants in the study were 205 elderly people with dementia admitted to a nursing home. The researchers divided them into two groups: a discontinuation group, whose participants phased out blood pressure-lowering drugs, and the control group that continued to use the drugs as usual. The study, which ran from 2018, involved 26 elderly care organizations from across the Netherlands.*

Unexpected findings

An independent safety committee recommended in May 2021 that no new participants enter the study because of the safety risk and because participants did not benefit from tapering.

177 participants eventually reached the key measurement point after four months. As expected, the blood pressure of the elderly in the phase-out group had increased markedly. There was no difference in terms of misunderstood behavior or quality of life between the two groups. However, the discontinuation group was found to have a higher risk of a “serious adverse effect,” such as falls or mortality, during the period studied. Because there are clear disadvantages without benefits, the researchers say this is a clear reason to advise against the routine tapering of blood pressure-lowering drugs in elderly people with dementia.

Precise cause impossible to determine

What the exact cause of the negative effects of tapering is, the researchers do not know. Gussekloo: “We think it has to do with the balance in the body, which is so vulnerable in this group of elderly people, that it cannot adapt to the medication change. At least it wasn't that they all got cardiovascular disease or Covid. But whether it has to do with the brain or the heart, for example, we don't know. Ideally we would have done ultrasounds and MRIs, but that is impracticable in this vulnerable group.”

What remains, according to the researchers, is that there is now solid evidence on which caregivers, elders and family members can rely when it comes to whether or not to routinely discontinue blood pressure-lowering medication. “Our aim now is to start putting this evidence into practice,” Gussekloo said. "In that, the promotion of Jonathan Bogaerts, the driving force** within this research, in 2025 is an important step."

Fitting care for the elderly

With the results of their study, the researchers hope to contribute to the development of appropriate medical care for the elderly. It is often thought that it is good to stop preventive medication as the elderly become more frail. The results of this study show that this is not always the case. In short, questions enough for further research. Researchers within the LUMC Center for Medicine for Older People are working hard on this.

* An important part (nine in total) of these organizations cooperate in the field of knowledge sharing within the University Network for the Care Sector South Holland (UNC-ZH), the partnership between the LUMC and eleven care institutions in South Holland.

** Bogaerts spent a lot of time within his PhD program recruiting healthcare organizations and participants. He was also involved in data collection and analysis and helped write the scientific paper.