August 2025: Reduction of Antihypertensive Treatment in Nursing Home Residents

The issue

In very old, frail nursing-home residents with low blood pressure, intentionally reducing blood-pressure medicines did not improve survival. In a French randomized trial of 1,048 residents aged ≥80 with systolic BP <130 mm Hg and on ≥2 antihypertensive drugs, a protocol-driven “step-down” strategy lowered pill count and raised systolic BP by about 4 mm Hg compared with usual care, but all-cause mortality was the same (hazard ratio 1.02). Falls, fractures, and major cardiovascular events were also similar between groups.

What do I need to know?

Participants were extremely old (mean age about 90), highly frail, and taking an average of 2.5 antihypertensives. Over a median potential follow-up of 38 months, step-down care reduced antihypertensives from 2.6 to 1.5 per person (versus 2.5 to 2.0 with usual care) and led to a modest systolic increase of 4.1 mm Hg, but this did not translate into fewer deaths or clear functional benefits. All-cause mortality occurred in 61.7% (step-down) versus 60.2% (usual care); major cardiovascular events were 19.3% vs 17.3% (not significant). Safety signals—including falls and fractures—were comparable. The trial suggests that routine deprescribing of antihypertensives in very frail residents with low SBP is feasible and generally safe, but it does not by itself improve survival; decisions should be individualized to symptoms, orthostatic drops, and patient goals.

Potential risk of overtreatment
Frail nursing-home resident with SBP 120–129 mm Hg on multiple antihypertensives, no clear symptoms from low BP.

Recommended Actions

• Review goals of care and discuss whether any drug can be safely paused without jeopardizing compelling indications (e.g., heart failure, arrhythmia).

• Monitor seated and standing BPs, pulse, and dizziness; check for over-sedation and dehydration.

• Consider small step-downs (one medicine at a time) with a clear plan to reinstate if SBP rises ≥160 mm Hg or symptoms appear. NEJMoa2508157

Imminent risk of harm from low BP
Resident has SBP consistently near 110–115 mm Hg or orthostatic symptoms, falls, or poor oral intake.
Recommended Actions

• Prioritize deprescribing of non-essential agents per a prespecified sequence (e.g., taper beta-blockers/loop diuretics; stop others outright), reassessing every 2–4 weeks.

• Track cognition, mobility, and quality-of-life measures alongside BP; adjust fluids and salt as clinically appropriate.

• Coordinate with pharmacy, nursing, and the primary clinician so only one agent changes at a time. NEJMoa2508157

Confirmed intolerance to current regimen
Recurrent syncope, acute kidney injury felt to be BP-related, or repeated falls clearly linked to hypotension.
Recommended Actions

• Implement a structured step-down with close vitals monitoring; document any improvement in dizziness, alertness, or mobility.

• Preserve agents with compelling indications; deprescribe those without, and set individualized SBP targets.

• Re-introduce the last removed drug at half-dose only if SBP rebounds to ≥160 mm Hg or symptoms of uncontrolled hypertension occur. NEJMoa2508157

What can I do?
Ask the care team, “Am I (or my loved one) at potential, imminent, or confirmed risk from low blood pressure, and which medicine—if any—should we reduce first?” Keep a simple log of morning/evening seated and standing BPs, dizziness, falls, and daily function. Make one medication change at a time, review within 2–4 weeks, and align BP targets with comfort, mobility, and life goals rather than numbers alone.