Consensus Statement on Practical Guidance for Optimizing Antihypertensive Therapy in Older Adults Needing Nursing Care by the Japan Geriatrics Society and the Japanese Society of Hypertension: English Translation of the Japanese Article

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This Consensus Statement outlines management for nursing care-dependent older adults (Categories 3–4). Key principles include prioritizing QOL over strict BP targets, avoiding reduction of SBP < 120 mmHg, and implementing stepwise deprescribing. It also emphasizes safety protocols during bathing and rehabilitation to prevent adverse event. The Japanese Society of Hypertension Guidelines for the Management of Elevated Blood Pressure and Hypertension 2025 (JSH 2025) generally recommend a target systolic blood pressure (SBP) < 130 mmHg. For older adults aged ≥ 75 years, however, this guideline emphasizes individualized target setting based on functional health categories [1]. This joint statement proposes practical guidance for the appropriate use of antihypertensive therapy in older adults who are in a state of needing nursing care (JSH 2025 Categories 3–4). In this population, management goals extend beyond blood pressure (BP) values to include prevention of falls, preservation of cognitive function, and maintenance of quality of life (QOL) [1]. Safe practices during bathing and rehabilitation, and avoidance of unnecessary activity restrictions in the situation of mild, asymptomatic BP elevations, are also key. Within the constraints of limited evidence, this proposal aims to provide realistic and safer management principles. The primary targets of this statement are older adults classified as Category 3 (needing nursing care) and Category 4 (end-of-life stage) in the JSH 2025 functional status classification [1] (Table 1). “Older adults requiring nursing care” include both residents of long-term care facilities and homebound individuals receiving home medical care. In other words, the scope encompasses older adults who require comprehensive caregiving regardless of setting. Note that even among institutionalized residents, when activities of daily living (ADL)—particularly independent ambulation—are preserved, antihypertensive therapy should be considered according to Categories 1 and 2. SBP < 140 mmHg SBP < 130 mmHg (set individually according to complications, etc.) SBP < 150 mmHg Complications may require further BP reduction through individual assessment, but avoid reduction SBP below 120 mmHg Individual judgment (Guideline: SBP 140–160 mmHg is acceptable) Consider gradual reduction or discontinuation of antihypertensive medications (Do not initiate treatment in untreated cases) Medical definition of “requiring nursing care” does not necessarily coincide with administrative certification under the Long-Term Care Insurance system. Medical judgment should be based on objective indices such as the Lawton Instrumental ADL scale and the Barthel Index for basic ADL. While medically defined dependency often corresponds roughly to care Levels 2–5 in the insurance system, detailed individual functional assessments are essential. The degree of ADL impairment should be evaluated comprehensively on medical grounds. High-quality evidence exists for relatively healthy, functionally independent older adults (approximately Category 1 in JSH 2025). A systematic review in JSH 2025 Clinical Question 14 confirmed the efficacy of targeting SBP < 130 mmHg in adults aged ≥ 75 years [1, 2]. Meta-analyses of randomized controlled trials (RCTs) that compared different BP targets among participants aged ≥ 75 years demonstrated that SBP < 130 mmHg was associated with (1) reduced risk of composite cardiovascular events, (2) reduced all-cause mortality, and (3) reduced cardiovascular and cerebrovascular mortality. Importantly, intensive BP lowering did not increase serious adverse events [1, 2]. Thus, achieving SBP < 130 mmHg in adults ≥ 75 years is supported by high-quality evidence for safety and benefit among functionally well older adults. The above trials rarely included nursing home residents or individuals with advanced dementia. Most available data in care-dependent older adults populations are observational, limiting causal inference [1, 3]. The PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study in France and Italy, in which nursing home residents aged ≥ 80 years who were taking ≥ 2 antihypertensive agents and had achieved SBP < 130 mmHg exhibited higher mortality risk [4]; a US study in Veterans Affairs (VA) nursing homes showing increased cardiovascular events and mortality at SBP < 110 mmHg [5]; and a Japanese home-care study of adults aged ≥ 65 years indicating higher hospitalization risk when SBP < 124 mmHg [6]. Although these observational data require careful interpretation, they collectively suggest that applying targets used for robust older adults may constitute overtreatment in frail or nursing care-dependent populations [7, 8]. A 2023 comparison of 13 hypertension guidelines (including those from Japan) found that only two specified thresholds for initiating antihypertensive therapy and only four provided actual BP targets for frail or dependent older adults [9]. Both guidelines that specified initiation thresholds recommended SBP ≥ 160 mmHg. Three other guidelines advised initiating therapy after considering patient background and comorbidities. None of the four target-setting guidelines advocated aiming for SBP < 130 mmHg in this population. However, the operational definitions of “frailty” and “nursing care dependency” vary across guidelines, and careful interpretation is required. Drawing on available evidence, JSH 2025 sets targets by functional category (Table 1). This statement focuses on Categories 3 and 4 [1]. Recent research suggests that antihypertensive dose reduction can be performed safely under certain conditions. In the RCT RETREAT-FRAIL (Reduction of Antihypertensive Treatment in Frail Patients), 1048 nursing home residents 80 years of age (mean 90.0 ± 4.8 years; baseline BP 113 ± 11/65 ± 10 mmHg) with SBP < 130 mmHg while taking ≥ 2 agents were randomized to the step-down group (from 2.6 ± 0.7 to 1.5 ± 1.1 drugs) versus the usual-care group (2.5 ± 0.7 to 2.0 ± 1.1). Mild elevation of SBP (+4.1 mmHg) was observed in the reduction group, but no increase in adverse events was observed over 3 years, supporting safety [10]. In the UK OPTIMISE (The Optimizing Treatment for Mild Systolic Hypertension in the Elderly) trial, 569 adults aged ≥ 80 years with SBP < 150 mmHg were randomized to removal of one drug versus usual care. At 12 weeks, maintenance of SBP < 150 mmHg was similar (86.4% vs. 87.7%). SBP increased modestly (+3.4 mmHg) in the reducing group without increased adverse events, indicating short-term safety. At 4-year follow-up, the reducing group remained on 0.4 fewer medications without increased hospitalization or mortality [11, 12]. The DANTON (Discontinuation of ANtihypertensive Treatment in Older people with dementia living in a Nursing home) trial, involving 205 hypertensive patients (median age 85.8 years, baseline SBP 134 mmHg) with SBP < 160 mmHg and moderate-to-severe dementia in Dutch nursing homes, compared antihypertensive medication discontinuation (baseline taking 2 types of medication) with continuation (baseline taking 1.5 types of medication). In the discontinuation group, SBP up to 180 mmHg was tolerated, and medication was restarted if BP > 200/120 mmHg. However, discontinuing the antihypertensives did not improve cognitive function or physical performance, and tended to increase the risk of cardiovascular events [13]. A 2020 Cochrane Review found no significant differences in all-cause mortality, hospitalization, or stroke between withdrawal and continuation, suggesting that reduction of antihypertensive medication can be safe in carefully selected patients [14]. In older adults requiring nursing care, stepwise reducing antihypertensive medications should be actively considered in appropriate scenarios. Among those taking ≥ 2 agents, reduction may be indicated, and supporting evidence is accumulating (Table 2). When reducing, ensure a monitoring p

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