Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis

doi:10.1016/j.jash.2018.01.008

Journal of the American Society of Hypertension

Volume 12, Issue 4, April 2018, Pages 248-267

Previous Presentations: Presented at the UK Public Health Science 2017 conference, London, UK November 2017 and published in abstract form.

https://doi.org/10.1016/j.jash.2018.01.008 Get rights and content

Highlights

•
The incidence of hypertension increases with advancing age and represents a significant burden of disease.
•
Lifestyle interventions for reducing blood pressure in the elderly have not previously been reviewed systematically.
•
Three months of exercise-based lifestyle intervention may produce a reduction in blood pressure of approximately 5 mmHg systolic and 3 mmHg diastolic in older individuals.

Abstract

The incidence of hypertension increases with advancing age and represents a significant burden of disease. Lifestyle modification represents the first-line intervention in treatment algorithms; however, the majority of evidence for this comes from studies involving young participants using interventions that may not always be feasible in the elderly. This manuscript presents a systematic review of all randomized controlled trials involving participants with a mean age of 65 or over investigating nonpharmacological strategies to reduce blood pressure (BP). Fifty-three randomized controlled trials were included. The majority of interventions described aerobic exercise training, dynamic resistance exercise training, or combined aerobic and dynamic resistance exercise training (COM), with limited studies reporting isometric exercise training or alternative lifestyle strategies. Aerobic exercise training, dynamic resistance exercise training, COM, and isometric exercise training all elicited significant reductions in both systolic and diastolic BP, with no additional benefit of COM compared with single modality exercise training. Three months of traditional exercise-based lifestyle intervention may produce a reduction in BP of approximately 5 mmHg systolic and 3 mmHg diastolic in older individuals, similar to that expected in younger individuals.

Introduction

In the UK, the prevalence of hypertension is estimated at 31% for men and 28% for women; unchanged for a decade.¹ Hypertension increases the risk of cardiovascular events, and this risk is lowered by reducing blood pressure (BP). A meta-analysis involving 464,000 patients showed that both ischemic heart disease and cerebrovascular events can be significantly reduced by a 10 mmHg reduction in systolic blood pressure (SBP) or 5 mmHg reduction in diastolic blood pressure (DBP).² Treating hypertension is expensive but is offset by reduction in the need for care following cardio-cerebro-vascular events. Reducing the BP of the population in general may save up to £850 million over 10 years.3, 4, 5

Hypertension is managed pharmacologically for the most part.6, 7, 8 Antihypertensives can be effective in lowering BP,⁹ but compliance remains an issue as many patients dislike taking medication for asymptomatic disease or experience problematic side effects.10, 11

Lifestyle modification is often the first line in management in treatment guidelines.6, 7, 12, 13 Although they are financially attractive¹⁴ and effective within studies,15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 lifestyle interventions, including sodium intake reduction and various forms of exercise training may suffer from poor compliance outside the setting of randomized controlled trials (RCTs).²⁸

There is a well-described association between advancing age and hypertension, with prevalence increasing from 8% in men and 2% in women in the age range of 16–24 years to 66% in men and 78% in women aged 75 years and above.¹ However, the majority of studies evaluating lifestyle and exercise interventions have been carried out in younger adults and not the elderly. Clinical guidelines and evidence in older adults are lacking, with a recent systematic review of cardiovascular disease prevention concluding that guidelines are often vague in their coverage of older people and often based on limited evidence.²⁹ No review to date has evaluated the evidence from lifestyle modification RCTs involving participants with a mean age of 65 years or above (the Organisation for Economic Co-operation and Development's definition of elderly³⁰), where interventions suitable for younger adults may be difficult for the elderly to adhere to because of mobility impairment and other challenges.³¹ We aim to address this gap in evidence in this review and meta-analysis.

Section snippets

Study Design

This systematic review was registered prospectively with PROSPERO (registration number CRD42017059443) and was carried out in accordance with the PRISMA statement.³² Only RCTs evaluating a physical activity or lifestyle modification intervention were included. Other inclusion criteria were mean participant age of 65 years or older,³⁰ interventions lasting 2 weeks or more, and trials where resting BP was reported before and after intervention. Trials involving a drug treatment or nutraceutical

Search Results

A total of 719 abstracts were screened for inclusion, 666 from the initial literature search, 32 from the reference lists of other identified studies, and 21 from other systematic reviews. No relevant unpublished studies were identified on Clinicaltrials.gov. Of the 719 abstracts screened, 639 were excluded as not being relevant, leaving 80 studies for full-text review. Of 80 studies, 27 were excluded leaving 53 studies36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54,

Discussion

This systematic review has demonstrated that AET, RET, or both performed together (COM), undertaken regularly over at least a 3-month period can lead to reductions of 5–6 mmHg in SBP and 2–3.5 mmHg in DBP in individuals aged greater than 65 years. However, this did not reach our a priori threshold for clinical significance (10/5 mmHg).² There was no additional benefit seen in exercise programmes lasting longer than 3 months and similar reductions in BP were seen in trials including both

Conclusions

In conclusion, the best available evidence suggests that nonpharmacological lifestyle interventions involving AET, RET, or a combination of the two can lead to statistically significant reductions in both SBP and DBP in older adults. However these reductions failed to reach thresholds for clinical significance and as such cannot be recommended as antihypertensive monotherapy, in the majority of individuals. Furthermore, the studies supporting these interventions contain various limitations.

Acknowledgments

P.H. is supported by a research training fellowship jointly awarded by the Royal College of Surgeons of England and the Dunhill Medical Trust. The authors would like to thank the Suzanne Toft, Chartered Health Librarian at the Royal Derby Hospital for her help with the electronic database searches.

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Chronic effect of resistance training on blood pressure in older adults with prehypertension and hypertension: A systematic review and meta-analysis
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The chronic antihypertensive effect of resistance training (RT) has been widely recognized in mixed-aged populations. However, the specific effect of RT on blood pressure (BP) in older individuals (≥60 years) remains unknown. Therefore, this meta-analysis of randomized controlled trials explored the chronic effects of dynamic RT alone on BP in older people. The study followed the PRISMA statement, and the search was performed using MeSH terms “strength training”, “blood pressure” and “aged” on MEDLINE (PubMed), SCOPUS, and Web of Science databases. From 1783 potential articles, 24 studies met all inclusion criteria resulting in 835 participants randomized into 26 RT interventions (n = 430) and 24 control groups (n = 405). Overall, BP reduction favoring RT was observed both in SBP (−6.88 [−10.02, −3.73] mmHg) and DBP (−3.37 [−4.71, −2.22] mmHg). Subgroup analysis revealed BP decreases in both participants with hypertension (SBP: −10.42 [−15.67, −5.17]; DBP: −3.99 [−5.76,-2.22] mmHg), and prehypertension (SBP: −4.87 [−7.76, −1.98]; DBP: −2.77 [−4.88, −0.66] mmHg). Improvement in BP was found in studies using traditional RT (free weights and machines) (SBP: −7.04 [−11.04, −3.05]; DBP: −2.60 [−3.72, −1.47] mmHg) and elastic band interventions (SBP: −2.79 [−3.72, −1.86]; DBP:-1.68 [−3.18, −0.18] mmHg). RT performed at moderate intensity (60–80 % 1RM) reduced SBP (−6.98, [−11.93, −2.03]mmHg) and DBP (−3.64 [−5.11, −2.18] mmHg). In conclusion, RT can reduce BP in older people at prehypertensive and hypertensive stage, with traditional RT performed with moderate loads leading to an effect estimate of approximately −7 mmHg for SBP and −4 mmHg for DBP.
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Non-pharmacological interventions are mainly lifestyle changes, including a low sodium diet, increased physical activity, weight reduction in obese individuals, and reduction of anxiety and fear.6 Several meta-analyses have assessed the efficacy of exercise and education for BP reduction in older adults.5,7-9 However, traditional meta-analysis can only compare the effectiveness of paired interventions.
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Methods: Primary endpoints were office systolic blood pressure (SBP) and diastolic blood pressure (DBP). The quality of evidence was assessed using the “risk of bias 2″ tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. We performed a Bayesian network meta-analysis using R-4.0.2 software to compare the efficacy of interventions.
Results: 36 eligible studies (3,531 patients) with a median follow-up of 12 weeks, assessing 18 non-pharmacological interventions, were included. The percentages of high, moderate, low, and very low certainty evidence were 16.7%, 38.9%, 33.3%, and 11.1%, respectively.
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View all citing articles on Scopus

: Supplemental Material can be found at www.ashjournal.com.

: Conflicts of interest: None.

¹: These authors contributed equally.

View full text

Review ArticleExercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis

Highlights

Abstract

Introduction

Section snippets

Study Design

Search Results

Discussion

Conclusions

Acknowledgments

Prev Med (Baltim)

Arch Gerontol Geriatr

Int J Nurs Stud

Am J Cardiol

Prev Med (Baltim)

Complement Ther Med

Metabolism

Lancet

Clinics (Sao Paulo)

Health survey for England: hypertension

Use of blood pressure lowering drugs in the prevention of cardiovascular disease : meta-analysis of 147 randomised epidemiological studies

Br Med J

Prescription cost analysis

Cost-Effectiveness of hypertension therapy according to 2014 guidelines

N Engl J Med

New figures show high blood pressure costs NHS billions each year

Hypertension in adults: diagnosis and management

NICE Guidel [CG127]

2013 ESH/ESC guidelines for the management of arterial hypertension the Task force for the management of arterial hypertension of the European Society of hypertension (ESH) and of the European Society

J Hypertens

Antihypertensive drug prescribing in Grampian

Br J Clin Pharmacol

Updated meta-analytical approach to the efficacy of antihypertensive drugs in reducing blood pressure

Clin Drug Investig

Patients’ responses to risk information about the benefits of treating hypertension

Br J Gen Pract

Discontinuation of antihypertensive drugs due to Adverse events: a systematic review and meta-analysis

Pharmacotherapy

Hypertension: evidence update March 2013

Evid Updat Hypertens

Clinical practice guidelines for the management of hypertension in the community a Statement by the American Society of hypertension and the International Society of hypertension

J Hypertens

Cost and effectiveness of exercise therapy for patients with essential hypertension

Nihon Koshu Eisei Zasshi

Exercise training for blood pressure: a systematic review and meta-analysis

J Am Heart Assoc

Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials

J Hypertens

Increasing physical activity for the treatment of hypertension: a systematic review and meta-analysis

Sport Med

Controlled aerobic exercise training reduces resting blood pressure in sedentary older adults

Blood Press

Effect of longer term modest salt reduction on blood pressure: cochrane systematic review and meta-analysis of randomised trials

BMJ

A meta-analysis of randomised controlled trials (RCT) among healthy normotensive and essential hypertensive elderly patients to determine the effect of high salt (NaCl) diet of blood pressure

J Hum Hypertens

Reduced dietary salt for the prevention of cardiovascular disease: a meta-analysis of randomized controlled trials (Cochrane review)

Am J Hypertens

The effectiveness of exercise training in lowering blood pressure: a meta-analysis of randomised controlled trials of 4 weeks or longer

J Hum Hypertens

A review of clinical trials of tai chi and qigong in older adults

West J Nurs Res

Tai chi for lowering resting blood pressure in the elderly: a systematic review

J Eval Clin Pract

Adherence to healthy lifestyle in hypertensive patients: ample room for improvement?

J Hum Hypertens

Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

BMC Fam Pract

Elderly population

Effects of a 12-week intervention period with football and running for habitually active men with mild hypertension

Scand J Med Sci Sports

Academia and clinic Annals of Internal medicine Preferred reporting Items for systematic reviews and meta-analyses: the PRISMA Statement

Ann Intern Med

Rayyan- a web and mobile app for systematic reviews

Syst Rev

WebPlotDigitizer version 3.12

Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension

Arch Intern Med

Decreased exercise blood pressure in older adults after exercise training: contributions of increased fitness and decreased fatness

Br J Sports Med

Review Article
Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis

Use of blood pressure lowering drugs in the prevention of cardiovascular disease : meta-analysis of 147 randomised epidemiological studies