This week, we’re focusing on geriatric care. Where guidelines start to blur and clinical judgement takes over.

Managing older patients means working in the grey areas. Evidence is limited, multimorbidity is the norm and treatment decisions rarely follow a clean algorithm.

This week, we look at what the data actually shows:

Ok let’s get into it!

Low-dose multi-drug pills are key. New ways to tackle resistant hypertension are emerging. We also need to rethink first-line therapy.

Since 2022, many Phase III antihypertensive trials have been reported. We looked at these studies to sketch a future that may move away from the usual monotherapy-first method.

Two trends stand out.

The first trend is using low-dose triple and quadruple single-pill combinations as initial therapy. The idea is simple: using three or four agents at a quarter or half dose lowers blood pressure more than one agent at a full dose. Plus, it causes fewer side effects. For older patients with multiple comorbidities the benefits are clear. Fewer tablets, lower doses, and a simpler routine are important advantages. This is especially true when polypharmacy is a concern.

The data…

None of these specific formulations are available in the UK yet; however, the path is clear: take fewer pills, use lower doses and combine treatments sooner. For patients, adherence is a key reason for poor control.

The second trend represents a completely new territory. Two new drug classes are showing Phase III data for resistant hypertension. This is important due to the ineffectiveness of current treatments for this population.

Aprocitentan is a dual endothelin receptor antagonist. The PRECISION trial found that patients on three or more antihypertensives had a systolic blood pressure about 4 mmHg lower than those on placebo after four weeks. Subgroup analyses found a significant benefit for patients aged 75 and older, as well as for those with CKD. These groups are common in older patients with resistant hypertension. Oedema and fluid retention were more common in older patients in the trial. This is important to consider for this age group.

Baxdrostat and lorundrostat are aldosterone synthase inhibitors, a completely different mechanism. Recent phase 3 data for baxdrostat showed a 9 to 10 mmHg drop in systolic pressure compared to placebo. Researchers saw this effect in cases of uncontrolled and resistant hypertension. The Launch-HTN trial of lorundrostat reported similar results. The key monitoring concern with this class is hyperkalaemia, a particularly relevant consideration in older patients with CKD or those already on renin-angiotensin system agents.

These reductions are modest in absolute terms. In patients on three or four medications who still exceed targets, an extra 4 to 10 mmHg matters. It can mean the difference between controlled and uncontrolled disease. We still lack long-term cardiovascular outcome data for these newer agents. This gap is significant. Right now, the evidence supports short-term blood pressure lowering. We still need to show whether that translates into fewer strokes and heart attacks.

For UK primary care, the practical implications are still over the horizon. None of these new agents are approved by NICE or listed on NHS formularies right now. But the pipeline is worth watching. Patients on your QOF register with resistant hypertension are the focus for these drugs. They remain above target even after using four agents. When they arrive, the referral conversation with secondary care may look quite different.

At what age do you stop offering statins for primary prevention? It's a question the guidelines can only partially answer.

QRISK3 stops at 84. You're then in clinical judgment territory and until recently, the evidence to guide that judgment has been quite limited.

A study in the Journal of the American Geriatrics Society provides valuable insights. Lavon et al. studied more than 15,700 patients aged 80 and older. This is the largest real-world dataset for this age group to date.

These patients had no history of cardiovascular disease. They used electronic medical records and pharmacy dispensing data for their analysis. They compared people who used statins on a regular basis with those who did not. Researchers conducted this over an average follow-up period of four years. The cohort's average age was 84.5 years, and two-thirds were female.

This group is more like the patients you see in your practice than most trial populations.

Statin use lowered all-cause mortality by 31% (HR 0.69; 95% CI: 0.34–0.74). It also cut new coronary events by 20% (HR 0.80; 95% CI: 0.68–0.94). The mortality signal increased with adherence. For users with high adherence (medication possession ratio ≥80%), the adjusted mortality hazard ratio is 0.58. In contrast, it was 0.74 for lower-adherence users. A dose-response pattern like that is harder to dismiss as confounding.

Researchers found no significant differences in cases of myopathy, new diabetes, or dementia. These three issues often lead to discussions about stopping medications in older patients. Dementia findings require caution because of other health risks in this age group. Yet, the data on myopathy and diabetes are reassuring.

Two findings stand out clinically.

The evidence base remains contested. Earlier work from Ramos et al found no mortality or CVD benefit in over-75s without diabetes. Plus, an ASPREE analysis also showed no improvement in disability-free survival. This study doesn't resolve the contradictions. It has clear limitations. It has a retrospective design, it focuses on one geographic area and cannot confirm cardiovascular-specific mortality.

NG238 suggests using statins for those over 85. This study supports that recommendation.

Artificial intelligence is arriving in care homes. Wearable devices monitoring blood pressure and blood sugar. Motion sensors that detect falls and alert staff within seconds. Apps like PainChek, which uses facial recognition to identify pain in residents who can't verbalise it. Remote monitoring systems eliminate the need for overnight checks every two hours. This allows residents to sleep without interruptions.

The potential is genuine. The UK has more than 10,000 care homes for individuals over 65, a workforce nearing 800,000, and demand that currently exceeds supply. Technology that boosts clinical oversight, cuts avoidable harm, and helps busy staff needs our focus.

But two problems underlie this, and they compound each other in complex ways that lack enough discussion.

Put those two problems together and the picture sharpens. We have tools that don't fully understand their target population being rolled out first to the patients who need them least. Residents who need better monitoring, earlier detection, and smarter care coordination are at the end of both lines.

So what can primary care actually do? Three things.

The technology is promising. The evidence base and the deployment strategy need to catch up. Primary care is well placed to push both in the right direction.

Intended for UK healthcare professionals only. This article reports on published clinical trial data and does not constitute prescribing advice.