ArticlePDF AvailableLiterature Review

Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan



Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient’s medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.
Int. J. Environ. Res. Public Health 2023, 20, 2227.
Medical Telemonitoring for the Management of Hypertension
in Older Patients in Japan
Takeshi Fujiwara 1,2,*, James P. Sheppard 1, Satoshi Hoshide 2, Kazuomi Kario 2 and Richard J. McManus 1
1 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
2 Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine,
Shimotsuke 329-0498, Japan
*Correspondence: or; Tel.: +44-1865-617834
Abstract: Hypertension is the most frequent modifiable risk factor associated with cardiovascular
disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has
been recommended to reduce CVD event risks. However, caution should be exercised since older
hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and
older patients eligible for clinical trials may not represent the general population. Medical telemon-
itoring systems, which enable us to monitor a patient’s medical condition remotely through digital
communication, have become much more prevalent since the coronavirus pandemic. Among vari-
ous physiological parameters, BP monitoring is well-suited to the use of such systems, which enable
healthcare providers to deliver accurate and safe BP management, even in the presence of frailty
and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could
help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable
multi-professional team-based management of hypertension. However, the implementation of
medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including
the development of user-friendly devices, integration with existing clinical systems, data security,
and cost of implementation and maintenance, need to be overcome. In this review, we focus on the
potential of medical telemonitoring for the management of hypertension in older people in Japan.
Keywords: aging; blood pressure; hypertension; medical telemonitoring; Japan
1. Introduction
Aging is an inevitable part of life, is irreversible and is becoming a worldwide prob-
lem as people live longer [1]. Age-related changes in physical function make it more dif-
ficult to maintain healthy lives, limit physical activity, and increase the risk of disability
[2]. Those biological degenerative changes and dysfunctions increase the clinical vulner-
ability of the older population [3]. Therefore, multi-dimensional health management in-
terventions are needed to support healthy aging in older people.
Older populations are generally more likely to have multimorbidity and experience
polypharmacy. Among the targets for improving the health of older people, hypertension
is the most frequent and modifiable risk factor [4]. In Japan, according to the National
Health and Nutrition Survey 2016, the prevalence of hypertension rises from 4160% for
people aged 4074 years and to 7477% for those aged ≥75, and is predicted to increase in
the future as the population undergoes further aging [57]. Relative treatment benefits for
hypertension are broadly consistent even as people age [8,9], but such treatment is often
difficult due to problems such as frailty, nonadherence, cognitive impairment, as well as
the risk of falls and postural hypotension which also increase with age. Judging carefully
for each patient whether antihypertensive medications would be beneficial or harmful is
crucial for the treatment of hypertension in older people.
Citation: Fujiwara, T.;
Sheppard, J.P.; Hoshide, S.;
Kario, K.; McManus, R.J. Medical
Telemonitoring for the Management
of Hypertension in Older Patients in
Japan. Int. J. Environ. Res. Public
Health 2023, 20, 2227.
Academic Editor:
Paul B. Tchounwou
Received: 13 December 2022
Revised: 13 January 2023
Accepted: 24 January 2023
Published: 26 January 2023
Copyright: © 2023 by the authors. Li-
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con-
ditions of the Creative Commons At-
tribution (CC BY) license (https://cre-
Int. J. Environ. Res. Public Health 2023, 20, 2227 2 of 15
In recent years, healthcare technology has remarkably progressed and our pursuit of
health has changed dramatically, particularly in light of the coronavirus pandemic. Med-
ical telemonitoring, defined as a continuous or non-continuous monitoring process that
allows a healthcare professional to remotely manage a patient’s medical follow-up
through digital communication [10], has become indispensable for healthcare. Among
various physiological indicators that can be digitally captured, BP monitoring and subse-
quent management of hypertension are particularly suited to the use of digital health so-
lutions [1114]. These enable accurate and automatic exchange of BP values between
healthcare professionals and their patients, which could be key to solving the current
problems of nonadherence to antihypertensive medications and clinical inertia, and help-
ful for judging whether the antihypertensive medication use is appropriate or inappropri-
ate. Older people would theoretically benefit significantly from BP telemonitoring; how-
ever, little evidence regarding the effectiveness of medical telemonitoring exists in this
group [15], and implementation of medical telemonitoring systems in clinical practice has
been slow.
In this review, we will examine the current evidence for BP management in older
people and consider future developments in medical telemonitoring. In addition, we will
discuss the prospects for BP management for older people in Japan using digital health
2. Methods
This narrative review aims to address and discuss the current evidence on medical
telemonitoring systems for the management of hypertension, especially in older people in
Japan. Key publications in the field were identified using PubMed and Google Scholar
searches conducted in October 2022 using the search terms medical telemonitoring or
blood pressure telemonitoring or digital health or digital intervention and older,
or elderly and hypertension. The search was restricted to papers published in English
and Japanese without time limit. Reference lists of articles identified in the search were
also reviewed to identify additional relevant publications. For information on global de-
mographic variables, including Japan, we searched them using Google (including Japa-
3. Current Evidence for Hypertension Management in Older People
The Hypertension in the Very Elderly Trial (HYVET) was a landmark randomized
clinical trial (RCT) of hypertension treatment focused specifically on those aged ≥80 years.
The trial unequivocally showed the benefits of lowering BP in reducing the risks of stroke,
all-cause mortality, and heart failure (HF) in older patients when treated to a target of
150/80 mmHg [16]. In recent years, it has been shown that even stricter BP control can be
beneficial in older patients. In the subgroup of patients aged ≥75 years who enrolled in the
Systolic Blood Pressure Intervention Trial (SPRINT), the intensive treatment group (sys-
tolic BP [SBP] target of <120 mmHg, automated unattended BP measurement) showed
significantly lower rates of cardiovascular disease (CVD) outcomes (hazard ratio [HR]
0.66, 95% confidence interval [CI] 0.51 to 0.85) and all-cause mortality (HR 0.67, 95% CI
0.49 to 0.91) compared with the standard treatment group (SBP target of <140 mmHg) [8].
Achieved BPs as measured in the clinic were, however, significantly above these targets.
The Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP)
trial also showed the clinical benefits of strict SBP control, at least in those aged 60-80 years
[9]. The intensive treatment group (SBP target of 110 to <130 mmHg) showed a signifi-
cantly lower incidence of the total CVD event than the standard treatment group (SBP
target of 130 to <150 mmHg) (HR 0.74, 95% CI 0.60 to 0.92). Among the components of
total CVD events, the greatest risk reduction was observed in the incident acute decom-
pensated HF (HR 0.27, 95% CI 0.08 to 0.98). In a sub-analysis of the nationwide practice-
based prospective Japan Morning Surge-Home Blood Pressure (J-HOP) study on mostly
medicated 349 hypertensive patients aged ≥80 years, the morning home BP showed a
Int. J. Environ. Res. Public Health 2023, 20, 2227 3 of 15
positive linear association with CVD events, especially with stroke [17]. The most recent
meta-analysis of the Blood Pressure Lowering Treatment Trialists’ Collaboration
(BPLTTC), which included 51 RCTs with 358,707 participants, also showed that pharma-
cological BP-lowering treatment reduced the risk of major CVD events, including stroke,
ischemic heart disease, and HF, regardless of age, down to less than 120/70 mmHg [18].
On the other hand, potential risks of hypertension treatment in older people should
also be considered. The use of antihypertensive medications in older patients may be as-
sociated with adverse drug reactions and drugdrug interactions [19]. Intensive BP ther-
apy in older patients may be harmful [20], increasing the risk of falls [21], syncope [22],
fractures [23], acute kidney injury, and electrolyte abnormalities [2426]. In addition, cau-
tion is needed when extrapolating the results of clinical trials to older people in clinical
practice. It should be noted that SPRINT excluded patients with diabetes and stroke,
which are common among older people, and that automated office BPs were used for the
assessment of the risks between CVD outcomes and BP level [8]. Automated office BP is
a fully automated unattended BP measurement technique, which has been designed to
record multiple BP readings in the office, with the patient resting alone in a quiet room
(no presence of medical staff), and reduce the white-coat effect associated with manual
office BP measurement [27]. Automated office BP values were lower than physicians of-
fice BP (SBP, −10.48 mmHg) and non-physician’s office BP (SBP, −6.89 mmHg) [28], which
meant that it is difficult to determine which office BP levels to target in clinical practice.
Furthermore, the long-term effect of intensive BP lowering has now been called into ques-
tion. In a recently reported long-term follow-up of the SPRINT (4.5 years of post-trial ob-
servation), the intensive treatment group showed an increase in SBP from 132.8 mmHg at
five years following randomization to 140.4 mmHg at 10 years. Moreover, the benefits of
intensive BP lowering were no longer evident for CVD outcomes (HR 1.02, 95% CI 0.84 to
1.24) and all-cause mortality (HR 1.08, 95% CI 0.94 to 1.23) compared to the standard treat-
ment group [29].
It is also important to note that most patients aged ≥80 years who participated in
RCTs would differ from the general population aged ≥80 years. In particular, those with
frailty, multiple cardiovascular medications, and multimorbidity are less likely to be eli-
gible [30]. For example, SPRINT excluded by design around 2:3 people over 80. Among
older Japanese patients with isolated systolic hypertension, a U-shaped relationship was
observed between the achieved SBP levels and the risks of CVD events and all-cause mor-
tality, that is, the risks of them were minimized in achieved SBP levels of 130 to <145
mmHg, but increased in achieved SBP levels of < 130 mmHg and 145 mmHg [31]. The
results of this study imply that excessive reduction of SBP in older people might increase
the risk of CVD events and all-cause mortality. Due to the complex and heterogeneous
pathological nature of hypertension in older people, further studies are warranted to con-
firm the efficacy and safety of pharmacological BP-lowering treatment for CVD risk re-
duction in older people.
4. State-of-the-Art Evidence of BP Telemonitoring for the Management of Hypertension
Digital technologies have potential for transforming healthcare across multiple di-
mensions, including quality, access, patient experience, and cost effectiveness. Indeed, re-
cent evidence demonstrates the feasibility, acceptability, and success of medical telemon-
itoring in changing the behavior of people with chronic conditions [3238]. Among the
management of chronic conditions, hypertension is a good target for medical telemonitor-
For the last 20 years, the effectiveness of BP telemonitoring systems have been eval-
uated [3941]. After the coronavirus pandemic, a significant demand for digital healthcare
and medical telemonitoring has grown rapidly around the world [42]. In response to those
trends, the management of hypertension using digital healthcare technology seems likely
to continue in this direction of travel [43].
Int. J. Environ. Res. Public Health 2023, 20, 2227 4 of 15
In the UK population of 622 hypertensive patients with treated but poorly controlled
(>140/90 mmHg), the Home and Online Management and Evaluation of Blood Pressure
(HOME BP) trial showed the potential of digital interventions, combined with self-moni-
toring, for the management of hypertension [44]. Compared with the usual care group (n
= 317, mean age 66.7 ± 10.2 years; including routine hypertension care, with appointments
and antihypertensive medication changes made at the discretion of the general practi-
tioner), the digital intervention group (n = 305, mean age 65.2 ± 10.3 years; including BP
self-monitoring, self-titration of antihypertensive medications based on self-monitored BP
levels, lifestyle advice, and behavioral support for patients and healthcare professionals)
showed a significant reduction of office SBP after 12 months (3.4 mmHg, 95% CI 6.1 to
0.8 mmHg). In a Japanese population of untreated patients with essential hypertension,
the HERB Digital Hypertension 1 (HERB-DH1) pivotal trial also highlighted the potential
effects of a digital intervention for non-pharmacological lifestyle modification to reduce
BP levels [45]. Untreated patients with hypertension (office SBP 140 to <180 mmHg, and
24-h ambulatory SBP ≥130 mmHg) were randomly assigned to the digital therapeutics
group (n = 199, mean age 52.4 ± 8.1 years; the HERB system with standard lifestyle modi-
fication) or the control group (n = 191, mean age 52.0 ± 7.6 years; standard lifestyle modi-
fication alone). In the digital therapeutics group, patients input their demographic profiles
and home BP values via the HERB application downloaded to their smartphone. Based
on these data, the HERB system generated a personalized program of lifestyle modifica-
tions designed to reduce BP. At 12 weeks, compared with the control group, the digital
therapeutics group showed significant reductions from baseline in 24-h ambulatory,
morning home, and office SBP; between group differences 2.4 mmHg (95% CI 4.5 to 0.3
mmHg), 4.3 (95% CI 6.7 to 1.9 mmHg), and 3.6 mmHg (95% CI 6.2 to 1.0 mmHg),
respectively. Even after addition of antihypertensive therapy being permitted from 12
weeks, the difference at 24 weeks remained significant. In addition, these trials also
showed that digital interventions can be cost-effective compared to conventional treat-
ment for reducing BP levels [46].
In an individual patient data meta-analysis of 15 studies including a total of 7138
individuals, self-monitoring of BP with co-intervention (including systematic medication
titration by doctors, pharmacists, or patients; education; or lifestyle counselling, using
telemonitoring systems) showed significant BP reduction compared to the usual care at
12-months follow-up [47]. In the subgroup analyses by age and comorbidities, the effects
of self-monitoring with co-intervention were similar [48].
5. Cardiovascular Disease and Hypertension: Current Status in Japan
Japan has one of the longest life expectancies in the world for both men and women
(men 82 years, women 88 years) [49]. However, this is whole life and not healthy life ex-
pectancy which is critically important for both personal quality of life (QOL) and public
health. In the annual report of the World Health Statistics 2022, healthy life expectancies
in Japan were considerably lower, at 72.6 years in men and 75.5 years in women [50],
meaning that people in Japan have to live with some kind of disability for approximately
the last 10 years of their lives. To maintain or extend the sustainability of health under
aging populations in Japan, it is important to understand the underlying causes of this
deterioration in later life.
According to the annual report 2019 from the Ministry of Health, Labor, and Welfare
in Japan, stroke and dementia are the leading causative diseases requiring long-term care,
including being bedridden, with these two diseases accounting for about 50% of all cases
[51]. Hypertension is a significant risk factor for both the onset of stroke and for the de-
velopment of dementia [5257]. The Evidence for Cardiovascular Prevention From Obser-
vational Cohorts in Japan (EPOCH-JAPAN), a meta-analysis of 10 cohort studies includ-
ing 67,309 Japanese individuals, showed that increased BP has been shown to be posi-
tively associated with increased risk of long-term CVD, even in very old people (age 75 to
89 years) [58]. Patients with CVD experience numerous physical symptoms including
Int. J. Environ. Res. Public Health 2023, 20, 2227 5 of 15
fatigue, dyspnea, or chest pain which affect their physical, emotional, and social well-be-
ing with significant impairment in QOL [59]. Among CVD, HF in older people is a major
public health problem significantly reducing activities of daily living and closely linked
to hypertension [6063,64].
It is evident that hypertension therefore increases CVD risk and reduces QOL for
older people; however, the control rate of hypertension in Japan for the elderly (age 70 to
79 years) remained only 44.2% among men and 43.4% among women in 2016 [65]. Various
factors, such as high salt intake/sodium sensitivity, autonomic dysfunction, obesity, mul-
timorbidity, frailty, nonadherence, and sleep disorders might affect the insufficient con-
trol rate of hypertension, but lower rates of awareness and insufficient treatment of hy-
pertension might also contribute [65]. The Japanese population, including older people,
need to change their perception of hypertension, and healthcare providers also need to
recognize and fight the pervasive problem of clinical inertia [66]. Since BP management
in older people is crucial for reducing the public health burden in Japan, measures to re-
duce the number of poorly controlled hypertensive patients are urgently needed.
6. Implementation of Medical Telemonitoring for Older People with Hypertension in
The traditional approach, in which only physicians make decisions for the patients
BP control, neglects modern scientific and technological advances, and this approach does
not address either patients nonadherence to antihypertensive medications or the clinical
inertia of healthcare providers. Modern healthcare systems require a shift toward patient-
centered care, where the patients goals and wishes are respected in determining the treat-
ment, with increasing awareness of evidence-based self-management (Figure 1) [48,67,68].
Figure 1. Patient-centered management of hypertension in older people using digital healthcare
solutions in Japan.
The table (Table 1) summarizes the advantages and disadvantages of using BP tele-
monitoring systems for the management of hypertension in older people [13]. To date, BP
telemonitoring has mostly been used in clinical trials and has not yet been widely used in
clinical practice. This section discusses the benefits of medical telemonitoring systems for
the management of hypertension in older people and the current barriers to its wide-
spread use in Japan.
Int. J. Environ. Res. Public Health 2023, 20, 2227 6 of 15
Table 1. Advantages and disadvantages of blood pressure telemonitoring system for the manage-
ment of hypertension in older patients.
For physicians
Assessment of whole blood pressure (BP) data sets
Need to provide simple and user-friendly devices
Accurate/reliable BP data
Need maintenance of systems
Easy to assess the mean BP data calculated automatically
May be time-consuming to input patients BP data
BP levels can be determined quickly after changes in antihy-
pertensive medication
Need to log onto websites for checking data
Provision of personalized self-care recommendations
May require help of others to make the system work
Saving time for consultation
Need to ensure data security and patients privacy
Identification of white-coat hypertension and masked hy-
Need to consider legal and ethical issues
Assessment of seasonal BP variation
Need to interoperate with existing systems
Medication adherence can be confirmed
Easy to share medical information and consult with special-
For patients
Good BP control
Additional costs to use data transmission system
Increased motivation for BP measurements
Need to build an internet environment
BP measured easily without the need to record BP levels in a
Need training to use devices correctly
Cost effective in reducing cardiovascular disease
Need to consider digital literacy
Reduced frequency of office visits
May cause anxiety and too frequent monitoring
Reduced risks of adverse events by antihypertensive medi-
May give a sense of insecurity that they are constantly
being monitored
Rural locations or natural disaster-affected areas not a bar-
Family or physicians can confirm the safe status of patients
Easy to communicate with his/her healthcare professionals
6.1. Blood Pressure Measurement
Accurate measurement of BP is particularly needed in older people, since any over
or underestimation of BP could expose them to either an increased risk of CVD events or
of adverse events, such as falls and postural hypotension [69]. Using a standardized re-
cording and transmission system allows physicians to assess all available BP values and
automatically calculate mean BP level, which could help to determine whether antihyper-
tensive medications should be up-titrated or withdrawn. BP management using telemon-
itoring systems can provide patients with a feeling of security and invoke greater interest
in their BP levels [70,71]. Capturing out-of-office BP using a telemonitoring system can
help to identify white-coat and masked hypertension, which are common in older people
[72,73]. It can also help to detect seasonal variations in BP that can be associated with
increased CVD risks of older people in the winter [7476].
On the other hand, many challenges remain to be overcome to disseminate medical
telemonitoring systems in clinical practice. The development of simple devices that can
measure BP accurately in all age groups is desirable. To use such devices, continuous
training and education about how the devices work are necessary. It is also necessary to
establish a robust social system for data security and privacy protection of individuals.
Some patients may feel anxiety with remote management, and this can lead to fre-
quent repeating of BP measurements. It may also give the impression of constant moni-
toring by physicians, which can feel excessive to some patients. For physicians, unless
patients use devices that can automatically transfer measured BP to the clinical record,
they would have to manually enter the BP values measured by patients, resulting in in-
creased workload. In addition, physicians often need to log on to standalone websites as
Int. J. Environ. Res. Public Health 2023, 20, 2227 7 of 15
an additional step in order to check the patients’ data whereas integrated systems would
avoid this. A qualitative study implied that traditional paper-diary methods may suit ex-
isting clinical practices compared to parallel BP management using telemonitoring sys-
tems, in the absence of appropriate integration [70]. Thus, increasing the generalizability
of medical telemonitoring systems is likely to depend on their interoperability with elec-
tronic health records, especially for generalists who could otherwise conceivably require
several different telemonitoring systems for the range of clinical problems they see.
6.2. Frailty
Frailty is a common condition among older people and becomes more prevalent with
age. The progression of frailty increases the vulnerability of all bodily functions, including
generalized muscle weakness, low vision, and hearing problems. These can make it diffi-
cult for older people to keep an accurate record of their home BP levels and lead to both
mis-reporting and complete lack of reporting (up to 50% may not inform their primary
care physician of their self-monitoring) [7779]. Older populations may also have lower
levels of technology literacy [70,80] and/or require the support of carers. Notwithstanding
the issues of standalone systems, we have previously demonstrated the high feasibility of
recording home BP using BP telemonitoring by older hypertensive patients (mean age
76.4 ± 7.8 years) in real-world clinical settings as a solution to these issues [81]. Digital
solutions can also facilitate team-based approaches in which not only physicians but also
nurses/public health nurses, pharmacists, care workers, dieticians, and other multidisci-
plinary professionals utilize their expertise and share their information [82,83].
6.3. Nonadherence
Nonadherence to antihypertensive medication is common, especially in patients with
uncontrolled BP or treatment resistance [84,85]. Nonadherence is also associated with
higher risk of future CVD events [86]. In addition, nonadherence is a significant cost bur-
den on healthcare systems [87]. Over half of older people are estimated to suffer from
multimorbidity [88], which usually requires complex medical treatment and can lead to
subsequent poor adherence [89]. Adherence to antihypertensive medication is essential to
achieve therapeutic benefits and management of hypertension [90,91].
Digital healthcare approaches can be useful for detecting nonadherence and for im-
proving adherence. Mobile phone text messaging and applications can improve medical
adherence in chronic disease [92,93]. A meta-analysis which evaluated the effectiveness of
mobile application-based interventions on medication adherence and BP levels in patients
with CVD also showed that application-based interventions could improve SBP and dias-
tolic BP levels to controls [94]. In recent years, the use of digital pill systems has been
reported to be useful in directly measuring adherence and may become more widespread
in the future [95,96].
These innovative and device-based strategies are useful tools for increasing drug ad-
herence but should be combined with reduced complexity of antihypertensive regimes
for the management of hypertension in older people [97]. Reducing or avoiding medica-
tions that can increase BP, such as non-steroidal anti-inflammatory drugs, corticosteroids,
some anti-rheumatic drugs, and sympathomimetic drugs, are other interventions that can
be taken when possible [98]. Educational approaches for patients on the importance of
taking antihypertensive medication regularly and on changing misconceptions about hy-
pertension and antihypertensive medications, such as stress-related conditions, including
headache, palpitations, and dizziness, and fear of addiction or dependence on drugs, are
also important [99]. Healthcare professionals must have many opportunities to discuss
therapeutics with patients for a greater understanding.
Int. J. Environ. Res. Public Health 2023, 20, 2227 8 of 15
6.4. Clinical Inertia
Clinical inertia, defined as a failure of healthcare providers to initiate or intensify
therapy when indicated [100], is one of the most challenging problems in the current man-
agement of hypertension. Clinical inertia is due to at least three problems: overestimation
of care provided; use of “soft” reasons to avoid intensification of therapy; and lack of ed-
ucation, training, and practice organization aimed at achieving therapeutic goals [100]. In
a recent general practitioner-based cohort study using electronic health record data in the
Netherlands, clinical inertia was reported to be the cause in 87% of cases of uncontrolled
BP [101]. Older age, readings closer to target BP, and concurrent diabetes were signifi-
cantly related to clinical inertia [101]. Most general practitioners in this study considered
near-target BP values acceptable in most cases for everyday primary care. BP telemonitor-
ing systems can help reduce such inertia by automatically providing comprehensive esti-
mates of mean BP level [102].
In Japan, significant differences in perceptions of hypertension management between
physicians and patients have been reported in the web-based survey: approximately 80%
of physicians reported that they had fully or sufficiently provided education to patients
about reasons for hypertension treatment and its associated risks, target BP levels, and
lifestyle modifications; however, only 4050% of patients considered those topics having
been fully or sufficiently discussed [103]. Medical telemonitoring systems can provide
both patient education and improved communication with physicians [70], and their ac-
tive use could help bridge these perception gaps between physicians and patients.
6.5. Monitoring of Adverse Events
Treatment benefits for hypertension are broadly consistent across age groups
[18,104]. However, in the recent meta-analysis of 58 RCTs including a total of 280,638 in-
dividuals, antihypertensive treatments were associated with an increased risk of acute
kidney injury, hyperkaliemia, hypotension, and syncope [26]. As physiological reserve
declines in older people, healthcare professionals should carefully monitor adverse effects
and consider withdrawing inappropriate antihypertensive medications in those at high
risk of harm [105].
There is still a lack of definitive evidence for monitoring adverse events of antihyper-
tensive medications using telemonitoring systems; however, those systems would have
many potential uses in routine clinical practice. Telemonitoring systems could enable
monitoring of excessive BP decreases or postural hypotension and reduce the risk of syn-
cope and falls. An innovative telemonitoring device that allows both actigraphy function
and BP measurement could assess the frequency of falls in the home and their relationship
to BP levels, which could aid the appropriate withdrawal of antihypertensive medications
[106]. Short-term BP assessment using telemonitoring systems after the withdrawal of an-
tihypertensive medication may also help to determine whether the decision was appro-
priate. Indeed, this was used effectively in the recent Optimising Treatment for Mild Sys-
tolic Hypertension in the Elderly (OPTIMISE) antihypertensive deprescribing trial [107],
where participants were given the opportunity to monitor their own BP following antihy-
pertensive drug withdrawal, enabling those experiencing large increases in BP to flag this
to their general practitioner and in some cases, have their medication reinstated.
6.6. Geographically Remote Rural Areas
Japan is comprised of nearly 7000 islands. In addition, approximately 60% of the area
in Japan is identified as underpopulated or remote, where 8.6% of the total population
(approximately 12 million people) live. In such areas, the proportion of older population
aged 65 years is high at 36.7% in 2017 [108]. In addition, the proportion of older people
is expected to continue to increase, including those living alone or living with an older
spouse only.
Int. J. Environ. Res. Public Health 2023, 20, 2227 9 of 15
There are significant cultural, social, and economic differences between rural and ur-
ban areas, and frequent visits to health facilities are often difficult to achieve. Indeed,
awareness, treatment, and control rates of hypertension were lower in rural areas com-
pared with urban ones [109]. There is an urgent need for healthcare promotion for hyper-
tension in such areas where medical resources are scarce.
BP telemonitoring systems have the potential to make a significant contribution to
controlling BP in geographically isolated settings [110], since they can allow healthcare
professionals to access a patient’s BP levels remotely [71]. In addition, such systems could
reduce the frequency of unnecessary office visits. In older people living alone, a medical
telemonitoring system could be used to manage their health, which could also be used as
a confirmation of safety status from remote areas. In such geographically remote areas,
mobile technologies, such as mobile phones and tablet computer applications, could be
particularly useful for self-management of hypertension since new equipment for internet
facilities and its regular maintenance can be costly. Medical telemonitoring systems have
the potential to enable high quality healthcare to be easily accessible at low cost, even in
areas previously referred to as medically underserved [111,112].
6.7. Patients Living in Nursing Care Facilities
Approximately 0.76% of the total population in Japan (almost a million people) live
in nursing care facilities as of 2022 and this is expected to continue to increase in the future
[113]. A previous study demonstrated that over 60% of patients living in nursing homes
had diagnosed hypertension and over 90% of patients took antihypertensive treatments
[114]. Since multimorbidity increases the risks of adverse events, frailty, cognitive impair-
ment, and polypharmacy are major concerns among patients living in nursing care facili-
ties [115]; intensified attention would be needed in management of hypertension.
Observational studies in older people living in nursing care facilities have shown that
intensive antihypertensive treatments may lead to paradoxical increase in CVD hospital-
ization and mortality [116118]. Therefore, it is also necessary to positively consider with-
drawal of antihypertensive medications for very old patients for whom competing risks
may also be important. Particularly those near the end-of-life stage who are living in nurs-
ing care facilities, based on comprehensive patient assessments. The use of medical tele-
monitoring systems could be useful for identifying those with excessive BP decreases and
for medication titration. Using wearable technology, biometric information, including BP
levels, could be obtained non-invasively and continuously, even in those with reduced
mobility or even bedridden patients. Further interventional studies are warranted to ex-
plore benefits or harms of antihypertensive medications in patients living in nursing care
facilities, and we believe that medical telemonitoring systems would be beneficial in the
management of hypertension in this growing population.
7. Conclusions
This review has summarized the current evidence on medical telemonitoring systems
for the management of hypertension in older people. Recent evidence on the management
of hypertension in older people suggests that strict BP control would be beneficial for re-
ducing CVD risks, and in this regard, BP telemonitoring systems could be useful to pro-
vide more accurate and safer BP management in older people. On the other hand, physi-
cians must monitor adverse events carefully and consider the benefits or harms of antihy-
pertensive medications in older people with frailty and multimorbidity. Medical telemon-
itoring systems have the potential to be a solution to the current problems of nonadher-
ence and clinical inertia, and to help to judge whether the antihypertensive medication
use is appropriate. However, there are many barriers that need to be resolved for wide
use in clinical practice. Hardware improvements, such as development of user-friendly
devices targeted at older people, and social infrastructure development, are essential, as
is the establishment of multidisciplinary professional support systems utilizing digital
healthcare solutions to support patient management.
Int. J. Environ. Res. Public Health 2023, 20, 2227 10 of 15
Healthcare innovation is expected to further accelerate in the management of hyper-
tension, as hypertension application-based treatment (CureApp HT, CureApp Inc. Tokyo,
Japan) has been covered by insurance for the first time in September 2022 in Japan [119].
Healthcare professionals should carefully and fully discuss how these modern devices can
be implemented into the existing healthcare delivery system. Further clinical trials are
needed to clarify long-term CVD risk management and the issues to be implemented in
the clinical practice of medical telemonitoring systems. These innovations and accumula-
tion of evidence could lead to healthy aging in Japan (Figure 1).
Funding: This work was financially supported by a grant from SENSHIN Medical Research Foun-
dation. JS receives funding from the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship
(ref: 211182/Z/18/Z). This research was funded in part by the Wellcome Trust. For the purpose of
open access, the author has applied a CC BY public copyright license to any Author Accepted Man-
uscript version arising from this submission. RJM is supported by NIHR Oxford and Thames Valley
Applied Research Consortium.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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We conducted a 16-week randomized controlled trial in psychiatric outpatients with a lifetime diagnosis of a mood and/or anxiety disorder to measure the impact of a first-of-its-kind precision digital intervention software solution based on social rhythm regulation principles. The full intent-to-treat (ITT) sample consisted of 133 individuals, aged 18–65. An exploratory sub-sample of interest was those individuals who presented with moderately severe to severe depression at study entry (baseline PHQ-8 score ≥15; N = 28). Cue is a novel digital intervention platform that capitalizes on the smartphone's ability to continuously monitor depression-relevant behavior patterns and use each patient's behavioral data to provide timely, personalized “micro-interventions,” making this the first example of a precision digital intervention of which we are aware. Participants were randomly allocated to receive Cue plus care-as-usual or digital monitoring only plus care as usual. Within the full study and depressed-at-entry samples, we fit a mixed effects model to test for group differences in the slope of depressive symptoms over 16 weeks. To account for the non-linear trajectory with more flexibility, we also fit a mixed effects model considering week as a categorical variable and used the resulting estimates to test the group difference in PHQ change from baseline to 16 weeks. In the full sample, the group difference in the slope of PHQ-8 was negligible (Cohen's d = −0.10); however, the Cue group demonstrated significantly greater improvement from baseline to 16 weeks ( p = 0.040). In the depressed-at-entry sample, we found evidence for benefit of Cue. The group difference in the slope of PHQ-8 (Cohen's d = −0.72) indicated a meaningfully more rapid rate of improvement in the intervention group than in the control group. The Cue group also demonstrated significantly greater improvement in PHQ-8 from baseline to 16 weeks ( p = 0.009). We are encouraged by the size of the intervention effect in those who were acutely ill at baseline, and by the finding that across all participants, 80% of whom were receiving pharmacotherapy, we observed significant benefit of Cue at 16 weeks of treatment. These findings suggest that a social rhythm-focused digital intervention platform may represent a useful and accessible adjunct to antidepressant treatment ( ).
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Background Sickle cell disease (SCD) is characterized by severe acute pain episodes as well as risk for chronic pain. Digital delivery of SCD pain self-management support may enhance pain self-management skills and accessibility for youth. However, little is known about how youth with SCD and their caregivers engage with digital health programs. iCanCope with pain is a digital pain self-management platform adapted for youth with SCD and caregivers through a user-centered design approach. The program was delivered via a website (separate versions for youth and caregiver) and mobile app (youth only). Objective We aimed to characterize patterns of user engagement with the iCanCope with SCD program among youth with SCD and their caregivers. Methods A randomized controlled trial was completed across multiple North American SCD clinics. Eligible youth were aged 12-18 years, diagnosed with SCD, English-speaking, and experiencing moderate-to-severe pain interference. Eligible caregivers were English-speaking with a child enrolled in the study. Dyads were randomized to receive the iCanCope intervention or attention-control education for 8-12 weeks. This report focused on engagement among dyads who received the intervention. User-level analytics were captured. Individual interviews were conducted with 20% of dyads. Descriptive statistics characterized quantitative engagement. Content analysis summarized qualitative interview data. Exploratory analysis tested the hypothesis that caregiver engagement would be positively associated with child engagement. Results The cohort included primarily female (60% [34/57] of youth; 91% [49/56] of caregivers) and Black (>90% of youth [53/57] and caregivers [50/56]) participants. Among 56 dyads given program access, differential usage patterns were observed: both the youth and caregiver engaged (16/56, 29%), only the youth engaged (24/56, 43%), only the caregiver engaged (1/56, 2%), and neither individual engaged (16/56, 29%). While most youth engaged with the program (40/57, 70%), most caregivers did not (39/56, 70%). Youth were more likely to engage with the app than the website (85% [34/57] versus 68% [23/57]), and the most popular content categories were goal setting, program introduction, and symptom history. Among caregivers, program introduction, behavioral plans, and goal setting were the most popular content areas. As hypothesized, there was a moderate positive association between caregiver and child engagement (χ21=6.6; P=.01; ϕ=0.34). Interviews revealed that most dyads would continue to use the program (11/12, 92%) and recommend it to others (10/12, 83%). The reasons for app versus website preference among youth were ease of use, acceptable time commitment, and interactivity. Barriers to caregiver engagement included high time burden and limited perceived relevance of content. Conclusions This is one of the first studies to apply digital health analytics to characterize patterns of engagement with SCD self-management among youth and caregivers. The findings will be used to optimize the iCanCope with SCD program prior to release. Trial Registration NCT03201874;
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Purpose of Review To summarise evidence on both appropriate and inappropriate antihypertensive drug withdrawal. Recent Findings Deprescribing should be attempted in the following steps: (1) identify patients with several comorbidities and significant functional decline, i.e. people at higher risk for negative outcomes related to polypharmacy and lower blood pressure; (2) check blood pressure; (3) identify candidate drugs for deprescribing; (4) withdraw medications at 4-week intervals; (5) monitor blood pressure and check for adverse events. Although evidence is accumulating regarding short-term outcomes of antihypertensive deprescribing, long-term effects remain unclear. Summary The limited evidence for antihypertensive deprescribing means that it should not be routinely attempted, unless in response to specific adverse events or following discussions between physicians and patients about the uncertain benefits and harms of the treatment. Perspectives Clinical controlled trials are needed to examine the long-term effects of deprescribing in older subjects, especially in those with comorbidities, and significant functional decline.
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Objectives The prevalence of activities of daily living (ADL) in patients with heart failure (HF) reported in current studies were inconsistent, ranging from 11.1 to 70.5%. The purpose of this study is to quantify the prevalence of ADL impairment in HF patients.Methods PubMed, Embase, Cochrane, CINAHL, CNKI, SinoMed, VIP, and Wanfang databases were systematically searched for relevant studies (up to March 2, 2022). Cross-sectional, case-control, or cohort studies with detailed descriptions of overall ADL impairment in HF were included. Stata 16.0 was used for statistical analysis. Fixed-effect or random-effect model was adopted according to heterogeneity which was evaluated by Cochran’s Q and I2 values. Sensitivity analysis, subgroup analysis, and meta-regression were performed to investigate the sources of heterogeneity.ResultsA total of 12 studies with 15,795 HF patients were included in the meta-analysis, and the pooled prevalence of ADL impairment in patients with HF was 38.8% (95%CI: 28.2–49.3%; I2 = 99.5%, P < 0.001). No possible sources of heterogeneity were found in subgroup analysis and meta-regression. Funnel plots and Egger’s test showed no publication bias (P = 0.595).Conclusion The prevalence of ADL impairment is relatively high in HF patients. Differences in the prevalence of ADL impairment in patients with HF may be influenced by country, region, and assessment time. We suggest that more researchers could focus on the changes of ADL impairment in HF patients during different disease periods in different regions and countries.
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Hypertension increases the risk of cardiovascular and other diseases. Lifestyle modification is a significant component of nonpharmacological treatments for hypertension. We previously reported the clinical efficacy of digital therapeutics (DTx) in the HERB-DH1 trial. However, there is still a lack of cost-effectiveness assessments evaluating the impact of prescription DTx. This study aimed to analyze the cost-effectiveness of using prescription DTx in treating hypertension. We developed a monthly cycle Markov model and conducted Monte Carlo simulations using the HERB-DH1 trial data to investigate quality-adjusted life-years (QALYs) and the cost of DTx for hypertension plus guideline-based lifestyle modification consultation treatment as usual (TAU), comparing DTx + TAU and TAU-only groups with a lifetime horizon. The model inputs were obtained from the HERB-DH1 trial, published or publicly available data, and expert assumptions. The incremental cost-effectiveness ratio (ICER) per QALY was used as the benchmark for cost-effectiveness. We performed probabilistic sensitivity analyses (PSAs) using the Monte Carlo simulation with two million sets. The DTx + TAU strategy produced 18.778 QALYs and was associated with ¥3,924,075 ($34,122) expected costs, compared with 18.686 QALYs and ¥3,813,358 ($33,160) generated by the TAU-only strategy over a lifetime horizon, resulting in an ICER of ¥1,199,880 ($10,434)/QALY gained for DTx + TAU. The monthly cost and attrition rate of DTx for hypertension have a significant impact on ICERs. In the PSA, the probability of the DTx arm being a cost-effective option was 87.8% at a threshold value of ¥5 million ($43,478)/QALY gained. In conclusion, the DTx + TAU strategy was more cost-effective than the TAU-only strategy.
Background Hypertension is the most important modifiable stroke risk factor, but blood pressure (BP) remains poorly controlled after stroke, especially among Black and Hispanic patients. We tested the feasibility of TASC (Telehealth After Stroke Care), a post-acute stroke care model integrating nurse-supported home BP telemonitoring, tailored infographics, and multidisciplinary team video visits. Methods Acute stroke patients with hypertension were randomized at discharge to usual care or usual care with TASC. Usual care patients received video visits with primary care and stroke. TASC included a tablet and monitor to wirelessly transmit BP data to the electronic health record, with telenursing support, tailored infographics to explain BP readings, and pharmacist visits. Outcomes assessment was blinded. Feasibility outcomes included recruitment, randomization, adherence, and retention. Systolic BP from baseline to 3 months after discharge was evaluated using generalized linear modeling. Results Fifty patients (64±14 years; 36% women‚ 44% Hispanic, 32% Black, 54% ≤high school education, 30% private insurance), and 75% of all eligible were enrolled over 6.3 months. Baseline systolic BP was similar in both (TASC n=25, 140±19 mm Hg; usual care n=25, 142±19 mm Hg). At 3 months, adherence to video visits (91% versus 75%, P =0.14) and retention (84% versus 64%, P =0.11) were higher with TASC. Home systolic BP declined by 16±19 mm Hg from baseline in TASC and increased by 3±24 mm Hg in usual care ( P =0.01). Among Black patients, systolic BP control (<130 mm Hg) improved from 40% to 100% with TASC versus 14% to 29%, and among Hispanic patients, from 23% to 62% with TASC, versus 33% to 17% in usual care. Conclusions Enhancing post-acute stroke care with home BP telemonitoring is feasible to improve hypertension in an underserved setting and should be tested in a definitive randomized clinical trial. Registration URL: ; Unique identifier: NCT04640519.
Importance: The Systolic Blood Pressure Intervention Trial (SPRINT) showed that intensive blood pressure control reduced cardiovascular morbidity and mortality. However, the legacy effect of intensive treatment is unknown. Objective: To evaluate the long-term effects of randomization to intensive treatment with the incidence of cardiovascular and all-cause mortality approximately 4.5 years after the trial ended. Design, setting, and participants: In this secondary analysis of a multicenter randomized clinical trial, randomization began on November 8, 2010, the trial intervention ended on August 20, 2015, and trial close-out visits occurred through July 2016. Patients 50 years and older with hypertension and increased cardiovascular risk but without diabetes or history of stroke were included from 102 clinic sites in the US and Puerto Rico. Analyses were conducted between October 2021 and February 2022. Interventions: Randomization to systolic blood pressure (SBP) goal of less than 120 mm Hg (intensive treatment group; n = 4678) vs less than 140 mm Hg (standard treatment group; n = 4683). Main outcomes and measures: Extended observational follow-up for mortality via the US National Death Index from 2016 through 2020. In a subset of 2944 trial participants, outpatient SBP from electronic health records during and after the trial were examined. Results: Among 9361 randomized participants, the mean (SD) age was 67.9 (9.4) years, and 3332 (35.6%) were women. Over a median (IQR) intervention period of 3.3 (2.9-3.9) years, intensive treatment was beneficial for both cardiovascular mortality (hazard ratio [HR], 0.66; 95% CI, 0.49-0.89) and all-cause mortality (HR, 0.83; 95% CI, 0.68-1.01). However, at the median (IQR) total follow-up of 8.8 (8.3-9.3) years, there was no longer evidence of benefit for cardiovascular mortality (HR, 1.02; 95% CI, 0.84-1.24) or all-cause mortality (HR, 1.08; 95% CI, 0.94-1.23). In a subgroup of participants, the estimated mean outpatient SBP among participants randomized to intensive treatment increased from 132.8 mm Hg (95% CI, 132.0-133.7) at 5 years to 140.4 mm Hg (95% CI, 137.8-143.0) at 10 years following randomization. Conclusions and relevance: The beneficial effect of intensive treatment on cardiovascular and all-cause mortality did not persist after the trial. Given increasing outpatient SBP levels in participants randomized to intensive treatment following the trial, these results highlight the importance of consistent long-term management of hypertension. Trial registration: Identifier: NCT01206062.
In 2021, the open-label randomized HERB-Digital Hypertension 1 (HERB-DH1) trial showed for the first time that hypertension digital therapeutics (a hypertension treatment app) successfully reduced blood pressure (BP) in patients with hypertension. Patients in the digital therapeutics group who used the app and home BP monitoring (HBPM) showed significant and persistent decreases in office, home and ambulatory BP values compared with the control group (who were under physician management using HBPM and lifestyle modifications). The results of the pivotal study led to the first global approval of this app for the treatment of hypertension in Japan in 2022, including medical insurance reimbursement. As a result, this hypertension app is expected to become widely used in the clinical management of all stages of hypertension. The most important remaining research issues include the identification of patients likely to respond to this therapeutic approach and the development of clinical efficacy indices. In addition, guidelines for the appropriate use of hypertension apps in the treatment of hypertension are needed. Next steps include the development and research of digital tools to facilitate the behavioral modifications required to prevent hypertension. Home BP-guided digital approach to prevent the onset of hypertension and its consequences from prehypertension to severe hypertension. SaMD, software of medical device; CVD, cardiovascular disease
Background Measurement of serum concentrations of drugs is a novelty found useful in detecting poor drug adherence in patients taking ≥2 antihypertensive agents. Regarding patients with treatment‐resistant hypertension, we previously based our assessment on directly observed therapy. The present study aimed to investigate whether serum drug measurements in patients with resistant hypertension offer additional information regarding drug adherence, beyond that of initial assessment with directly observed therapy. Methods and Results Nineteen patients assumed to have true treatment‐resistant hypertension and adherence to antihypertensive drugs based on directly observed therapy were investigated repeatedly through 7 years. Serum concentrations of antihypertensive drugs were measured by ultra‐high‐performance liquid chromatography–tandem mass spectrometry from blood samples taken at baseline, 6‐month, 3‐year, and 7‐year visits. Cytochrome P450 polymorphisms, self‐reported adherence and beliefs about medicine were performed as supplement investigations. Seven patients (37%) were redefined as nonadherent based on their serum concentrations during follow‐up. All patients reported high adherence to medications. Nonadherent patients expressed lower necessity and higher concerns regarding intake of antihypertensive medication ( P =0.003). Cytochrome P450 polymorphisms affecting metabolism of antihypertensive drugs were found in 16 patients (84%), 21% were poor metabolizers, and none were ultra‐rapid metabolizers. Six of 7 patients redefined as nonadherent had cytochrome P450 polymorphisms, however, not explaining the low serum drug concentrations measured in these patients. Conclusions Our data suggest that repeated measurements of serum concentrations of antihypertensive drugs revealed nonadherence in one‐third of patients previously evaluated as adherent and treatment resistant by directly observed therapy, thereby improving the accuracy of adherence evaluation. Registration URL: ; unique identifier: NCT01673516.
Background and Objective: Hypertension is the most prevalent chronic disease in older adults. Antihypertensive drug use increases with aging. In some studies, hypotension developing under antihypertensive medication use has been indicated as a potential risk factor for morbidity and mortality in older adults. Our objective was to assess the relationship between hypotension under antihypertensive treatment and incident hospitalization of nursing home residents. Methods: We detailed blood pressure measurements of the previous 1-year period that were noted regularly at 2-week intervals and studied their mean values. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) thresholds to define low SBP (≤ 110 mm Hg) and DBP (≤ 65 mm Hg) were derived from our previous study. We noted demograph-ics, number of co-morbidities and regular medications, mobility status, and nutritional assessment via the Mini Nutritional Assessment Short Form. Results: We included 253 participants (66% male, mean age 75.7 ± 8.7 years). The prevalence of low SBP (≤ 110 mmHg) and low DBP (≤ 65 mmHg) was 34.8% and 15.8%, respectively. Among residents, 4% were bedridden, 15.8% wheelchair bound, 14.5% needing assistance for reduced mobility, and 62.7% were ambulatory. At a median of 15 months of follow-up, hospitalization incidence from any cause was 50.8% (n = 134). Incident hospitalization was more common in the group that had low DBP (odds ratio = 3.06; 95% confidence interval 1.02-9.15; p = 0.04) after adjusting for age, number of comorbidi-ties and medications, mobility status, and nutritional status. Low SBP was not associated with hospitalization. Conclusions: The low DBP (≤ 65 mm Hg) during the previous year was associated with incident hospitalization of nursing home residents after adjustment for several factors. These findings indicate that lower DBP may be a causative factor for incident hospitalization. We need further studies to explore whether a correction of diastolic hypotension may decrease the hospitalization risk in this vulnerable population. Key Points Among older adults receiving hypertension treatment in a nursing home, systolic hypotension (≤ 110 mmHg) and diastolic hypotension (≤ 65 mmHg) were present in about one third and 15% of the residents, respectively; which indicates prevalent overtreatment. Low diastolic blood pressure was associated with a higher risk of incident hospitalization after adjustment for several confounding factors.