CATEGORY: HEALTHY AGING & LONGEVITY
Frail nursing-home residents in their late eighties and nineties who had some of their blood-pressure pills gradually withdrawn survived at essentially the same rate as those who kept taking them all—61.7% versus 60.2% died over a follow-up of up to four years, a difference small enough to be due to chance—in a randomized trial conducted at 108 French nursing homes and published in the New England Journal of Medicine.1 The trial, called RETREAT-FRAIL, tackles a question that families and physicians face constantly and that earlier drug trials, which rarely enrolled the very old and frail, had left unanswered: once blood pressure is running low on a handful of daily pills, does taking some of them away help, hurt, or change nothing?
Two or More Pills a Day, and Readings Already Low
The researchers enrolled 1,048 nursing-home residents aged 80 and older—average age about 90, roughly four in five of them women—who were all taking at least two blood-pressure medications and whose systolic pressure (the higher of the two blood-pressure numbers, measured when the heart beats) was already below 130. Each resident was assigned by chance either to a step-down group, in which physicians followed a preset protocol to gradually withdraw pressure-lowering drugs—a planned, supervised winding-down of medicines known as deprescribing—or to usual care, in which treatment continued as before. Because chance rather than choice decided who tapered, the two groups started out alike, and any gap at the end could be credited to the strategy itself. Over up to four years the teams tracked deaths from any cause as the trial’s main measure, along with blood pressure, major cardiovascular events, and side effects.
One Pill Fewer a Day, Four Points Higher on the Cuff
The taper did what it was designed to do. Residents in the step-down group went from an average of 2.6 blood-pressure medications a day to 1.5, while the usual-care group drifted only from 2.5 to 2.0—so by the end, the small daily medicine cup that had held two or three pressure pills now typically held one or two. Systolic pressure rose about 4 points higher in the tapered group, a moderate shift. What did not change was the outcome the trial was built around: 326 residents in the step-down group died (61.7%) compared with 313 in the usual-care group (60.2%), a hazard ratio of 1.02 with a confidence interval of 0.86 to 1.21—statistically, no difference at all. Major cardiovascular events occurred in 19.3% of the tapered group versus 17.3% with usual care, a gap whose confidence interval (0.84 to 1.56) was wide enough that chance cannot be ruled out in either direction, and side effects overall occurred at similar rates in both groups.
The Benefit the Taper Was Meant to Deliver
RETREAT-FRAIL was not designed merely to show that tapering is tolerable—it was designed to test whether lightening the medication load would actually lower death rates in this very frail population, where an aggressive drug regimen pushing pressure low has long been suspected of doing more harm than good. That hoped-for benefit never appeared: the investigators concluded plainly that the step-down strategy did not lead to lower all-cause mortality than usual care and produced a moderate rise in blood pressure. The trial’s answer is symmetrical—fewer pills bought no extra survival, and the extra pills the usual-care group kept taking bought none either.
An English Study of Home-Dwelling Elders Points the Same Way
The French result does not stand alone. A separate randomized study in English primary care, called OPTiMISE, followed 569 adults aged 80 and older with controlled blood pressure on two or more drugs, half of whom had one medication withdrawn. Over a median of four years, 72% of the reduction group versus 77% of the usual-care group died or were hospitalized for any cause—a hazard ratio of 0.93 (confidence interval 0.76 to 1.12), again no statistical difference, with no sign of harm from the lighter regimen.2 Taken together, the two trials point the same way: in adults in their eighties and nineties whose readings are already low or well controlled, a carefully supervised reduction changed neither survival nor safety in a measurable way. Neither study speaks to younger adults or to anyone with high, untreated blood pressure, where lowering pressure has repeatedly been shown to prevent strokes and heart attacks.
Key Takeaways
- In frail nursing-home residents aged 80 and older taking two or more blood-pressure drugs with low readings, gradually tapering medications left survival unchanged over up to four years—61.7% versus 60.2% mortality.
- Tapering cut the average daily count of pressure medications from 2.6 to 1.5 and raised systolic pressure by about 4 points, with side effects no more common than under usual care.
- A separate randomized trial in adults over 80 living at home found the same pattern: withdrawing one drug brought no rise in deaths or hospitalizations over four years.
- Both trials concern very old adults whose pressure was already low or controlled; they say nothing about treating high blood pressure in younger or healthier people.
References
- Benetos A, Gautier S, Freminet A, et al. Reduction of Antihypertensive Treatment in Nursing Home Residents. New England Journal of Medicine. 2025;393(20):1990–2000. link
- Sheppard JP, Temple E, Wang A, et al. Effect of antihypertensive deprescribing on hospitalisation and mortality: long-term follow-up of the OPTiMISE randomised controlled trial. The Lancet Healthy Longevity. 2024;5(8):e563–e573. link