Abstract
Objectives
Geriatric palliative care approaches support deprescribing of antihypertensives in
older nursing home (NH) residents with limited life expectancy and/or advanced dementia
(LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world
deprescribing patterns in this population is limited. We examined the incidence and
factors associated with antihypertensive deprescribing.
Design
National, retrospective cohort study.
Setting and Participants
Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with
potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive
class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg.
Measures
Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive
for ≥7 days. Competing risk models assessed cumulative incidence and factors associated
with deprescribing.
Results
Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was
41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives
and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence
interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment
(ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis
(ie, recent weight loss, poor appetite, dehydration, dependence for activities of
daily living, pain) and later admission year were associated with increased likelihood
of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart
failure, obesity), shortness of breath, and admission source from another NH or home/assisted
living setting (vs acute hospital) were associated with decreased likelihood.
Conclusions and Implications
Real-world deprescribing patterns of antihypertensives among NH residents with HTN
and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity
and individualization of patient care in a population with potential overtreatment.
Factors facilitating deprescribing included treatment intensity and markers of poor
prognosis. Comparative effectiveness and safety studies are needed to guide clinical
decisions around deprescribing and HTN management.
Keywords
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References
- Choosing wisely? Measuring the burden of medications in older adults near the end of life: Nationwide, longitudinal cohort study.Am J Med. 2017; 130: 927-936.e9
- The burden of polypharmacy in patients near the end of life.J Pain Symptom Manage. 2016; 51: 178-183.e2
- Reducing inappropriate polypharmacy: The process of deprescribing.JAMA Intern Med. 2015; 175: 827-834
- Clinical consequences of polypharmacy in elderly.Expert Opin Drug Saf. 2014; 13: 57-65
- Inappropriate prescribing of preventative medication in patients with life-limiting illness: A systematic review.BMJ Support Palliat Care. 2017; 7: 113-121
- Deaths from Alzheimer's disease—United States, 1999-2014.MMWR Morb Mortal Wkly Rep. 2017; 66: 521-526
- Prevalence of preventive cardiovascular medication use in nursing home residents. Room for deprescribing? The SHELTER Study.J Am Med Dir Assoc. 2017; 18: 1037-1042
- An expert opinion from the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the management of hypertension in very old, frail subjects.Hypertension. 2016; 67: 820-825
- Hypertension management in nursing homes: Review of evidence and considerations for care.Curr Hypertens Rep. 2020; 22: 8
- Antihypertensive drug deintensification and recurrent falls in long-term care.Health Serv Res. 2018; 53: 4066-4086
- Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus.JAMA Intern Med. 2015; 175: 1942-1949
Intrator O, Cai S, Miller S. The Veterans Health Administration residential history file: A resource for research and operations. Paper resented at: The 2015 HSR&D/QUERI National Conference; July 8-10, 2015; Philadelphia, PA.
- The Residential History File: Studying nursing home residents’ long-term care histories.Health Serv Res. 2011; 46: 120-137
- Veterans' access to and use of Medicare and Veterans Affairs health care.Med Care. 2007; 45: 214-223
- VA/CMS Data. VHA directive 1153: Access to Centers for Medicare and Medicaid Services (CMS) and the United States Renal Data System (USRD) Data for Veterans Health Administration (VHA) Users within the Department of Veterans Affairs (VA) Information Technology (IT) Systems.US Department of Veterans Affairs, Washington, DCApril 15, 2016
- Minimum Data Set 3.0 Public Reports Overview.(2012. Available at:)
- Overview of significant changes in the Minimum Data Set for Nursing Homes Version 3.0.J Am Med Dir Assoc. 2012; 13: 595-601
- VHA Support Service Center Products 2019.(Available at:)https://vssc.med.va.gov/VSSCMainAppDate accessed: June 24, 2019
- The MDS Mortality Risk Index: The evolution of a method for predicting 6-month mortality in nursing home residents.BMC Res Notes. 2010; 3: 200
- Adaptation and initial validation of Minimum Data Set (MDS) mortality risk index to MDS version 3.0.J Am Geriatr Soc. 2018; 66: 2353-2359
- Physician recognition of cognitive impairment: Evaluating the need for improvement.J Am Geriatr Soc. 2004; 52: 1051-1059
- MDS Cognitive Performance Scale.J Gerontol. 1994; 49: M174-M182
- Chronic Condition Data Warehouse Medicare Administrative Data User Guide.2013, US Department of Veterans Affairs: Washington, DC
- Validating Emergency Department Vital Signs Using a Data Quality Engine for Data Warehouse.Open Med Inform J. 2013; 7: 34-39
- Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: A comparison across health states.Cardiovasc Diabetol. 2018; 17: 27
- Immortal time bias in pharmacoepidemiology.Am J Epidemiol. 2008; 167: 492-499
- Risk for health events after deprescribing acetylcholinesterase inhibitors in nursing home residents with severe dementia.J Am Geriatr Soc. 2020; 68: 699-707
- Incidence and predictors of aspirin discontinuation in older adult veteran nursing home residents at end-of-life.J Am Geriatr Soc. 2020; 68: 725-735
- Can administrative data identify active diagnoses for long-term care resident assessment?.J Rehabil Res Dev. 2010; 47: 719
- The Aggressive Behavior Scale: A new scale to measure aggression based on the Minimum Data Set.J Am Geriatr Soc. 2008; 56: 2298-2303
- Identification of fractures from computerized Medicare files.J Clin Epidemiol. 1992; 45: 703-714
- Using medical services claims to assess injuries in the elderly: Sensitivity of diagnostic and procedure codes for injury ascertainment.J Clin Epidemiol. 2000; 53: 183-194
- Comorbidity measures for use with administrative data.Med Care. 1998; 36: 8-27
- Examining the association between comorbidity indexes and functional status in hospitalized Medicare Fee-for-Service beneficiaries.Phys Ther. 2016; 96: 232-240
- A systematic review of validated methods for identifying venous thromboembolism using administrative and claims data.Pharmacoepidemiol Drug Saf. 2012; 21: 154-162
- Obesity and overweight.(2018. Available at:)https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweightDate accessed: January 31, 2020
- Exploring end-of-life care in Veterans Affairs Community Living Centers.J Am Geriatr Soc. 2015; 63: 644-650
- Site of death in the hospital versus nursing home of Medicare skilled nursing facility residents admitted under Medicare's Part A benefit.J Am Geriatr Soc. 2004; 52: 1247-1254
- Do palliative consultations improve patient outcomes?.J Am Geriatr Soc. 2008; 56: 593-599
- Urban influence codes.(2019. Available at:)https://www.ers.usda.gov/data-products/urban-influence-codes.aspxDate accessed: October 22, 2019
- Data downloads: Area Health Resources Files.(Available at:)https://data.hrsa.gov/data/downloadDate accessed: October 22, 2019
- Multiple Imputation.(2013. Available at:) (Accessed May 22, 2020)
- A Proportional hazards model for the subdistribution of a competing risk.J Am Stat Assoc. 1999; 94: 496-509
- Intensification of older adults' outpatient blood pressure treatment at hospital discharge: National retrospective cohort study.BMJ. 2018; 362: k3503
- Optimizing drug therapy in patients with advanced dementia: A patient-centered approach.Eur Geriatr Med. 2014; 5: 66-71
- Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing?.Cancer. 2019; 125: 2309-2317
- Hypertension treatment in US long-term nursing home residents with and without dementia.J Am Geriatr Soc. 2019; 67: 2058-2064
- Reconsidering medication appropriateness for patients late in life.Arch Intern Med. 2006; 166: 605-609
- Time to move? Factors associated with burden of care among informal caregivers of cognitively impaired older people facing housing decisions: Secondary analysis of a cluster randomized trial.BMC Geriatr. 2019; 19: 249
- Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: The CareAD Study.Int Psychogeriatr. 2008; 20: 406-418
- Perceptions of family decision-makers of nursing home residents with advanced dementia regarding the quality of communication around end-of-life care.J Am Med Dir Assoc. 2018; 19: 879-883
- Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: The PARTAGE study.JAMA Intern Med. 2015; 175: 989-995
Article info
Publication history
Published online: July 25, 2020
Footnotes
The work was supported by the U.S. Department of Veterans Affairs (IIR 14-306, principal investigator C.T.T.; Office of Academic Affairs Fellowship in Medication Safety & Pharmacy Outcomes, M.V., S.P.S.). J.D.N. was funded by a T32 award from the National Institute on Aging (T32AG021885). The views expressed are those of the authors and do not represent the views of the Department of Veterans Affairs.
The authors declare no conflicts of interest.
Preliminary research as part of this study was presented as a poster at the American Society for Health-Systems Pharmacists Midyear Meeting in December 2019 in Las Vegas, NV, and was accepted for presentation at the American Geriatrics Society Meeting in May 2020 in Long Beach, CA (cancelled due to COVID-19).
Identification
Copyright
Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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