Antihypertensive Drug Deintensification and Recurrent Falls in Long‐Term Care

Abstract

Objective To examine the relationship between antihypertensive drug deintensification and recurrent falls in long‐term care. Data Sources/Settings Department of Veterans Affairs (VA) inpatient, outpatient, and purchased care data, Minimum Data Set assessments from VA nursing homes (NHs), and Medicare claims from fiscal years 2010 – 2015. Study Design We identified NH residents with evidence of overaggressive antihypertensive treatment, defined as systolic blood pressure (SBP) 80–120 and an index fall. Recurrent fall, hospitalization, and mortality within 30 days were compared between veterans whose antihypertensive medications were deintensified versus those whose antihypertensive medications were not using propensity score methods (PSM). Principal Findings Among 2,212 NH residents with possibly overaggressive antihypertensive treatment, 11 percent experienced antihypertensive drug deintensification. Lower blood pressure, >1 antihypertensive drug, no congestive heart failure, fracture from index fall, and older age were associated with higher likelihood of deintensification. Antihypertensive deintensification was associated with statistically significant (p‐value < .01) lower risk of recurrent fall among residents with SBP 80–100 (marginal effect = −11.4 percent; PSM = −13.6 percent) and higher risk of death among residents with SBP 101–120 (marginal effect = 2.1 percent, p‐value = .07; with PSM = 4.3 percent, p‐value = .04). Conclusions Results provide some needed evidence and guidelines for deintensifying antihypertensive medication among frail older residents; since hypertension is prevalent among 54 percent of NH residents, the potential impact of new evidence is great.

Hypertension Treatment in US Long‐Term Nursing Home Residents With and Without Dementia

“…Since each first‐line antihypertensive pharmacologic class can cause adverse effects, such as diuresis, orthostasis, falling, metabolic changes, and constipation, clinicians should always prescribe these drugs with caution and be alert to the possibility that a patient's symptoms are adverse drug effects. In addition, these medications are reasonable targets for deintensification in NH residents with dementia in whom this is consistent with their goals of care …”

“…Because medication adverse effects may not be recognized in individuals with cognitive or physical impairment, antihypertensives may contribute to adverse geriatric syndromes in individuals with dementia. In a previous article, we found an association between antihypertensive deintensification and fewer falls in selected NH residents . Moreover, due to differences in physiology, survival, and goals of care, findings observed in relatively well older adults who participated in randomized clinical trials, such as Hypertension in the Very Elderly Trial (HYVET) and Systolic Blood Pressure Intervention Trial, cannot be automatically extrapolated to a relatively ill population with reduced expected survival .…”

“…In a previous article, we found an association between antihypertensive deintensification and fewer falls in selected NH residents. 34 Moreover, due to differences in physiology, survival, and goals of care, findings observed in relatively well older adults who participated in randomized clinical trials, such as Hypertension in the Very Elderly Trial (HYVET) 35 and Systolic Blood Pressure Intervention Trial, 6 cannot be automatically extrapolated to a relatively ill population with reduced expected survival. 36 In fact, the rates of cardiovascular hospitalization and death in our study, which reflect rates in the entire US NH population, resemble those in studies of disabled older adults 37 but not those reported in HYVET.…”

“…In addition, these medications are reasonable targets for deintensification in NH residents with dementia in whom this is consistent with their goals of care. 34…”

Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit

“…Even among the relatively healthy people included in SPRINT, there was a higher incidence of hypotension and possibly syncope in those who had intensive lowering of blood pressure . A study published in Health Services Research described 2,212 VA NH residents (mean age = 81 years; 98% male) with overaggressive antihypertensive treatment (systolic blood pressure = 80‐120 mm Hg) and a fall over a 5‐year period . Eleven of these residents had deintensification of antihypertensive treatment within 7 days of the index fall.…”