Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life

Abstract

BACKGROUND/OBJECTIVES: Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN: Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING: VA NHs, known as community living centers (CLCs). PARTICIPANTS: Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS: Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS: Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION: Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.

Inverse Association between Statin Use and Cancer Mortality Relates to Cholesterol Level

“…The main indication for the use of statins is the prevention of cardiovascular events, and usually, the need for statins is assessed individually depending on the patient’s risk profile [ 39 ]. In cancer patients with a limited life-expectancy, medications such as statins are usually discontinued when the benefit of drug use is assessed to be lower than its potential harms, and hence criteria for initiating statins differ compared to patients without cancer [ 40 ]. To manage the bias caused by the tendency to discontinue statins in late-stage terminal cancer, we ignored the discontinuation of statin use during the follow-up.…”

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

“…One general approach frequently used to define discontinuation relies on identifying gap periods in medication use. Gap periods have included 7 days [ 16 ], 14 days [ 17 ], and 30 days [ 18 ] between drug fills in published end-of-life studies based on pharmacy dispensing and claims. Non-end-of-life studies have also used 60 days [ 19 ] or 90 days [ 20 ].…”

Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents

“…Due to small numbers, we excluded women ( n = 22 excluded). Finally, we excluded residents who received hospice care at or before the start of follow-up ( n = 301 excluded), based on the admission treating specialty or a treatment indicator from the MDS ( 3 , 4 ). We excluded hospice residents due to the high overall mortality rate, proximal inevitability of death, and small sample size, which reduced our ability to conduct stratified analyses.…”

“…Potential overuse of medications ( 1 ) is well-documented among older nursing home (NH) residents with limited life expectancy (LLE) and those with dementia, with as many as 50% being exposed to at least one medication with uncertain benefit near end of life ( 2 ). Specifically, investigators of recent observational studies have identified a high prevalence of possible overuse of aspirin ( 3 ), statins ( 4 ), antihypertensives ( 5 ), and diabetes medications ( 6 ) in NH residents with advanced dementia (AD) or LLE. Efforts are needed to reduce the risk for adverse effects through deprescribing and deintensifying medications (i.e., reducing the dose or number of drugs).…”