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

Abstract

OBJECTIVES To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia. DESIGN Observational cohort study. SETTING All US NHs. PARTICIPANTS Long‐term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale. MEASUREMENTS The primary exposure was intensity of antihypertensive treatment, as defined as number of first‐line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180‐day follow‐up period. RESULTS Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6‐month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%‐0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%‐0.39%) and a small decrease in ADL decline (difference per additional medication = −0.46%; 95% confidence interval = −0.67% to −0.25%). There was no significant difference in mortality (difference per additional medication = −0.05%; 95% confidence interval = −0.23% to 0.13%). CONCLUSION Long‐term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care. J Am Geriatr Soc 67:2058–2064, 2019

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes

“…Another national study of NH residents also found that poor prognosis factors (cognitive impairment and functional impairment) were associated with potential overtreatment for HTN in residents with dementia. 47 This is consistent with the geriatric palliative Fig. 3.…”

“…NH residents with LLE/AD may be at lower risk of fall or fracture, given institutional monitoring and dependence in ADL; however, an opportunity to improve fall prevention via less intensive treatment remains for mobile residents. Documentation of LP was not strongly associated with antihypertensive deprescribing; other studies showed mixed associations, where this factor was strongly associated with less intensive antihypertensive treatment 47 but not with deprescribing. 10 Again, lack of associations between these factors and deprescribing can stem from the unclear clinical recommendations in this population.…”

Therapeutic optimization through goal-oriented prescription in nursing homes

“…There are currently several pieces of evidence that recommend less intensive control in people with multimorbidity, especially in cases of dementia or limited life expectancy [ 25 ]. In general, blood pressure lower than 140/90 mmHg has been associated with a higher risk of falls and even mortality [ 8 , 26 , 27 ]. In our study we have proposed measures for pharmacological adjustment in people whose mean systolic blood pressure (SBP) was under 130 mmHg in the last year.…”

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort

“…Hypertension (HT) and Cardiovascular Therapy: There is currently evidence suggesting less intensive monitoring in people with multimorbidity, particularly in cases of dementia or limited life expectancy [ 38 ]. Globally, blood pressure under 140/90 mmHg has been associated with a higher risk of falls and mortality [ 39 , 40 , 41 ]. We considered an antihypertensive medication as an IP in EOL patients when the patient’s mean systolic blood pressure has been lower than 130 mmHg over the last year [ 31 ].…”