Recommendations for (Discontinuation of) Statin Treatment in Older Adults: Review of Guidelines

Ploeg, Milly A. van der; Floriani, Carmen; Achterberg, Wilco P.; Bogaerts, Jonathan; Gussekloo, Jacobijn; Mooijaart, Simon P.; Streit, Sven; Poortvliet, Rosalinde K.E.; Drewes, Yvonne M.

doi:10.1111/jgs.16219

Cited by 49 publications

(28 citation statements)

References 49 publications

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“…Despite higher rates of discontinuation in nursing homes residents with a limited life expectancy and evidence that life expectancy has been considered when deprescribing statins, 15,16 we still found that over half of those with a prognosis less than six months remained on statins after their nursing home admission. A growing body of evidence suggests that older adults with a limited life expectancy are unlikely to benefit from statins 3,17,37 and could potentially be harmed from continued use.…”

Section: Discussionmentioning

confidence: 67%

“…4 Currently, the few national guidelines on statin prescribing (and deprescribing) for older adults, older than 75 years, are inconsistent. 16,39 Part of the issue underlying inconsistent guidelines is likely the insufficient availability of evidence on the efficacy and safety of statins in older adults. Clinical trials on treatment of CVD have historically excluded older adults.…”

Section: Potential Mechanisms and Implicationsmentioning

confidence: 99%

“…14 Although most physicians will deprescribe cardiovascular medications in light of debilitating adverse events, 15 there remains wide discretion without consistent guidelines on prescribing and deprescribing statins in adults older than 75 years. 16 For those with a limited life expectancy, recommendations against routine statin prescribing exist. 17 Despite this, less than half of nursing home residents on statins with progressive, severe cognitive impairment discontinue statins.…”

Section: Introductionmentioning

confidence: 99%

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Statin Discontinuation and Life‐Limiting Illness in Non–Skilled Stay Nursing Homes at Admission

Mack

Baek

Tjia

et al. 2020

J American Geriatrics Society

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OBJECTIVES To estimate 30‐day statin discontinuation among newly admitted nursing home residents overall and within categories of life‐limiting illness. DESIGN Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING U.S. Medicare‐ and Medicaid‐certified nursing home facilities (n = 13,092). PARTICIPANTS Medicare fee‐for‐service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non–skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS Residents were categorized using evidence‐based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life‐limiting illness classification (no life‐limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end‐of‐life: 45.0%). Relative to those with no life‐limiting illness, risk of 30‐day statin discontinuation increased with life‐limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02–1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10–1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43–1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42–1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life‐limiting illness status. CONCLUSION Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.

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Section: Discussionmentioning

confidence: 67%

Section: Potential Mechanisms and Implicationsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Statin Discontinuation and Life‐Limiting Illness in Non–Skilled Stay Nursing Homes at Admission

Mack

Baek

Tjia

et al. 2020

J American Geriatrics Society

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“…However, discussions may arise as to what to monitor and how frequently to monitor in elderly populations, especially when the frail and vulnerable elderly with short life expectancy are taken into account. For example, it can be argued that the measurement of blood glucose is still necessary in the (frail) elderly to prevent short-term complications, whereas the monitoring of blood lipids seems less necessary, given its association with longer-term complications in a population with a short life expectancy [ 49 , 50 ].…”

Section: Discussionmentioning

confidence: 99%

Applicability of somatic monitoring instructions in clinical practice guidelines on antipsychotic drug use

Brouwer

Hengel

Risselada³

et al. 2021

BMC Psychiatry

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Background Clinical practice guidelines (CPGs) recommend the monitoring of somatic parameters in patients treated with antipsychotic drugs in order to detect adverse effects. The objective of this study was to assess, in adult and (frail) elderly populations, the consistency and applicability of the somatic monitoring instructions recommended by established CPGs prior to and during antipsychotic drug use. Methods A search for national and international CPGs was performed by querying the electronic database PubMed and Google. Somatic monitoring instructions were assessed for adult and (frail) elderly populations separately. The applicability of somatic monitoring instructions was assessed using the Systematic Information for Monitoring (SIM) score. Somatic monitoring instructions were considered applicable when a minimum SIM score of 3 was reached. Results In total, 16 CPGs were included, with a total of 231 somatic monitoring instructions (mean: 14; range: 0–47). Of the somatic monitoring instructions, 87% were considered applicable, although critical values and how to respond to aberrant values were only present in 28 and 52% of the available instructions respectively. Only 1 CPG presented an instruction specifically for (frail) elderly populations. Conclusions We emphasize the need for a guideline with somatic monitoring instructions based on the SIM definition for both adult and (frail) elderly populations using antipsychotic drugs. In addition, CPGs should state that clear agreements should be made regarding who is responsible for interventions and somatic monitoring prior to and during antipsychotic drug use.

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“…Additionally, future studies could explore the possibility of developing a clinical deprescribing trial framework to guide future trials. On the deprescribing of statins, more high-quality evidence is needed to guide physicians on appropriate treatment for older adults, which may be facilitated through N-of-1 trials, or other robust trial methods [36].…”

Section: Discussionmentioning

confidence: 99%

The Feasibility of Using N-Of-1 Trials to Investigate Deprescribing in Older Adults with Dementia: A Pilot Study

et al. 2019

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N-of-1 trials may provide insights into the impact of deprescribing medications in populations where evidence is currently lacking, such as the effect of statins on cognition in people with dementia. For this pilot, N-of-1, double-blinded, deprescribing trial, adults over 80 years of age with dementia taking statins for at least 6-months were recruited from a hospital's geriatric medicine outpatient clinic in Sydney, Australia. Participants discontinued and restarted statins over the study period. At enrolment, the hospital pharmacy-using a random number generator, randomised recruited participants to their usual statin or placebo regimen, with assessment and switching of treatment every 5 weeks from baseline (0-weeks) until Visit 4 (15-weeks). Primary outcome was measured using the rate of change in Alzheimer's Disease Assessment Score-Cognitive Subscale (ADAS-CoG). Over 6-months, 81 participants were screened, 14 were eligible, and four were randomised. One participant (female, 88 years) completed all four assessments with no major harms reported. Cognitive impairment, as measured by ADAS-CoG score, was similar on placebo (15.5/70) compared to statin (15/70). This study suggests there are significant challenges in performing N-of-1 trials and recruiting people with dementia into deprescribing trials from outpatient settings.Healthcare 2019, 7, 161 2 of 9 provide information in patient populations where the effects of medications on particular disease states is poorly understood [8]. For example, N-of-1 trials have been previously used to determine the optimum treatment for people with chronic diseases, such as schizophrenia, and can overcome the heterogeneity of treatment effects in these populations [9][10][11]. Inclusion of people with chronic diseases, who are generally excluded in clinical trials, appears to be safe, indicating the potential of recruitment involving older adults with cognitive impairment in N-of-1 trials [10,11]. N-of-1 trials have also been used in studying the side effects of statins, specifically, statin-related myalgia in older adults 65-years-old and above, indicating their potential for investigating the relationship between statins and other non-specific outcomes such as cognitive impairment [12]. Furthermore, deprescribing N-of-1 trials are safe and can generate strong patient-specific evidence on the benefits and harms of discontinuing medications, potentially informing and facilitating the conduct of subsequent, robust, clinical deprescribing trials [13].The aim of this pilot study was to examine the feasibility of conducting an N-of-1, deprescribing, trial in older adults with dementia, and to generate pilot data on the short-term impact of deprescribing statins on cognition in older adults with dementia.

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Recommendations for (Discontinuation of) Statin Treatment in Older Adults: Review of Guidelines

Cited by 49 publications

References 49 publications

Statin Discontinuation and Life‐Limiting Illness in Non–Skilled Stay Nursing Homes at Admission

Statin Discontinuation and Life‐Limiting Illness in Non–Skilled Stay Nursing Homes at Admission

Applicability of somatic monitoring instructions in clinical practice guidelines on antipsychotic drug use

The Feasibility of Using N-Of-1 Trials to Investigate Deprescribing in Older Adults with Dementia: A Pilot Study

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