Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
BACKGROUND:
Hypertension is the most common chronic condition among nursing home residents in the U.S., yet it is unclear whether frail older adults experience a net benefit or net harm from aggressive hypertension management. As a result, medication review and de-intensification ("deprescribing") is a component of many nursing home (and geriatrics) safety improvement strategies. This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Using VA and Medicare data from FY2010 through FY2015, investigators identified 2,212 older Veterans (>65 years) who resided in one of 132 VA nursing homes and were treated for hypertension (46% took two or more antihypertensive medications at baseline). Anti-hypertensive de-intensification was defined as discontinuation of one or more first-line hypertension medications without substitution within 7 days of the index date (date of measurement of low blood pressure). Outcomes included recurrent falls, hospital admission, and mortality within 30 days of the end of the treatment decision period.
FINDINGS:
- Among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization, suggesting an SBP of 100 as a possible threshold for distinguishing benefit (SBP <100) from harm (SBP >100) from antihypertensive de-intensification.
- Most predictors of being a nursing home resident – including end-of-life status, physical function impairment, and dementia diagnosis – were not associated with the likelihood of de-intensification.
IMPLICATIONS:
- In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual's prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
LIMITATIONS:
- This was an observational study where the intervention of antihypertensive de-intensification was not randomly assigned, but was possibly related to unmeasured resident and other parameters.
- The clinical scenario (low SBP followed by a fall within 3 days) created in this study to mark over-aggressive treatment was tailored to available data. The actual scenarios faced by clinicians may be far more complex.
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Dr. Boockvar is a former HSR&D Career Development Awardee and part of the James J. Peters VA Medical Center, Bronx, NY. Wei Song and Orna Intrator are with the VA Office of Geriatrics & Extended Care (GEC) Field Office, Geriatrics & Extended Care Data Analysis Center (GECDAC). Dr. Lee is part of the San Francisco VA.
Song W, Intrator O, Lee S, and Boockvar K. Antihypertensive Drug Deintensification and Recurrent Falls in Long-term Care. Health Services Research. December 1, 2018;53(6):4066-86.
