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

Abstract

Objectives: Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing.

Design: National, retrospective cohort study.

Setting and participants: Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg.

Measures: Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing.

Results: Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood.

Conclusions and implications: Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.

Keywords: Hypertension; antihypertensives; deprescribing; end-of-life; nursing homes; older adults.

Fig. 1.

Flow diagram of sample construction of older Veterans with limited life expectancy and/or advanced dementia and hypertension admitted to VA CLCs in FY2009-2015 with potential overtreatment for HTN. Potentially overtreated: mean daily systolic BP <120 mm Hg and receipt of at least 1 antihypertensive medication. MMRI-R, Mortality Risk Index for predicting death in the next 6 months validated in VA nursing home population.

Fig. 2.

Cumulative incidence of antihypertensive deprescribing with 95% confidence interval bands at 30-day follow-up and 7-day deprescribing window among older Veterans with limited life expectancy and/or advanced dementia and HTN living in VA CLCs in FY2009-2015 with potential overtreatment for HTN (n = 10,574).

Fig. 3.

Sociodemographic, environment of care, CV risk, markers of poor prognosis, and facility-level factors with statistically significant (P < .05) associations with antihypertensive deprescribing among older Veterans with limited life expectancy and/or advanced dementia and HTN living in VA CLCs in FY2009-2015 with potential overtreatment for HTN, N = 10,574. Distance of NOK: between the NOK’s zip code centroid and the address of the CLC, categorized in quartiles of the distribution. ADL: activities of daily living per Morris categories of dependency (independent, requires supervision, or requires limited assistance), (requires extensive assistance), (dependent or totally dependent); VLSBP: <100 mm Hg measured during days 2-7 of CLC stay (baseline); LSBP: 100 to <120 mm Hg at baseline; class: antihypertensive class; BMI: underweight (<18.5), normal weight (18.5 to <25), overweight (25 to <30), or obese (≥30); Facility complexity: complexity level of the VA parent station with which the CLC was affiliated (1a, 1b, 1c, 2, or 3, in order of decreasing complexity). BMI, body mass index; CV, cardiovascular; LSBP, low systolic blood pressure; VLSBP, very low systolic blood pressure.