Multiple antihypertensive use and risk of mortality in residents of aged care services: a prospective cohort study

Deprescribing Opportunities for Frail Residents of Nursing Homes: A Multicenter Study in Australia, China, Japan, and Spain

OBJECTIVE

Deprescribing opportunities may differ across health care systems, nursing home settings, and prescribing cultures. The objective of this study was to compare the prevalence of STOPPFrail medications according to frailty status among residents of nursing homes in Australia, China, Japan, and Spain.

DESIGN

Secondary cross-sectional analyses of data from 4 cohort studies.

SETTING AND PARTICIPANTS

A total of 1142 residents in 31 nursing homes.

METHODS

Medication data were extracted from resident records. Frailty was assessed using the FRAIL-NH scale (non-frail 0-2; frail 3-6; most-frail 7-14). Chi-square tests and prevalence ratios (PRs) were used to compare STOPPFrail medication use across cohorts.

RESULTS

In total, 84.7% of non-frail, 95.6% of frail, and 90.6% of most-frail residents received ≥1 STOPPFrail medication. Overall, the most prevalent STOPPFrail medications were antihypertensives (53.0% in China to 73.3% in Australia, P < .001), vitamin D (nil in China to 52.7% in Australia, P < .001), lipid-lowering therapies (11.1% in Japan to 38.9% in Australia, P < .001), aspirin (13.5% in Japan to 26.2% in China, P < .001), proton pump inhibitors (2.1% in Japan to 32.0% in Australia, P < .001), and antidiabetic medications (12.3% in Japan to 23.5% in China, P = .010). Overall use of antihypertensives (PR, 1.15; 95% CI, 1.06-1.25), lipid-lowering therapies (PR, 1.78; 95% CI, 1.45-2.18), aspirin (PR, 1.31; 95% CI, 1.04-1.64), and antidiabetic medications (PR, 1.31; 95% CI, 1.00-1.72) were more prevalent among non-frail and frail residents compared with most-frail residents. Antihypertensive use was more prevalent with increasing frailty in China and Japan, but less prevalent with increasing frailty in Australia. Antidiabetic medication use was less prevalent with increasing frailty in China and Spain but was consistent across frailty groups in Australia and Japan.

CONCLUSIONS AND IMPLICATIONS

There were overall and frailty-specific variations in prevalence of different STOPPFrail medications across cohorts. This may reflect differences in prescribing cultures, application of clinical practice guidelines in the nursing home setting, and clinician or resident attitudes toward deprescribing.

New National Institute for Health and Care Excellence guidance for hypertension: a review and comparison with the US and European guidelines

The UK National Institute for Health and Care Excellence (NICE) guidance for hypertension management has recently been updated. This review article summaries the main recommendations in NICE guidelines, and compares them with the American and European guidelines. NICE and the European Society of Cardiology (ESC) recommend diagnosing hypertension at a higher level than the American College of Cardiology/American Heart Association (ACC/AHA). NICE treats to less stringent targets than both the ACC/AHA and the ESC, while using similar, although non-combination pill based, treatment regimens.

Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment

BACKGROUND

Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians.

METHODS

Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls.

RESULTS

Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences.

CONCLUSIONS

Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.

Prediction of Nursing Home Admission Using the FRAIL-NH Scale Among Older Adults in Post-Acute Care Settings

OBJECTIVES

The FRAIL-NH scale was developed to identify frailty status in nursing home residents. The purpose of this study was to examine the utility of the FRAIL-NH scale for predicting nursing home admission among patients in post-acute care settings. Design/ Setting/ Participants: This single-center, prospective, observational cohort study included participants aged 65 years or older who were admitted to a community-based integrated care ward (CICW) between July 2015 and November 2020.

MEASUREMENTS

Using the CICW database, we retrospectively classified participants as robust, prefrail, or frail based on the FRAIL-NH scale the score by identifying variables from our database that were most representative of each component. The following data were collected: examination findings, CICW admission and discharge information, length of CICW stay, and nursing home admission. The participants were divided into two groups based on whether or not they were admitted to a nursing home after CICW discharge. The hazard ratios (HRs) and 95% confidence intervals (CIs) for nursing home admission were calculated according to the FRAIL-NH categories using the Cox proportional hazards models with reference to the robust group. In the multivariate adjusted model, we adjusted for age, sex, nutritional status, cognitive function, living status, and economic status.

RESULTS

Data of 550 older adults were analyzed, of which 118 were admitted and 432 were not admitted to a nursing home. The frail group had a higher risk of nursing home admission (HR, 2.22; 95% CI 1.32-3.76) than the robust group.

CONCLUSIONS

This study showed that the FRAIL-NH scale was beneficial for predicting nursing home admission among older adults in the post-acute care setting. Thus, assessment using the FRAIL-NH scale may help to consider preparation and support for life after discharge.

The relationship between C-Reactive protein and mortality in adults with diabetes: Influences of demographic characteristics, lifestyle behaviors, and medications

BACKGROUND AND AIMS

This study assesses the influence of demographic, lifestyle, and medication in the association between CRP and mortality in a national sample of adults with diabetes.

METHODS AND RESULTS

Cross-sectional study of data from 1999 to 2010 National Health and Nutrition Examination Survey (unweighted n = 3952; Weighted n = 19,064,710). Individuals were categorized as having diabetes if told by a provider they had diabetes, were taking insulin or other diabetes medications, or had a glycosylated hemoglobin A1c (HbA1c) ≥ 6.5%. CRP was classified into four categories: normal (≤0.1 mg/dL); moderate risk (0.11-0.3 mg/dL); high-risk (0.31-1.0 mg/dL); very high-risk (>1.0 mg/dL). Higher risk for mortality was associated with a very high-risk of CRP (HR = 1.88 (95% CI: 1.27-2.78), being a current (HR = 1.49 (95% CI: 1.10-2.01) or former (HR = 1.34 (95% CI: 1.03-1.73) smoker, and taking insulin (HR = 1.60 (95% CI: 1.25-2.05), taking anti-hypertensives (HR = 1.50 (95% CI: 1.22-1.85), and having co-morbidities such as cancer (HR = 1.32 (95% CI: 1.05-1.66) and hepatitis infection (HR = 1.76 (95% CI: 1.07-2.91), while taking Metformin (HR = 0.62 (95% CI: 0.50-0.76) had a lower risk of mortality.

CONCLUSION

In this sample of adults with diabetes, demographic, lifestyle, and medication factors influenced the association between CRP and mortality. Interventions should focus on these factors to reduce mortality in adults with diabetes.

Frailty Status and Cognitive Function Should Guide Prescribing in Long-term Care Facilities

Frailty, dementia and complex multimorbidity are highly prevalent among residents of long-term care facilities (LTCFs). Prescribing for residents of LTCFs is often informed by disease-specific clinical practice guidelines based on research conducted among younger and more robust adults. However, frailty and cognitive impairment may modify medication benefits and risks. Residents with frailty and advanced dementia may be at increased susceptibility to adverse drug events (ADEs) and often have a lower likelihood of achieving long-term therapeutic benefit from chronic preventative medications. For this reason, there is a strong rationale for deprescribing, particularlyamong residents with high medication burdens, swallowing difficulties or limited dexterity. Conversely, frailty and dementia have also been associated with under-prescribing of clinically indicated medications. Unnecessarily withholding treatment based on assumed risk may deprive vulnerable population groups from receiving evidence-based care. There is a need for specific evidence regarding medication benefits and risks in LTCF residents with frailty and dementia. Observational studies conducted using routinely collected health data may complement evidence from randomized controlled trials that often exclude people living with dementia, frailty and in LTCFs. Balancing over- and under-prescribing requires consideration of each resident's frailty and cognitive status, therapeutic goals, time-to-benefit, potential ADEs, and individual values or preferences. Incorporating frailty screening into medication review may also provide better alignment of medication regimens to changing goals of care. Timely identification of frail residents as part of treatment decision-making may assist with targeting interventions to minimize and monitor for ADEs. Shifting away from rigid application of conventional disease-specific clinical practice guidelines may provide an individualized and more holistic assessment of medication benefits and risks in the LTCF setting.

The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes

OBJECTIVES

To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Frail residents living in nursing homes.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language.

RESULTS

Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1-79.5% (frail) to 28.5-75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried's phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cut-offs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively.

CONCLUSION

In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes.