That was the question addressed in a recent target trial emulation approach including 12,644 nursing home residents. The report in the Journal of the American Medical Association Internal Medicine found that deprescribing antihypertensive medication was associated with less cognitive decline, especially among those with dementia.
“These findings suggest the importance of patient-centered approaches to deprescribing antihypertensive medication, ensuring that regimens for older adults are optimized to preserve cognitive function and minimize potential harm,” wrote University of California San Francisco–led researchers.
The researchers pointed out that antihypertensive medication deprescribing is common among nursing home residents, but its association with cognitive decline has not been clear. That led the study team to investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.
The cohort study using a target trial emulation approach included Veterans Affairs long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Excluded from the study were residents who were not prescribed antihypertensive medication, with blood pressure (BP) greater than 160/90 mmHg, or with heart failure.
Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Data analyses were performed from May 1, 2023, and July 1, 2024.
For purposes of the study, deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks. The Cognitive Function Scale (CFS) was used to measure effects, and participants were classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).
The study included 12,644 residents (mean [standard deviation (SD)] age 77.7 [8.3] years; 329 [2.6%] females and 12,315 [97.4%] males) and 12,053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11,739 [97.4%] males) who met eligibility for ITT and per-protocol analyses, respectively.
The results indicated that by the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score); 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score, according to the authors.
Specifically, in the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared with the stable user group. Interestingly, the study team noted, among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.
“This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia,” the researchers concluded. “More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.”
Background information in the report advised that polypharmacy is common among older adults, with more than 40% taking five or more medications. “Antihypertensive medications are important contributors to polypharmacy, with the prevalence notably high at 70%,” the researchers added. “While antihypertensive medications reduce cardiovascular risks, they also pose risks of adverse effects such as falls, orthostatic hypotension, and drug-drug interactions. The risk to benefit ratio of antihypertensive medication is unclear in adults with multimorbidity who are institutionalized given that they have been largely excluded from clinical trials.
“Considering that this population is at high risk for adverse effects, deprescribing—the strategic reduction or discontinuation of medications that may no longer be beneficial or could be associated with harm—may be clinically appropriate.”
The relationship between antihypertensive medication management and cognitive function in older adults is complex. While elevated BP in midlife is a well-documented risk factor for cognitive decline, the optimal BP targets for older adults—especially those in nursing homes—remain unclear. Randomized clinical trials have shown mixed evidence on the effect of intensive BP control in reducing cognitive decline and the incidence of dementia. First, most trials enrolled relatively healthier older adults, specifically excluding nursing home residents and individuals with dementia who comprise a substantial segment of the aging population and who are at higher risk for cognitive decline. Second, several observational studies have observed an association between higher BP and less cognitive decline in older adults, especially among those with poor functional status. Therefore, a substantial knowledge gap persists regarding the long-term cognitive impact of antihypertensive treatment in frail older individuals, particularly those in nursing homes or those with dementia.
The study aimed to fill this gap by estimating the association of antihypertensive deprescribing with change in cognitive function of older nursing home residents, using a target trial approach using data from the U.S. Department of Veterans Affairs. The researchers carried out a prespecified subgroup analysis based on dementia status given the paucity of data in this population and the potentially distinct responses to antihypertensive medications.
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