The problem is that prescribers aren’t always sure what to do. While guidelines recommend using clinical judgment when prescribing the drugs to frail older patients, including the possibility of deprescribing, the guidance tends to be nonspecific on when and how to do that.
A study of older adults living in U.S. Department of Veterans’ Affairs (VA) long-term care facilities looked at the incidence of deprescribing of antihypertensive medication, as well as how potentially triggering events affected those decisions. Results were published in JAMNDA.
Included in the retrospective cohort study were long-term care residents aged 65 years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure (BP) medication at admission.
Stanford University and VA Palo Alto Healthcare System researchers extracted data from the VA electronic health record, Centers for Medicare & Medicaid Services Minimum Data Set, and Bar Code Medication Administration. Deprescribing was defined as a reduction in the number or dose of antihypertensive medications for 2 weeks or more.
The study team also assessed potentially triggering events for deprescribing, including:
• Low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%)
• Electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L)
• Falls otherwise unexplained
Results indicate that, among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had one or more deprescribing events over a median length of stay of 6 months, and 48.7% had a net reduction in antihypertensive medications over that stay.
The study found that deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. “Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent four weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference = 30.3%, P <.001). A fall in the past 30 days was associated with the smallest magnitude increased risk of deprescribing (risk difference = 3.8%, P <.001) of the events considered,” the authors write.
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