Deprescribing Antihypertensives May Slow Cognitive Decline in Nursing Home Patients

Antihypertensive medication deprescribing may benefit elderly individuals living in long-term care facilities by limiting the risk of cognitive decline, according to data from the Veterans Health Administration.

Compared with elderly patients who remained on their usual level of BP medication, those in whom medications were deprescribed—via a strategy that reduced either the overall number of antihypertensive drugs or the dosage—had a slower rate of cognitive decline, which was particularly pronounced in those with dementia.

Senior study author Michelle C. Odden, PhD (Veterans Affairs Palo Alto Health Care System, CA), said her group was excited about the findings, which were published this week in JAMA Internal Medicine.

“We think they are at a minimum reassuring for patients and their providers who are considering reducing antihypertensive medication use in a nursing home population,” she told TCTMD. “We've been really good at conducting studies to look at the benefits of adding a medication in older adults, but there have been very limited studies looking at the effects of reducing medication use. We are seeing though that patients and their providers have a big interest in deprescribing and . . . having conversations around deprescribing risks and benefits.”

Odden and colleagues say the study supports the need for data on patient-centered approaches to deprescribing that may benefit cognitive function and minimize the known potential harms of polypharmacy. While studies in younger individuals clearly show that higher BP is a risk factor for cognitive decline, data on the long-term cognitive benefit of keeping pressures low are less clear for older individuals because they have largely been excluded from trials.

With regard to a more pronounced cognitive improvement in those with dementia with deprescribing, that finding is in line with other studies that have suggested that slightly elevated blood pressure may actually be necessary for adequate blood flow when there is vascular disease in the brain, Odden added.

“That's our hypothesized mechanism . . .  and it is something that needs further investigation,” she said.

Less Decline Across Cognitive Function Categories

For the study, Odden and colleagues led by Bocheng Jing, MS (Northern California Institute for Research and Education, San Francisco), included 12,644 veterans (mean age 77.7 years; 0.4% women) who had been living in a long-term care facility for at least 12 weeks and were taking any antihypertensive medication.

Observational data were applied to a target trial emulation approach, with patients who stayed on the same regimen serving as controls and the deprescribing group consisting of those in whom there had been a reduction in the overall number of antihypertensive agents or a 30% decrease in medication dosage compared to the previous week that was sustained for at least 2 weeks.

At baseline, cognitive impairment was mild in 38.8% of those in the stable-use arm, moderate in 23.9%, and severe in 7.6%. The percentages were similar in the deprescribing group at 39.6%, 23.6%, and 8.5%, respectively. Slightly more than one-third in each group were on 2 antihypertensives at baseline, with 4.1% in the stable-use group and 5.2% in the deprescribing group on 4 or more. Among the most common comorbidities were diabetes and depression, as well as dementia, which affected 47% of the stable use group and 45% of the deprescribing group.

At a median follow-up of 23 weeks in the deprescribing group and 21 weeks in the control group, overall changes to the Cognitive Function Scale (CFS) were worse in 12% and improved in 7.7%: 10.8% of the deprescribing group and 12.1% of controls had a worsened CFS score.

Across all categories of cognitive function, those in the deprescribing group showed a slower rate of decline versus controls.

While the deprescribing group saw a 12% reduction in the odds of progressing to a worse CFS category compared with keeping medication the same, those with dementia who were in the deprescribing group had a 16% reduction compared with controls.  

Deprescribing Considerations and Strategies

The study findings are in alignment with the OPTIMISE study, which found that deprescribing in elderly hypertensive patients was noninferior to usual care over 3-month follow-up, with a median BP creep of about a 3.4-mm Hg when one antihypertensive medication was removed.

Deprescribing itself is becoming of heightened interest as 2030 draws closer and an estimated 61 million adults in the “baby boomer” generation will all have reached the age of 65, presenting a significant burden of hypertension, diabetes, and CVD.

Odden said while available data including the new study are helpful, more are needed looking at the effect of deprescribing BP medications on the risk of MI, stroke, and other BP-related events in the elderly.

Looking beyond just antihypertensives, the United States and Canada both have deprescribing networks that provide targeted information to help patients and their providers work through considerations when dropping common medications.

Two studies in the same issue of JAMA Internal Medicine looked at a strategy that involved providing educational brochures to patients to inform them about deprescribing so they could discuss it with their providers. Both studies showed a modest effect on deprescribing habits.

In an editorial accompanying the studies, Timothy S. Anderson, MD (University of Pittsburgh, PA), says these results taken with prior data on this type of proactive, patient-centric approach suggests that “while educational brochures likely do prompt deprescribing conversations, much more is needed to deprescribe effectively.”