患有和未患有痴呆症的退伍军人长期护理居民的降压药停用与功能状态
Antihypertensive Deprescribing and Functional Status in VA Long-Term Care Residents With and Without Dementia.
作者信息
Liu Xiaojuan, Graham Laura A, Jing Bocheng, Dave Chintan V, Li Yongmei, Kurella Tamura Manjula, Steinman Michael A, Lee Sei J, Liu Christine K, Abdel Magid Hoda S, Manja Veena, Fung Kathy, Odden Michelle C
机构信息
Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA.
Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA.
出版信息
J Am Geriatr Soc. 2025 Apr;73(4):1144-1154. doi: 10.1111/jgs.19342. Epub 2025 Jan 3.
BACKGROUND
Deprescribing antihypertensives is of growing interest in geriatric medicine, yet the impact on functional status is unknown. We emulated a target trial of deprescribing antihypertensive medications compared with continued use on functional status measured by activities of daily living (ADL) in a long-term care population.
METHODS
We included 12,238 Veteran Affairs long-term care residents age 65+ who had a stay ≥ 12 weeks between 2006 and 2019. After 4+ weeks of stable antihypertensive medication use, residents were classified as either deprescribed antihypertensives (reduced ≥ 1 medication or ≥ 30% dose) or continued users. Residents were followed up for 2 years, or censored at discharge, admission to hospice, protocol deviation (per-protocol analysis only), or Sept 30, 2019. The outcome was ADL dependencies (scored 0-28; higher score = worse functionality), assessed approximately every 3 months. Our primary approach was to estimate per-protocol effects using linear mixed-effects regressions with inverse probability of treatment and censoring weighting, overall and stratified by dementia status. We estimated intention-to-treat effects as a secondary analysis.
RESULTS
In long-term care residents, ADL scores worsened by a mean of 0.29 points (95%CI = 0.27, 0.31) per 3 months and antihypertensive deprescribing did not impact this worsening (difference between groups -0.04 points every 3 months, 95%CI = -0.15, 0.06). In the non-dementia subgroup, ADL worsened by 0.15 points (95%CI = 0.11, 0.19) every 3 months. However, residents who were deprescribed showed a slightly improved ADL score over time while the continued users showed ADL decline (difference between groups -0.23 points every 3 months, 95%CI = -0.43, -0.03). Deprescribing was not associated with ADL change in the dementia subgroup. The intention-to-treat results were not meaningfully different.
CONCLUSIONS
Antihypertensive deprescribing did not have a deleterious effect on functional status in long-term care residents with or without dementia. This may be reassuring to residents and clinicians who are considering antihypertensive medication reduction or discontinuation in long-term care settings.
背景
在老年医学中，停用抗高血压药物越来越受到关注，但其对功能状态的影响尚不清楚。我们模拟了一项关于停用抗高血压药物的目标试验，并将其与长期护理人群中持续使用抗高血压药物对通过日常生活活动（ADL）测量的功能状态的影响进行比较。
方法
我们纳入了12238名年龄在65岁及以上的退伍军人事务长期护理居民，他们在2006年至2019年期间住院时间≥12周。在稳定使用抗高血压药物4周以上后，居民被分类为停用抗高血压药物（减少≥1种药物或≥30%剂量）或持续使用者。对居民进行了2年的随访，或在出院、入住临终关怀机构、方案偏离（仅用于符合方案分析）或2019年9月30日时进行截尾。结局是ADL依赖程度（评分0 - 28分；分数越高 = 功能越差），大约每3个月评估一次。我们的主要方法是使用具有治疗和截尾加权逆概率的线性混合效应回归来估计符合方案效应，总体上以及按痴呆状态分层进行估计。我们将意向性分析效应作为次要分析进行估计。
结果
在长期护理居民中，ADL评分每3个月平均恶化0.29分（95%置信区间 = 0.27, 0.31），停用抗高血压药物对此恶化情况没有影响（两组之间每3个月的差异为 - 0.04分，95%置信区间 = - 0.15, 0.06）。在非痴呆亚组中，ADL每3个月恶化0.15分（95%置信区间 = 0.11, 0.19）。然而，随着时间的推移，停用抗高血压药物的居民ADL评分略有改善，而持续使用者的ADL评分下降（两组之间每3个月的差异为 - 0.23分，95%置信区间 = - 0.43, - 0.03）。在痴呆亚组中，停用抗高血压药物与ADL变化无关。意向性分析结果没有显著差异。
结论
停用抗高血压药物对患有或未患有痴呆的长期护理居民的功能状态没有有害影响。这可能会让在长期护理环境中考虑减少或停用抗高血压药物治疗的居民和临床医生感到安心。
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