Hypertension Treatment in US Long-Term Nursing Home Residents With and Without Dementia
Hypertension Treatment in US Long-Term Nursing Home Residents With and Without Dementia
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DOI：
10.1111/jgs.16081
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发表时间：
2019-07-22
影响因子：
6.3
通讯作者：
Intrator, Orna
中科院分区：
文献类型：
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作者：
Boockvar, Kenneth S.;Song, Wei;Intrator, Orna
描述高血压疗养院（NH）居民伴和不伴痴呆的降压药物治疗模式，并确定降压治疗与痴呆患者重要结局之间的相关性。设计观察性队列研究。设置所有的美国国家卫生署。参与者在2013年第二季度接受高血压治疗的长期NH居民，有和没有中度或重度认知障碍，由NH最小数据集（MDS）认知功能量表定义。测量主要暴露是抗高血压治疗的强度，定义为医疗保险D部分配药数据中一线抗高血压药物的数量。结果指标为住院、使用医疗保险分级疾病分类的心血管疾病住院、使用MDS日常生活活动（ADL）量表的身体功能下降以及180天随访期间的死亡。结果在255670名接受高血压治疗的NH居民中，117732人（46.0%）有中度或重度认知功能障碍。在基线时，分别有54.4%、34.3%和11.4%的患者接受了一种、两种和三种或更多种降压药物治疗。中度或重度认知功能障碍（OR = 0.80 vs无或轻度认知功能障碍; P < .0001）、身体功能较差（OR = 0.64最差vs最佳三分位数; P < .0001）、临终关怀或预期寿命少于6个月（OR = 0.80; P < .0001）与接受较少降压药物治疗有关。抗高血压治疗强度的增加与住院率的小幅增加相关（每种额外药物的差异= 0.24%; 95%置信区间= 0.03%-0.45%）和心血管住院（每种额外药物的差异= 0.30%; 95%置信区间= 0.21%-0.39%）和ADL下降的小幅下降（每种额外药物的差异= -0.46%; 95%置信区间= -0.67%至-0.25%）。死亡率无显著差异（每种额外药物的差异= -0.05%; 95%置信区间= -0.23%至0.13%）。结论：长期NH居民高血压患者没有从更强化的抗高血压治疗中获益。对于符合护理目标的居民来说，抗高血压药物是降低强度的合理目标。
OBJECTIVES To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia. DESIGN Observational cohort study. SETTING All US NHs. PARTICIPANTS Long-term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale. MEASUREMENTS The primary exposure was intensity of antihypertensive treatment, as defined as number of first-line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180-day follow-up period. RESULTS Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6-month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%-0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%-0.39%) and a small decrease in ADL decline (difference per additional medication = -0.46%; 95% confidence interval = -0.67% to -0.25%). There was no significant difference in mortality (difference per additional medication = -0.05%; 95% confidence interval = -0.23% to 0.13%). CONCLUSION Long-term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care.