The next #GeriMedJC will take place on December 18 at 08:00 ET / 13:00 GMT. Don’t forget to use the hashtag in your tweets!
We’ll be extending an invitation to our colleagues #NephJC given the topic for the long article. At the live version of #GeriMedJC, the first 40 minutes are devoted to a critical appraisal of the long article, followed by a 20 minute discussion of the short article. In September, we reviewed a study on the effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs (JAMA Intern Med. 2015 Apr;175(4):57885.) In case you missed that discussion, you can download transcript. This month’s choice, the Discontinuation of Antihypertensive Treatment in Elderly (DANTE) Study Leiden should serve as an interesting extension on the topic.
Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning-the DANTE Study Leiden: A Randomized Clinical Trial. JAMA Intern Med. 2015 Oct 1;175(10):1622-30.
IMPORTANCE: Observational studies indicate that lower blood pressure (BP) increases risk for cognitive decline in elderly individuals. Older persons are at risk for impaired cerebral autoregulation; lowering their BP may compromise cerebral blood flow and cognitive function.
OBJECTIVE: To assess whether discontinuation of antihypertensive treatment in older persons with mild cognitive deficits improves cognitive, psychological, and general daily functioning.
DESIGN, SETTING, AND PARTICIPANTS: A community-based randomized clinical trial with a blinded outcome assessment at the 16-week follow-up was performed at 128 general practices in the Netherlands. A total of 385 participants 75 years or older with mild cognitive deficits (Mini-Mental State Examination score, 21-27) without serious cardiovascular disease who received antihypertensive treatment were enrolled in the Discontinuation of Antihypertensive Treatment in Elderly People (DANTE) Study Leiden from June 26, 2011, through August 23, 2013 (follow-up, December 16, 2013). Intention-to-treat analyses were performed from January 20 through April 11, 2014.
INTERVENTIONS: Discontinuation (n = 199) vs continuation (n = 186) of antihypertensive treatment (allocation ratio, 1:1).
MAIN OUTCOMES AND MEASURES: Change in the overall cognition compound score. Secondary outcomes included changes in scores on cognitive domains, the Geriatric Depression Scale-15, Apathy Scale, Groningen Activity Restriction Scale (functional status), and Cantril Ladder (quality of life).
RESULTS: Compared with 176 participants undergoing analysis in the control (continuation) group, 180 in the intervention (discontinuation) group had a greater increase (95% CI) in systolic BP (difference, 7.36 [3.02 to 11.69] mm Hg; P = .001) and diastolic BP (difference, 2.63 [0.34 to 4.93] mm Hg; P = .03). The intervention group did not differ from the control group in change (95% CI) in overall cognition compound score (0.01 [-0.14 to 0.16] vs -0.01 [-0.16 to 0.14]; difference, 0.02 [-0.19 to 0.23]; P = .84). The intervention and control groups did not differ significantly in secondary outcomes, including differences (95% CIs) in change in compound scores of the 3 cognitive domains (executive function, -0.07 [-0.29 to 0.15; P = .52], memory, 0.08 [-0.12 to 0.29; P = .43], and psychomotor speed, -0.85 [-1.72 to 0.02; P = .06]), symptoms of apathy (0.17 [-0.65 to 0.99; P = .68]) and depression (0.14 [-0.20 to 0.48; P = .41]), functional status (-0.72 [-1.52 to 0.09; P = .08]), and quality-of-life score (-0.09 [-0.34 to 0.16; P = .46]). Adverse events were equally distributed.
CONCLUSIONS AND RELEVANCE: In older persons with mild cognitive deficits, discontinuation of antihypertensive treatment did not improve cognitive, psychological, or general daily functioning at the 16-week follow-up.
While the long article is an attempt at deprescribing, this month’s short article will tackle a different aspect of medication management:
Practical problems with medication use that older people experience: a qualitative study. J Am Geriatr Soc. 2014 Dec;62(12):2339-44. PMID: 25516030
OBJECTIVES: To identify the practical problems that older people experience with the daily use of their medicines and their management strategies to address these problems and to determine the potential clinical relevance thereof.
DESIGN: Qualitative study with semistructured face-to-face interviews.
SETTING: A community pharmacy and a geriatric outpatient ward.
PARTICIPANTS: Community-dwelling people aged 70 and older (N = 59).
MEASUREMENTS: Participants were interviewed at home. Two researchers coded the reported problems and management strategies independently according to a coding scheme. An expert panel classified the potential clinical relevance of every identified practical problem and associated management strategy using a 3-point scale.
RESULTS: Two hundred eleven practical problems and 184 management strategies were identified. Ninety-five percent of the participants experienced one or more practical problems with the use of their medicines: problems reading and understanding the instructions for use, handling the outer packaging, handling the immediate packaging, completing preparation before use, and taking the medicine. For 10 participants, at least one of their problems, in combination with the applied management strategy, had potential clinical consequences and 11 cases (5% of the problems) had the potential to cause moderate or severe clinical deterioration.
CONCLUSION: Older people experience a number of practical problems using their medicines, and their strategies to manage these problems are sometimes suboptimal. These problems can lead to incorrect medication use with clinically relevant consequences. The findings pose a challenge for healthcare professionals, drug developers, and regulators to diminish these problems.