疗养院居民的抗高血压药物减量与认知功能。

IF 22.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL
Bocheng Jing, Xiaojuan Liu, Laura A Graham, Chintan V Dave, Yongmei Li, Kathy Fung, Christine K Liu, Hoda S Abdel Magid, Matthew E Growdon, W James Deardorff, W John Boscardin, Sei J Lee, Michael A Steinman, Michelle C Odden
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引用次数: 0

摘要

重要性:在养老院居民中,停用降压药的情况很普遍,但其与认知功能下降之间的关系仍不确定:调查降压药减量与疗养院居民认知功能变化的关系:这项队列研究采用目标试验仿真法,纳入了 2006 年至 2019 年期间入住疗养院至少 12 周、年龄在 65 岁或以上的退伍军人长期疗养院居民。未服用降压药、血压超过 160/90 mm Hg 或患有心力衰竭的住户被排除在外。符合条件且稳定用药 4 周的住院患者被分为停药组和稳定用药组,并随访 2 年或直至死亡或出院,以进行意向治疗 (ITT) 分析。在按协议分析中,切换治疗组的参与者将被剔除。采用序数广义线性混合模型对随访期间的认知功能测量结果进行分析,并通过治疗的逆概率加权调整混杂因素。每项协议分析均采用逆概率删减加权法。数据分析从 2023 年 5 月 1 日开始,到 2024 年 7 月 1 日结束:取消处方的定义是减少降压药物的总数或药物剂量减少 30%,并持续至少 2 周:认知功能量表(CFS)分为认知功能完好(CFS = 1)、轻度受损(CFS = 2)、中度受损(CFS = 3)和严重受损(CFS = 4):在 45 183 名长期护理居民中,12 644 名居民(平均 [SD] 年龄 77.7 [8.3] 岁;329 [2.6%] 名女性和 12 315 [97.4%] 名男性)和 12 053 名居民(平均 [SD] 年龄 77.7 [8.3] 岁;314 [2.6%] 名女性和 11 739 [97.4%] 名男性)分别符合 ITT 和按协议分析的资格。在随访结束时,12.0%的居民的CFS恶化(得分较高),7.7%的居民的CFS改善(得分较低),其中10.8%的停药组和12.1%的稳定用药组的CFS得分恶化。在按协议分析中,与稳定用户组相比,去处方组每 12 周 CFS 类别恶化的几率降低了 12%(几率比 0.88;95% CI,0.78-0.99)。在患有痴呆症的住院患者中,取消处方与认知能力下降几率降低 16% 相关(几率比为 0.84;95% CI 为 0.72-0.98)。这些模式在 ITT 分析中保持一致:这项队列研究表明,去处方化与减少疗养院居民,尤其是痴呆症患者的认知能力下降有关。我们需要更多的数据来了解降压药减量的益处和害处,从而为养老院以患者为中心的用药管理提供依据。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Deprescribing of Antihypertensive Medications and Cognitive Function in Nursing Home Residents.

Importance: Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain.

Objective: To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.

Design, setting, and participants: This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024.

Exposures: Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks.

Main outcomes and measures: Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).

Results: Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.

Conclusions and relevance: This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

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来源期刊
JAMA Internal Medicine
JAMA Internal Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
43.50
自引率
1.30%
发文量
371
期刊介绍: JAMA Internal Medicine is an international, peer-reviewed journal committed to advancing the field of internal medicine worldwide. With a focus on four core priorities—clinical relevance, clinical practice change, credibility, and effective communication—the journal aims to provide indispensable and trustworthy peer-reviewed evidence. Catering to academics, clinicians, educators, researchers, and trainees across the entire spectrum of internal medicine, including general internal medicine and subspecialties, JAMA Internal Medicine publishes innovative and clinically relevant research. The journal strives to deliver stimulating articles that educate and inform readers with the latest research findings, driving positive change in healthcare systems and patient care delivery. As a member of the JAMA Network, a consortium of peer-reviewed medical publications, JAMA Internal Medicine plays a pivotal role in shaping the discourse and advancing patient care in internal medicine.
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