Discontinuing antihypertensive drugs did not appear to improve function in older patients with cognitive deficits over the short term
At 16 weeks, a greater increase in systolic and diastolic blood pressure was noted in the discontinuation group versus the continuation group, but no significant differences were seen between groups in change in overall cognition compound score.
Stopping antihypertensive treatment in older patients with cognitive deficits did not appear to improve cognitive function, psychological function, or general daily function, according to a new 16-week study.
Researchers hypothesized that discontinuing antihypertensive medication in older patients with cognitive impairment might help cognition and other outcomes, given observational research showing that lower blood pressure increases risk for cognitive decline in the elderly. They performed a community-based randomized clinical trial with blinded outcome assessment comparing continuation and discontinuation of antihypertensives in patients from 128 general practices in the Netherlands from June 26, 2011, through Aug. 23, 2013. The last follow-up date was Dec. 16, 2013, and intention-to-treat analyses were done from Jan. 20 through April 11, 2014.
Patients 75 years of age and older who took antihypertensives, had a systolic blood pressure of 160 mm Hg or lower, and had a Mini-Mental State Examination (MMSE) score of 21 to 27 were included. Those with a history of peripheral arterial disease, myocardial infarction, or coronary reperfusion and those with diabetes were also able to participate if their systolic blood pressure was 140 mm Hg or lower. The primary outcome was change in overall cognition compound score, while secondary outcomes were changes in scores on cognitive domains and on other measures of depression, apathy, function, and quality of life. The study results were published online Aug. 24 by JAMA Internal Medicine.
One hundred ninety-nine patients were randomly assigned to the discontinuation group, and 186 patients were randomly assigned to the continuation group. Of these, 180 and 176 patients, respectively, were included in the 16-week analyses. At 16 weeks, a greater increase in systolic and diastolic blood pressure was noted in the discontinuation versus the continuation group, but no significant differences were seen between groups in change in overall cognition compound score or in any of the secondary outcomes. Adverse events occurred equally between groups.
The authors noted that patients and physicians were not blinded to study group and that they did not examine potential long-term cognitive benefit of antihypertensive discontinuation, among other limitations. However, they concluded that discontinuing antihypertensive treatment in older adults who have mild cognitive deficits does not appear to improve short-term cognitive, psychological, or general daily function. They called for future randomized trials with longer follow-up to determine whether less stringent blood pressure targets might be beneficial in older patients who have impaired cerebral autoregulation.
An invited commentary said that the current study had modest substantive value but “enormous” methodologic value, specifically because it looked at patient-centered outcomes, was based on strong scientific rationale, examined a usually underrepresented study population, and used many safety checkpoints to ensure that discontinuing treatment did not harm patients. “We have made great strides in building the evidence base for initiating and intensifying antihypertensive therapy, but we have neglected to study the effects of continuing and discontinuing therapy in older adults,” the commentary author wrote. “This study is the first step forward in answering these important scientific questions.”
Another study, published online as a research letter Aug. 24 by JAMA Internal Medicine, examined statin use in very elderly patients, defined as those older than age 79, using data from the Medical Expenditure Panel Survey from 1999 to 2012. The study included 13,099 patients and found that rates of vascular disease increased from 27.6% in 1999 to 2000 to 43.7% in 2011 to 2012. Statin use in the primary prevention population increased from 8.8% to 34.1% over the same time period, with an increasing trend seen also for secondary prevention (P<0.001 for both comparisons). Use of atorvastatin peaked in 2005 to 2006 and then declined steadily, while use of simvastatin held steady until 2007 to 2008 and then began to increase. Rosuvastatin use, meanwhile, increased steadily. In addition, no association was seen between use of high-potency statins and vascular disease.
The authors concluded that a significant percentage of community-dwelling very elderly adults who did not have vascular disease reported having a statin prescription despite a lack of supporting data from randomized clinical trials. “Although the medical community has embraced the use of statins for primary prevention in the very elderly, caution should be exercised given the potential dangers of expanding marginally effective treatments to untested populations,” the authors wrote.