Benefits and Harms of Antihypertensive Management Strategies for Nursing Home Residents with ADRD

About This Grant

Project Summary Hypertension (HTN) affects over 90% of older adults with Alzheimer's disease and related dementias (ADRD). Randomized trials have shown that an intensive HTN treatment strategy (increasing the dose or adding medications when the systolic blood pressure [SBP] is >130 mmHg) reduces the risk of cardiovascular events, mortality, incident dementia, and cognitive decline among healthy older adults. Harms of intensive HTN treatment included syncope, fall-related injuries, electrolyte abnormalities, and acute renal injury. However, trials excluded persons with ADRD and those residing in nursing homes (NH). Little data exist to provide direct evidence on the benefits and harms of an intensive HTN treatment strategy for older adults with ADRD, half of whom reside in NH. Intensive HTN treatment may offer critical benefits for older adults with ADRD, as they are at high risk of CV events and cognitive decline. Conversely, intensive HTN treatment may cause disproportionate harms in this population because of a high prevalence of risk factors for falls and adverse events, like polypharmacy, frailty, and cognitive impairment. Given the diverse range of patients with ADRD residing in NH, these benefits and harms are also likely modified by clinical (e.g., prior stroke, heart failure) and demographic (e.g., sex) characteristics. Evidence-based HTN treatment strategies are needed to avoid harms while maximizing benefits for older adults with ADRD. Without additional evidence, providers may continue to either over- or undertreat HTN in people with ADRD. The overall objective of this proposal is to compare the safety and effectiveness of different HTN treatment strategies for older adults with ADRD residing in NH. This proposal has three aims: (1) describe HTN treatment strategies among NH residents with ADRD, including BP measures and changes to medications; 2) estimate the benefits and harms of an intensive HTN treatment strategy for NH residents with ADRD; and (3) identify optimal HTN treatment strategies for clinically relevant subgroups of NH residents. Our central hypothesis is intensive HTN treatment provides limited benefits and increased harms for many NH residents with ADRD, yet select subgroups can still derive benefits. Our rigorous pharmacoepidemiologic studies will combine novel NH resident electronic health record (EHR) data from up to 10,000 NHs linked with several other rich data sources including: (1) Medicare Part A and Part B claims data; (2) Medicare Part D drug claims; (3) Minimum Data Set version 3.0 clinical assessments; (4) the Certification and Survey Provider Enhanced Reports and LTCFocus databases; and (5) several other databases, including U.S. Census data. Studies will leverage innovative causal inference methods including dynamic treatment strategies, g-computation, and target trial emulation. This project will produce critical, generalizable evidence to optimize HTN treatment strategies for older adults with and without ADRD and inform deprescribing interventions. This research project will address Strategic Goals C and D of the National Institute on Aging and NOT-AG-21-045: “Opportunities for Research in Epidemiology of AD/ADRD and Cognitive Resilience.”