Association between antihypertensive medication use and non-cardiovascular outcomes in older men

Antihypertensive treatment and depressive symptoms in Chinese middle-aged and older hypertensive adults: A population-based longitudinal study

OBJECTIVES

Hypertension is a risk factor for depressive disorders. Although the benefits of lowering blood pressure on the subsequent depressive disorders are supported by biological interpretation, the effect of antihypertensive therapies on depressive disorders is not clear. This study aimed to assess whether blood-pressure-lowering treatment have a protective effect on subsequent depressive symptoms in China.

METHODS

We used data from the nationally representative survey, including 2428 hypertensive participants free from depressive symptoms at baseline in 2011 to 2012. We assessed the depressive symptoms based on the 10-item Center for Epidemiological Studies Depression scale. We conducted Cox proportional hazards regression models to examine the effect of antihypertensive treatment on the incidence of depressive symptoms in 2011 to 2015.

RESULTS

In the total sample, all the models resulted in nonsignificant results and an estimated 8% reduction in risk (95% CI, 0·76-1·12) in the model adjusted for all covariates for the antihypertensive treatment takers with blood pressure controlled. In the group of urban residents, the antihypertensive treatment takers with blood pressure controlled had lower odds (HR: 0.68; 95% CI, 0·49-0·96) of depressive disorders.

CONCLUSION

The protective effect of the antihypertensive therapies might be relative to not only lowering blood pressure per se but also the management of hypertension. We proposed the early intervention to achieve the long-term protective effect of being antihypertensive and the supply of effective and collaborative care of hypertension and depression.

Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed?

Background: Many older adults with hypertension receive multiple antihypertensives. It is unclear whether treatment with several antihypertensive classes results in greater cardiovascular benefits than fewer antihypertensive classes. Objectives: We investigated (a) the longitudinal associations between treatment with ≥ 3 versus 1-2 classes and death and major adverse cardiovascular events (MACE) and (b) whether these associations varied by the presence of mobility disability. Methods: We included 6,011 treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey (MEPS), a nationally representative community sample. Times to MACE and death were compared between those receiving ≥3 versus 1-2 classes using multivariable proportional hazards regression. We used inverse probability of treatment weighting to account for indication and contraindication bias. Results: There were no significant differences in the risk of mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR = 1.10, p = .574) between the exposure groups, and there were no significant exposure × mobility disability interactions. Discussion: We found no benefit of ≥3 versus 1-2 antihypertensive classes in reducing mortality and cardiovascular events in a representative cohort of older adults, raising concern about the added benefit of additional antihypertensives in the real world.

Antidepressant use and cognitive deficits in older men: addressing confounding by indications with different methods

PURPOSE

Antidepressant use has been associated with cognitive impairment in older persons. We sought to examine whether this association might reflect an indication bias.

METHODS

A total of 544 community-dwelling hypertensive men aged ≥65 years completed the Hopkins Verbal Learning Test at baseline and 1 year. Antidepressant medications were ascertained by the use of medical records. Potential confounding by indications was examined by adjusting for depression-related diagnoses and severity of depression symptoms using multiple linear regression, a propensity score, and a structural equation model (SEM).

RESULTS

Before adjusting for the indications, a one unit cumulative exposure to antidepressants was associated with -1.00 (95% confidence interval [CI], -1.94, -0.06) point lower HVLT score. After adjusting for the indications using multiple linear regression or a propensity score, the association diminished to -0.48 (95% CI, -0.62, 1.58) and -0.58 (95% CI, -0.60, 1.58), respectively. The most clinical interpretable empirical SEM with adequate fit involves both direct and indirect paths of the two indications. Depression-related diagnoses and depression symptoms significantly predict antidepressant use (p < .05). Their total standardized path coefficients on Hopkins Verbal Learning Test score were twice (0.073) or as large (0.034) as the antidepressant use (0.035).

CONCLUSION

The apparent association between antidepressant use and memory deficit in older persons may be confounded by indications. SEM offers a heuristic empirical method for examining confounding by indications but not quantitatively superior bias reduction compared with conventional methods.

Medication use and functional status decline in older adults: a narrative review

BACKGROUND

Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use.

OBJECTIVE

Our aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly.

METHODS

The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review.

RESULTS

Nineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly.

CONCLUSIONS

Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.

The association between use of cardiovascular drugs and antidepressants: a nationwide register-based study

PURPOSE

To investigate whether cardiovascular drug classes and specific beta-blockers are associated with antidepressant drug use in a large study population of older people.

METHODS

We analyzed data from the Swedish Prescribed Drug Register from October-December 2005 for people aged 75 years and older (n = 732,230). Logistic regression analysis was used to study the association between the cardiovascular drugs and antidepressants, after adjustment for age, sex, and number of other dispensed drugs.

RESULTS

All the cardiovascular drug classes were negatively or not associated with use of any antidepressant, non-selective monoamine reuptake inhibitors, and SSRIs, after adjustment for age, sex, and number of other dispensed drugs. However, propranolol was associated with an increased use of any antidepressant, non-selective monoamine reuptake inhibitors, and SSRIs, after adjustment for age, sex, and number of other dispensed drugs. Atenolol was positively associated with non-selective monoamine reuptake inhibitors, although to a lesser extent than propranolol.

CONCLUSIONS

None of the cardiovascular drug classes were associated with increased antidepressant drug use, after adjustment for age, sex, and use of other drugs. However, when focusing specifically on beta-blockers, our results indicate that propranolol may be the beta-blocker most closely associated with use of antidepressants in the elderly.

Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes

OBJECTIVES

To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes.

DESIGN

Interview.

SETTING

Community.

PARTICIPANTS

One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk.

MEASUREMENTS

Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome.

RESULTS

Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P=.02), unsteadiness (P=.02), functional dependency (P=.04), lower cognition (P=.02) and depressive symptoms (P=.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics.

CONCLUSION

Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals.

Development of a tool for eliciting patient priority from among competing cardiovascular disease, medication-symptoms, and fall injury outcomes

OBJECTIVES

To develop a choice task for eliciting priorities in the face of competing cardiovascular disease (CVD) outcomes, medication-related symptoms, and fall injuries.

DESIGN

Conjoint analysis.

SETTING

Senior housing site.

PARTICIPANTS

Convenience sample of 15 senior housing residents for the pretest, 13 residents for the pilot test.

MEASUREMENTS

The final task included 11 sets of choices. In each, one option optimized the risk of one or two of the three outcomes at the expense of the other(s); the second option did the reverse. Relative importance scores for CVD, fall injury, and medication-symptom outcomes were calculated. Reliability was assessed for two administrations using intraclass correlations (ICCs). Wilcoxon rank sum tests were used to evaluate order effects.

RESULTS

The ICCs between choice task administrations were 0.70 for fall injuries, 0.73 for medication symptoms, and 0.56 for CVD outcomes. The ICCs with removal of two outliers were 0.84, 0.72, and 0.84, respectively. Whether CVD or fall injuries appeared first had no effect on scores.

CONCLUSION

Preliminary evidence of comprehensibility and reliability supports using the choice task to determine whether individuals' priorities differ in the face of competing outcomes.