Prevalent Statin Use in Long-Stay Nursing Home Residents With Life-Limiting Illness

Deborah S. Mack, MPH; Jennifer Tjia, MD, MSCE; Anne L. Hume, PharmD; Kate L. Lapane, PhD, MS

Disclosures

J Am Geriatr Soc. 2020;68(4):708-716. 

In This Article

Abstract and Introduction

Abstract

Objectives: To evaluate the prevalence and factors associated with statin pharmacotherapy in long-stay nursing home residents with life-limiting illness.

Design: Cross-sectional.

Setting: US Medicare- and Medicaid-certified nursing home facilities.

Participants: Long-stay nursing home resident Medicare fee-for-service beneficiaries aged 65 years or older with life-limiting illness (n = 424 212).

Measurements: Prevalent statin use was estimated as any low-moderate intensity (daily dose low-density lipoprotein-cholesterol [LDL-C] reduction <30%-50%) and high-intensity (daily dose LDL-C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90-day look-back period. Life-limiting illness was operationally defined to capture those near the end of life using evidence-based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.

Results: A total of 34% of residents with life-limiting illness were prescribed statins (65–75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life-limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.

Conclusion: Despite having a life-limiting illness, more than one-third of clinically compromised long-stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted.

Introduction

Cardiovascular disease is one of the most common medical conditions among older adults.[1] In the nursing home, almost 50% of advanced age residents have active vascular diagnoses.[2] Despite this, early clinical trials evaluating statin pharmacotherapy for primary and secondary prevention systematically excluded those older than 75 years.[3–5] Although some subsequent trials included older adults,[6,7] a recent meta-analysis found no significant clinical benefit from statins when this age group was treated for primary prevention.[8] The study did find benefit in secondary prevention treatment across age, but these trials continue to account insufficiently for older adults, particularly those who are frail and clinically complex.[5,6,9–11] The altered physiology of clinically impaired advanced age individuals can change medication sensitivities and effects.[12] For the frail, myopathy-related adverse effects from statins can be especially debilitating with baseline physical weakness.[13] These differences render the existing data inadequate to guide statin treatment effectively in clinically impaired older adults.

Consequently, US guidelines regarding statin use in older adults vary. As of 2016, the US Preventive Services Task Force (USPSTF) has abstained from providing recommendations for adults older than 75 years, citing insufficient evidence.[14] Nevertheless, statin use has continued to proliferate across age. In the United States, approximately one-half of the community-dwelling age 75 and older population were prescribed statins from 2012 to 2013,[15] a nearly 20% increase over the past decade.[15] However, little is known about statin-prescribing patterns in the nursing home environment, where most residents are clinically impaired.[2] A few studies found that statin use in the nursing home is prevalent and persists in the presence of life-limiting illnesses.[16–18] Yet these findings are dated and were also conducted in only a limited number of states[16,17] or outside of the United States.[18]

Some evidence suggests that discontinuation of statins among those with a limited life expectancy may be associated with improved quality of life.[19] Moreover, the American Medical Directors Association does not recommend prescribing statins to those with a limited life expectancy due in part to reports of potential harm in older patients.[20] The purpose of this study was to evaluate the prevalence and clinical correlates of statin pharmacotherapy among nursing home residents who are not likely to benefit from treatment. We hypothesized that statin use persists among nursing home residents with life-limiting illness but decreases with cognitive and functional decline.

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