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

Discussion

In this national sample of long-stay nursing home residents with life-limiting illness, 4 in 10 residents aged 65 to 75 years and nearly one-third older than 75 years were on statins, with some receiving high-intensity doses. As expected, statin use was associated with an ASCVD diagnosis but also with related risk factors and a high volume of concurrent non-statin medications.

Our statin use estimates are similar to those reported by a study of Canadian nursing home residents, a sample that was not restricted to those near the end of life.[18] The authors reported that 33.6% of their nursing home population were on statins. In another study with a sample from a few US states and 2007–2008 data, the prevalence of statin use in nursing home residents with newly advanced dementia was reported to be 16.6%.[16] This finding is similar to our rates in residents with a prognosis less than 6 months. However, our rates in those with severe cognitive impairment and dementia were notably higher.[16] It is possible that the 2013 ACC/AHA guideline update influenced prescribing in the nursing home setting. These guidelines broadened the indications for statin treatment and expanded the population recommended to treat.[29,36] If these guidelines diffused into the nursing home setting, this could explain the higher prevalence estimates observed in our study.

Overall, the results of this study highlight the high proportion of statin use in the nursing home, despite the end-of-life nature of residents. Although a prognosis less than 6 months or a palliative care consult were strongly associated with lower use of statins, other life-limiting diagnoses were not strongly associated with statin use. This is consistent with another study that found the presence of a life-limiting condition did not affect statin discontinuation.[17]

Major US guidelines for statin prescribing to older adults remain inconsistent.[31] Perhaps at the heart of the issue is that clinical trials for the efficacy and safety of statins in older adults, especially those with life-limiting conditions, are largely absent.[4,5,11] Nevertheless, some evidence suggests statins are not helpful[37] and could contribute to therapeutic burdens of older adults near the end of life.[6,19] A recent meta-analysis showed no significant clinical benefit from statin use for primary prevention of ASCVD in those age 75 and older.[8] In our study, even among those older than 75 years with life-limiting illness, ASCVD risk factors (with no ASCVD diagnosis) were still highly associated with statin use. In addition, we found almost one-quarter of those 65 to 75 years with a prognosis less than 6 months on statins. The American Medical Directors Association sponsored a statement recommending against routine prescribing of lipid-lowering medications for older patients with limited life expectancies.[20] This recommendation is supported by data that show statin deprescribing in this population does not increase mortality[19] and for older adults with ASCVD, treatment may require at least 2 years before clinical benefits are realized,[38] if at all.[37] National guidelines should be updated to provide more specific information for this special population.

Although the inappropriate use of statins among those with a limited prognosis is relatively straightforward, statin use in the broader category of "serious illness" is less clear. We found 30% to 45% of these residents (or approximately 350 000 residents) were on statins. For this potentially more heterogeneous population, in the absence of a limited prognosis, the approach to statin use should be individualized as suggested by the American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity.[39]

Of note, 50% to 60% of our cohort were on 11 or more non-statin prescription medications (eg, PRNs, standing orders) depending on age. It appeared that the more non-statin medication residents were on, the more likely they were to be on statins. According to a 2015 study, the strongest predictor of inappropriate medications and adverse events in older adults is the number of medications prescribed.[40] The US Centers for Medicare & Medicaid Services (CMS) designated the number of nursing home residents on nine or more medications an indicator of poor quality of care.[41] The high proportion of residents on 11 or more medications calls into question rational medication use in this setting. CMS does assess unnecessary medication use in nursing homes (Survey F-Tag F-329),[42] but this may not be enough. Tools to address inappropriate prescribing or deprescribing[43] should be considered. The Five-Step Deprescribing Protocol[40] calls for medication (1) review, (2) risk assessment, (3) discontinuation eligibility, (4) priority of discontinuation, and (5) plan for discontinuation/monitoring. Medications should be reviewed in the context of a resident's goals of care.[16] Because statins do not appear to promote longevity and comfort in older patients near the end of life, use in this population should be carefully reviewed.

These findings should be interpreted with strengths and limitations in mind. This is the first national study to examine statin use in nursing home residents with life-limiting illness. Applying four different operational definitions, life-limiting illness was defined broadly to explore statin use across a range of definitions. Generalizing beyond fee-for-service Medicare beneficiaries to those on Medicare Advantage should be done with caution. If medications were discontinued while residents still had a supply of medications, use may have been overestimated. There are likely factors associated with statin use not collected on the MDS. Cross-sectional study designs are limited by short time periods. Future research should investigate patterns and safety of statin discontinuation over time.

In conclusion, this was the first nationwide study to report statin use in US nursing homes among a population not likely to benefit from continued use. Given the extensive use of statins in those 65 to 75 years of age and those older than 75 years, major US medical societies and organizations should clarify guidelines for older frail populations with limited life expectancies. Research to further our understanding of the extent to which statins are discontinued, the factors associated with discontinued statin use, and whether residents experience any untoward effects of discontinuation of statins is needed in nursing home populations.

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