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Change in Prescribing for Secondary Prevention of Stroke and Coronary Heart Disease in Finnish Nursing Homes and Assisted Living Facilities

  • Natali JokanovicEmail author
  • Hannu Kautiainen
  • J. Simon Bell
  • Edwin C. K. Tan
  • Kaisu H. Pitkälä
Original Research Article

Abstract

Background

One quarter of residents in long-term care facilities (LTCFs) have a diagnosis of CHD or stroke and over half use at least one preventative cardiovascular medication. There have been no studies that have investigated the longitudinal change in secondary preventative cardiovascular medication use in residents in LTCFs over time.

Objective

The aim of this study was to investigate the change in cardiovascular medication use among residents with coronary heart disease (CHD) and prior stroke in nursing homes (NHs) and assisted living facilities (ALFs) in Finland over time, and whether this change differs according to dementia status.

Methods

Three comparable cross-sectional audits of cardiovascular medication use among residents aged 65 years and over with CHD or prior stroke in NHs in 2003 and 2011 and ALFs in 2007 and 2011 were compared. Logistic regression analyses adjusted for gender, age, mobility, cancer and length of stay were performed to examine the effect of study year, dementia and their interaction on medication use.

Results

Cardiovascular medication use among residents with CHD (NHs: 89% vs 70%; ALFs: 89% vs 84%) and antithrombotic medication use among residents with stroke (NHs: 72% vs 63%; ALFs: 78% vs 69%) declined between 2003 and 2011 in NHs and 2007 and 2011 in ALFs. Decline in the use of diuretics, nitrates and digoxin were found in both groups and settings. Cardiovascular medication use among residents with CHD and dementia declined in NHs (88% [95% CI 85–91] in 2003 vs 70% [95% CI 64–75] in 2011) whereas there was no change among people without dementia. There was no change in cardiovascular medication use among residents with CHD in ALFs with or without dementia over time. Antithrombotic use was lower in residents with dementia compared with residents without dementia in NHs (p < 0.001) and ALFs (p = 0.026); however, the interaction between dementia diagnosis and time was non-significant.

Conclusions

The decline in cardiovascular medication use in residents with CHD and dementia suggests Finnish physicians are adopting a more conservative approach to the management of cardiovascular disease in the NH population.

Notes

Compliance with Ethical Standards

Funding

NJ is supported through an Australian Government Research Training Program Scholarship. ECKT is supported by an NHMRC-ARC Dementia Research Development Fellowship (APP1107381). JSB is supported by an Australian National Health and Medical Research Council Dementia Leadership Fellowship.

Conflict of Interest

Natali Jokanovic, Hannu Kautiainen, J. Simon Bell, Edwin C. K. Tan and Kaisu H. Pitkälä declare that they have no potential conflicts of interest that might be relevant to the contents of this manuscript.

Ethics Approval

Ethics approval was obtained for all three studies by the Helsinki University Central Hospital Ethics Committee. The study was registered with the Monash University Human Research Ethics Committee. Written informed consent was obtained from residents and/or their closest proxy to participate in each study.

Supplementary material

40266_2019_656_MOESM1_ESM.docx (475 kb)
Supplementary material 1 (DOCX 475 kb)

References

  1. 1.
    American Heart Association and American Stroke Association. Heart disease and stroke statistics 2017—at a glance. 2017. https://healthmetrics.heart.org/wp-content/uploads/2017/06/Heart-Disease-and-Stroke-Statistics-2017-ucm_491265.pdf. Accessed 21 Jan 2018.
  2. 2.
    Cowman S, Royston M, Hickey A, Horgan F, McGee H, O’Neill D. Stroke and nursing home care: a national survey of nursing homes. BMC Geriatr. 2010;10:4.CrossRefGoogle Scholar
  3. 3.
    Foebel AD, Liperoti R, Gambassi G, Gindin J, Ben Israel J, Bernabei R, et al. Prevalence and correlates of cardiovascular medication use among nursing home residents with ischemic heart disease: results from the SHELTER study. J Am Med Dir Assoc. 2014;15(6):410–5.CrossRefGoogle Scholar
  4. 4.
    Malek Makan A, van Hout H, Onder G, Finne-Soveri H, van der Roest H, van Marum R. Prevalence of preventive cardiovascular medication use in nursing home residents. Room for deprescribing? The SHELTER study. J Am Med Dir Assoc. 2017;18(12):1037–42.CrossRefGoogle Scholar
  5. 5.
    Australian Institute of Health and Welfare. Australia’s health 2016. 2016. https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true. Accessed 21 Jan 2018.
  6. 6.
    Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.CrossRefGoogle Scholar
  7. 7.
    Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2015;16(6):535.e1–12.CrossRefGoogle Scholar
  8. 8.
    Jokanovic N, Jamsen KM, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and variability in medications contributing to polypharmacy in long-term care facilities. Drugs Real World Outcomes. 2017;4(4):235–45.CrossRefGoogle Scholar
  9. 9.
    Liu E, Dyer SM, O’Donnell LK, Milte R, Bradley C, Harrison SL, et al. Association of cardiovascular system medications with cognitive function and dementia in older adults living in nursing homes in Australia. J Geriatr Cardiol. 2017;14(6):407–15.Google Scholar
  10. 10.
    Johnell K, Fastbom J. Comparison of prescription drug use between community-dwelling and institutionalized elderly in Sweden. Drugs Aging. 2012;29(9):751–8.CrossRefGoogle Scholar
  11. 11.
    Shah SM, Carey IM, Harris T, Dewilde S, Cook DG. Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study. BMJ. 2011;342:d912.CrossRefGoogle Scholar
  12. 12.
    Centre for Disease Control and Prevention. Long-term care providers and services users in the United States: data from the national study of long-term care providers, 2013–2014. 2016. https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf. Accessed 21 Jan 2018.
  13. 13.
    Onder G, Carpenter I, Finne-Soveri H, Gindin J, Frijters D, Henrard JC, et al. Assessment of nursing home residents in Europe: the services and health for elderly in long TERm care (SHELTER) study. BMC Health Serv Res. 2012;12:5.CrossRefGoogle Scholar
  14. 14.
    Holmes HM, Sachs GA, Shega JW, Hougham GW, Cox Hayley D, Dale W. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56(7):1306–11.CrossRefGoogle Scholar
  15. 15.
    Tan EC, Bell JS, Lu CY, Toh S. National trends in outpatient antihypertensive prescribing in people with dementia in the United States. J Alzheimers Dis. 2016;54(4):1425–35.CrossRefGoogle Scholar
  16. 16.
    Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011;58(23):2432–46.CrossRefGoogle Scholar
  17. 17.
    Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160–236.CrossRefGoogle Scholar
  18. 18.
    Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.CrossRefGoogle Scholar
  19. 19.
    Ferri C, Ferri L, Desideri G. Management of hypertension in the elderly and frail elderly. High Blood Press Cardiovasc Prev. 2017;24(1):1–11.CrossRefGoogle Scholar
  20. 20.
    Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98.CrossRefGoogle Scholar
  21. 21.
    Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: a randomized clinical trial. JAMA. 2016;315(24):2673–82.CrossRefGoogle Scholar
  22. 22.
    Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F, et al. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: the PARTAGE study. JAMA Intern Med. 2015;175(6):989–95.CrossRefGoogle Scholar
  23. 23.
    Kjeldsen SE, Stenehjem A, Os I, Van de Borne P, Burnier M, Narkiewicz K, et al. Treatment of high blood pressure in elderly and octogenarians: european Society of Hypertension statement on blood pressure targets. Blood Press. 2016;25(6):333–6.CrossRefGoogle Scholar
  24. 24.
    Fleg JL, Forman DE, Berra K, Bittner V, Blumenthal JA, Chen MA, et al. Secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013;128(22):2422–46.CrossRefGoogle Scholar
  25. 25.
    Bushnell CD, Colon-Emeric CS. Secondary stroke prevention strategies for the oldest patients: possibilities and challenges. Drugs Aging. 2009;26(3):209–30.CrossRefGoogle Scholar
  26. 26.
    Zullo AR, Sharmin S, Lee Y, Daiello LA, Shah NR, John Boscardin W, et al. Secondary prevention medication use after myocardial infarction in U.S. nursing home residents. J Am Geriatr Soc. 2017;65(11):2397–404.CrossRefGoogle Scholar
  27. 27.
    Kantoch A, Gryglewska B, Wojkowska-Mach J, Heczko P, Grodzicki T. Treatment of cardiovascular diseases among elderly residents of long-term care facilities. J Am Med Dir Assoc. 2018;19:428–32.CrossRefGoogle Scholar
  28. 28.
    Poudel A, Yates P, Rowett D, Nissen LM. Use of preventive medication in patients with limited life expectancy: a systematic review. J Pain Symptom Manage. 2017;53(6):1097–110.e1.CrossRefGoogle Scholar
  29. 29.
    Hosia-Randell H, Pitkala K. Use of psychotropic drugs in elderly nursing home residents with and without dementia in Helsinki, Finland. Drugs Aging. 2005;22(9):793–800.CrossRefGoogle Scholar
  30. 30.
    Muurinen S, Savikko N, Soini H, Suominen M, Pitkala K. Nutrition and psychological well-being among long-term care residents with dementia. J Nutr Health Aging. 2015;19(2):178–82.CrossRefGoogle Scholar
  31. 31.
    Pitkala KH, Juola AL, Hosia H, Teramura-Gronblad M, Soini H, Savikko N, et al. Eight-year trends in the use of opioids, other analgesics, and psychotropic medications among institutionalized older people in Finland. J Am Med Dir Assoc. 2015;16(11):973–8.CrossRefGoogle Scholar
  32. 32.
    Suominen MH, Sandelin E, Soini H, Pitkala KH. How well do nurses recognize malnutrition in elderly patients? Eur J Clin Nutr. 2009;63(2):292–6.CrossRefGoogle Scholar
  33. 33.
    Sanford AM, Orrell M, Tolson D, Abbatecola AM, Arai H, Bauer JM, et al. An international definition for “nursing home”. J Am Med Dir Assoc. 2015;16(3):181–4.CrossRefGoogle Scholar
  34. 34.
    WHO Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) Classification Index. 2016. https://www.whocc.no/atc_ddd_index/. Accessed 21 Jan 2018.
  35. 35.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.CrossRefGoogle Scholar
  36. 36.
    Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin Geriatr Med. 2002;18(4):737–57.CrossRefGoogle Scholar
  37. 37.
    Berry SD, Mittleman MA, Zhang Y, Solomon DH, Lipsitz LA, Mostofsky E, et al. New loop diuretic prescriptions may be an acute risk factor for falls in the nursing home. Pharmacoepidemiol Drug Saf. 2012;21(5):560–3.CrossRefGoogle Scholar
  38. 38.
    Tay KH, Lane DA, Lip GY. Challenges facing anticoagulation among the elderly and frail. Age Ageing. 2009;38(2):140–2.CrossRefGoogle Scholar
  39. 39.
    Lindley RI. Stroke prevention in the very elderly. Stroke. 2018;49(3):796–802.CrossRefGoogle Scholar
  40. 40.
    Neidecker M, Patel AA, Nelson WW, Reardon G. Use of warfarin in long-term care: a systematic review. BMC Geriatr. 2012;12:14.CrossRefGoogle Scholar
  41. 41.
    Korhonen MJ, Ilomaki J, Sluggett JK, Brookhart MA, Visvanathan R, Cooper T, et al. Selective prescribing of statins and the risk of mortality, hospitalizations, and falls in aged care services. J Clin Lipidol. 2018;12(3):652–61.CrossRefGoogle Scholar
  42. 42.
    Campitelli MA, Maxwell CJ, Giannakeas V, Bell CM, Daneman N, Jeffs L, et al. The variation of statin use among nursing home residents and physicians: a cross-sectional analysis. J Am Geriatr Soc. 2017;65(9):2044–51.CrossRefGoogle Scholar
  43. 43.
    Ruscica M, Macchi C, Pavanello C, Corsini A, Sahebkar A, Sirtori CR. Appropriateness of statin prescription in the elderly. Eur J Intern Med. 2018;50:33–40.CrossRefGoogle Scholar
  44. 44.
    Fowler NR, Barnato AE, Degenholtz HB, Curcio AM, Becker JT, Kuller LH, et al. Effect of dementia on the use of drugs for secondary prevention of ischemic heart disease. J Aging Res. 2014;2014:897671.CrossRefGoogle Scholar
  45. 45.
    Alhusban A, Fagan SC. Secondary prevention of stroke in the elderly: a review of the evidence. Am J Geriatr Pharmacother. 2011;9(3):143–52.CrossRefGoogle Scholar
  46. 46.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2016;50(5):e1–88.CrossRefGoogle Scholar
  47. 47.
    Maddison AR, Fisher J, Johnston G. Preventive medication use among persons with limited life expectancy. Prog Palliat Care. 2011;19(1):15–21.CrossRefGoogle Scholar
  48. 48.
    Tan ECK, Sluggett JK, Johnell K, Onder G, Elseviers M, Morin L, et al. Research priorities for optimizing geriatric pharmacotherapy: an international consensus. J Am Med Dir Assoc. 2018;19(3):193–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Natali Jokanovic
    • 1
    • 2
    Email author
  • Hannu Kautiainen
    • 3
  • J. Simon Bell
    • 1
  • Edwin C. K. Tan
    • 1
    • 4
    • 5
  • Kaisu H. Pitkälä
    • 3
  1. 1.Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneAustralia
  2. 2.Pharmacy DepartmentAlfred HospitalMelbourneAustralia
  3. 3.Department of General Practice and Unit of Primary Health CareUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
  4. 4.School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
  5. 5.Aging Research Centre, Department of Neurobiology, Care Sciences and SocietyKarolinska Institute and Stockholm UniversityStockholmSweden

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