The risks, benefits of polypharmacy after MI for frail nursing home residents

Nursing home residents who were prescribed three or four preventive medications after myocardial infarction (MI) were 26% less likely to die within 90 days than those prescribed only one drug, researchers reported April 9 in Circulation: Cardiovascular Quality and Outcomes.

However, the results were less clear-cut when it came to assessing functional decline. Patients taking three or four medications were 12% more likely to show functional decline during the three-month follow-up than those taking one medication. The number of drugs prescribed had little impact on the risk of rehospitalization over 90 days, the researchers found.

“Based on our findings, using more medications to prevent another heart attack may be useful for vulnerable older adults who wish to live longer,” lead author Andrew R. Zullo, PharmD, PhD, with Brown University in Providence, Rhode Island, said in a press release.

“However, since using more medications may interfere with older adults’ ability to do their daily activities, more medications should not be taken by older adults who wish to maintain their independence and daily functioning rather than live longer. Using more medications after a heart attack does not simply improve all health outcomes.”

Zullo et al. used Medicare claims and the national U.S. Minimum Data Set from 2007 to 2010 to study 4,787 nursing home residents who had experienced MI. They were grouped by the number of evidence-based secondary prevention medicines—including antiplatelets, beta-blockers, statins and renin-angiotensin-aldosterone system inhibitors—they were prescribed following their events. Sixty-eight percent of patients were women, 84% were white and the average age of the cohort was 84.

“Secondary prevention medications are often not prescribed to frail, older adults, especially those residing in nursing homes long-term,” Zullo and colleagues wrote in the journal. “Prescribing fewer medications is due, in part, to perceived lack of benefit, concern over potential harms, and lack of supporting data.”

But their study found a survival benefit across multiple subgroups based on age, cognition or baseline functional status in those taking three or four medications compared to one. There was no significant difference in 90-day survival for those taking two versus one preventive drug.

Because the study was observational, it couldn’t prove cause and effect for the outcomes studied. The authors were also unable to account for differences in medication doses, as well as the potential confounding arising from patients who may have also taken over-the-counter drugs.

Nonetheless, Susan K. Bowles, PharmD, MSc, and Melissa Andrews, MD, PhD, said in a related editorial the study is “an important contribution to the discussion of polypharmacy in frail, nursing home residents.”

“Polypharmacy in this population is often thought about only in quantitative terms: ‘the fewer drugs the better’ without consideration of appropriateness of therapy, goals of care, and patient preference,” they wrote. “Some may elect to take more medications to reduce short-term risk as they perceive benefit to exceed harm. Others may place a higher value on symptom control over longevity and choose fewer or no medications.”