Deprescribing Cardiovascular Medications among Persons with and without Alzheimer's Disease and Related Dementias in Long-Term Care - PROJECT SUMMARY/ABSTRACT The use of preventive cardiovascular medications among nursing home residents with Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) presents a clinical conundrum. On one hand, the majority of nursing home residents with AD/ADRD have a history of cardiovascular disease, or are at high risk of events. On the other hand, residents with AD/ADRD are at higher risk for medication-related adverse events and have less opportunity to benefit from preventive medications such as aspirin and statins. This has led some patients and their providers to consider deprescribing. Deprescribing is the process of stopping a medication when it is no longer useful, or when the risks outweigh the benefits. Despite the thousands of randomized controlled trials that have been conducted for starting cardiovascular medications, only a handful have been conducted for deprescribing. The effects of deprescribing cardiovascular medications, and which patients could benefit, is unknown. The goal of this renewal application is to provide novel, unparalleled evidence on the effects of deprescribing cardioprotective medications in patients with and without AD/ADRD. We will build upon our prior successful cohort of nursing home residents (nearly half of whom have AD/ADRD) to conduct this research in approximately 150,000 residents aged 65 years and older in Veteran's Health Administration (VA) nursing homes. The VA is the only feasible setting to execute this research because of the ability to link inpatient and outpatient data with data from the nursing home. Moreover, unlike data from the Centers from Medicaid/Medicare, the VA includes data on vital signs, laboratory measurements, and bar-coded medication administrations. We will start with descriptive epidemiology regarding the frequency of deprescribing as well as the common precipitating events and characteristics of residents whom are commonly deprescribed cardiovascular medication. This will identify which drugs are the most important targets for further research, and the populations in which there is clinical uncertainty. Traditional clinical trials are challenging in residents with AD/ADRD due to their care complexity and often impaired decision-making capacity. Thus, we will next implement target trial emulation of deprescribing cardiovascular medications; this is a method of estimating trial effects using observational data. This approach applies a structured analytic process to address common biases in observational research and leverages causal inference statistics to address confounding by indication. We have successfully applied this approach to study the effect of changes in antihypertensives in older residents with and without AD/ADRD. In this renewal application, we will study the effects of deprescribing multiple cardioprotective medications, specifically, antiplatelets including aspirin, statins, and anticoagulants in nursing home residents with and without AD/ADRD.
