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BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.

OBJECTIVES: To better understand indications for beta-blocker prescriptions among older adults hospitalized with heart failure with preserved ejection fraction (HFpEF) DESIGN/SETTING: Retrospective observational study of hospitalizations derived from the geographically-diverse REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. PARTICIPANTS: We examined Medicare beneficiaries aged ≥65 years with an expert-adjudicated hospitalization for HFpEF (left ventricular ejection fraction ≥50%). MEASUREMENTS: Discharge medications and indications for beta-blockers were abstracted from medical records. RESULTS: Of 306 hospitalizations for HFpEF, beta-blockers were prescribed at discharge in 68%. Among hospitalizations resulting in beta-blocker prescriptions, 60% had a compelling indication for beta-blocker—44% had arrhythmias and 29% had myocardial infarction history. Among the 40% with neither indication, 57% had CAD without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD), both clinical scenarios with little supportive evidence of benefit of beta-blockers. Among hospitalizations resulting in beta-blocker prescription at discharge, 69% had geriatric conditions (functional limitation, cognitive impairment, hypoalbuminemia, or history of falls). There were no significant differences in the prevalence of geriatric conditions between hospitalizations of individuals with compelling indications for beta-blockers and hospitalizations of individuals with non-compelling indications. CONCLUSIONS: Beta-blockers are commonly prescribed following a hospitalization for HFpEF, even in the absence of compelling indications. This occurs even for hospitalizations of individuals with geriatric conditions, a subpopulation that may be at elevated risk for experiencing harm from beta-blockers.

BACKGROUND Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. OBJECTIVE To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. DESIGN Qualitative study using semi-structured interviews. SETTING Academic and community primary care practices within University of Pittsburgh Medical Center health system. PARTICIPANTS Sixteen primary care physicians. MEASUREMENTS We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. RESULTS We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. CONCLUSIONS Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Objective To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. Design Two-round modified Delphi survey. Participants Expert panel of 19 clinical pharmacists. Measurements Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score. Results The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). Conclusion An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.

Objectives To examine the association between central nervous system (CNS) medication dosage burden and risk of serious falls, including hip fractures, in individuals with a history of a recent fall. Design Nested case–control study. Setting Veterans Health Administration (VHA) Community Living Centers (CLCs). Participants CLC residents aged 65 and older with a history of a fall or hip fracture in the year before a CLC admission between July 1, 2005, and June 30, 2009. Each case (n = 316) was matched to four controls (n = 1264) on age, sex, and length of stay. Measurements Outcomes were serious falls identified using International Classification of Diseases, Ninth Revision (ACD‐9) or Current Procedural Terminology (CPT) E codes, diagnosis codes, or procedure codes associated with a VHA emergency department visit or hospitalization during the CLC stay. Bar code medication administration data were used to calculate CNS standardized daily doses (SDDs) for opioid and benzodiazepine receptor agonists, some antidepressants, antiepileptics, and antipsychotics received in the 6 days before the outcome date by dividing residents' actual CNS daily doses by the minimum effective geriatric daily doses and adding the results. Multivariable conditional logistic regression models were used to evaluate the association between total CNS medication dosage burden, categorized as 0, 1 to 2, and 3 or more SDDs, and the outcome of recurrent serious falls. Results More cases (44.3%) than controls (35.8%) received 3.0 or more CNS SDDs (p = .02). Risk of serious falls was greater in residents with 3.0 or more SDDs than in those with 0 (adjusted odds ratio (aOR)=1.49, 95% confidence interval (CI)=1.03–2.14). Those with 1.0 to 2.9 SDDs had a risk similar to that of those with 0 SDDs (aOR=1.03, 95%CI=0.72–1.48). Conclusion Nursing home residents with a history of a fall or hip fracture receiving 3.0 or more CNS SDDs were more likely to have a recurrent serious fall than those taking no CNS medications. Interventions targeting this vulnerable population may help reduce serious falls. J Am Geriatr Soc 67:74–80, 2019.

BACKGROUND/OBJECTIVE: Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia. DESIGN: Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.0, Area Health Resource File, and Nursing Home Compare. Marginal structural models with inverse probability of treatment weights were used to evaluate the association of deprescribing AChEIs and all-cause negative events as well as serious falls or fractures. SETTING: US Medicare certified NHs. PARTICIPANTS: Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS: The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). Deprescribing AChEIs was associated with an increased likelihood of all-cause negative events in unadjusted models (odds ratio [OR] = 1.17; 95% confidence interval [CI] = 1.11-1.23; P < .01), but not in fully adjusted models (adjusted OR [aOR] = 1.00; 95% CI = 0.94-1.06; P = .94). By contrast, deprescribing was associated with a reduced likelihood of serious falls or fractures in unadjusted models (OR = 0.59; 95% CI = 0.52-0.66; P < .001) and remained significant in adjusted models (aOR = 0.64; 95% CI = 0.56-0.73; P < .001). CONCLUSION: Deprescribing AChEIs was not associated with a significant increase in the likelihood for all-cause negative events and was associated with a reduced likelihood of falls and fractures in older NH residents with dementia. Our findings suggest that deprescribing AChEIs is a reasonable approach to reduce the risk of serious falls or fractures without increasing the risk for all-cause events. J Am Geriatr Soc 68:699-707, 2020.