COVID-19 has certainly put a spotlight on so many challenges we face in health care. How do we provide care in times of uncertainty? How do we allocate resources equitably? How do we use technology to connect providers and families with older adults in their homes and care facilities? Another question that many of us are wrestling with now, for example, is how to continue learning about advances in research and care as conferences, meetings, and in-person gatherings remain on hold.
COVID-19 has changed much, but it also has not changed many of the issues we have long faced in health care—including those tied to the “Ms” that define our expertise as geriatrics health professionals: care for mentation, mobility, medication, multicomplexity, and what matters most to our patients. We have a duty to continue advancing those frontiers during COVID-19 and beyond, which is why I am so happy that the American Geriatrics Society (AGS) continues to support opportunities to make that happen.
A recent virtual presentation stemming from the original #AGS20 program is a perfect case in point. In the three presentations included in the AGS Plenary Paper Session held this June, researchers looked critically at top-ranked studies addressing a key concern for older adults—medication management.
Angiotensin-II Stimulating Antihypertensives are Associated with Lower Incident Dementia Rates in Community-Dwelling Older Adults (presented by Zachary Marcum, PharmD, PhD, MS). As more of us look forward to the prospect of increased longevity, figuring out the most effective ways to manage the several, often serious health conditions we may live with will be key. Certain medications used to treat high blood pressure, for example, may also reduce the risk for developing dementia. Researchers believe this may be because some medications increase the activity of angiotensin-II at certain receptors, which is hypothesized to play a role in providing greater brain protection (Marcum, 2020).
In this study, an international team from the United States and the Netherlands tested whether certain hypertension medications could lead to a lower dementia risk based on whether they increased or decreased activity at two angiotensin receptors. The team analyzed dementia diagnoses for more than 1,900 people between the ages of 70 and 78 prescribed medications that either increased or decreased angiotensin-II activity at certain receptors (Marcum, 2020).
Dementia occurred for 5.6% of people using medications that increased angiotensin-II activity, compared with 8.2% of those who used medications that decreased angiotensin-II activity (and 6.9% of people who used both types of medications). Adjusting for risk factors, such as blood pressure and medical history, researchers found that participants using medications that increased angiotensin-II activity had a 44% lower dementia rate (without a higher mortality rate) compared to those taking medications that decreased such activity. If their findings can be replicated, the researchers believe dementia prevention could become a compelling indication for older individuals receiving antihypertensive treatment (Marcum, 2020).
Time to Benefit for Stroke Reduction After More Intensive Blood Pressure Control in Older Adults (presented by Vanessa Ho, MS). Even as hypertension treatment improves a range of health outcomes, many experts still struggle to strike the right balance for addressing high blood pressure safely and effectively. In this study, researchers looked critically at the time it took for hypertension treatment to begin delivering one of its most important benefits: reducing the risk for stroke (Ho, 2020).
The team looked at randomized clinical trials comparing control versus intervention with more intensive treatment and estimated how quickly tighter blood pressure control led to fewer strokes. According to study findings, more intensive hypertension treatment for 100 persons prevents one stroke in 2 years. Because rates of harms from more intensive hypertension treatment range from 1% to 7%, the results suggest that more intensive hypertension treatment is most beneficial for older adults with a life expectancy >2 years (Ho, 2020).
Acceptability of a Deprescribing E-Consult for Older Veterans at Risk for Falls (presented by Kristin Smith, PharmD, BCPS). An increased risk for falls is a common, costly issue associated with several medications that older adults use. Deprescribing represents an important opportunity for decreasing the risk for falls. In this study, researchers evaluated a pilot program, Falls Assessment of Medications in the Elderly (FAME), to determine whether it offered a useful option for deprescribing as part of an older person's health care (Smith, 2020).
In the FAME study, Veterans age 65 and older identified to be at high risk for falls were randomly selected for team members to make deprescribing recommendations using an electronic consultation. The team then forwarded those recommendations to the patient's primary care and/or mental health provider for approval. If recommendations were approved, the FAME team then implemented the deprescribing plan with the older adult during a telephone visit (Smith, 2020).
Primary care providers accepted at least one deprescribing recommendation for >90% of e-consults, and mental health providers accepted at least one deprescribing recommendation for 70% of e-consults. Of eligible patients, 71% of Veterans agreed to taper or discontinue at least one fall-related medication. According to researchers, this study shows that FAME e-consults are not only well-accepted but also useful in safely reducing falls risks associated with certain medications (Smith, 2020).
Our discussion of these studies during the Plenary Paper Session sparked some interesting conversation and will likely continue to do so as our perspective on health evolves with COVID-19. If you missed the session, not to worry: A recording is available to all for free from GeriatricsCareOnline.org. And if you are looking to help expand and explore findings even further, we are happy to offer platforms for that, too. MyAGSOnline ( http://myagsonline.americangeriatrics.org), the online forum for AGS members, is a great place to start. Asking more questions—big and small—in the days, weeks, and months ahead may not yield immediate answers, but it will bring us closer to consensus by bringing us closer together—and that collaboration deserves the spotlight as much as anything else.
Annette Medina-Walpole, MD, AGSF
President, American Geriatrics Society