By Carolyn Crist
(Reuters Health) – – After a heart attack, frail older adults may live longer by taking several medications typically prescribed to prevent future heart problems, but the drugs might also contribute to increased frailty, a U.S. study suggests.
Within 90 days of a heart attack, elderly nursing home residents who took three or more medications were less likely to die than those who took just one. But in some circumstances, functional decline was more common with more medications, the study found.
“Secondary prevention medications are recommended for all adults, even those who are frail and older,” said lead study author Andrew Zullo of the Brown University School of Public Health in Providence, Rhode Island.
Despite recommendations, however, little data is available about the effectiveness and safety of medications for the frailest and oldest adults, he said, particularly with regard to physical functioning. Since the average age at first heart attack is 65 for men and 72 for women, seniors represent a large portion of patients who need secondary prevention medicines.
“Many frail older adults value maintaining independence and quality of life more than simply living longer,” he told Reuters Health by email. “We should ensure that treatment helps older adults to achieve their care goals.”
Zullo and colleagues analyzed Medicare claims data between 2007-2010 for more than 4,700 nursing home residents over age 65. Medications started after a heart attack included blood thinners known as antiplatelet medications, anticholesterol drugs in the statin class, blood pressure drugs in the beta-blocker class and renin-angiotensin-aldosterone system inhibitor drugs, which are used for several conditions.
The researchers compared people who were taking one drug, two drugs, or three or more drugs to see how they fared in the first 90 days after the heart attack in terms of death, rehospitalization and functional decline – measured by bed mobility, dressing, eating, speaking, toilet use and personal hygiene.
Overall, there were more than 500 deaths, 1,200 rehospitalizations and 800 instances of functional decline. The group was about two-thirds female, and half were age 84 or older, according to the report in Circulation: Cardiovascular Quality and Outcomes.
Patients who took three or more medications were 26 percent less likely than those taking just one to die during the 90 days after their heart attack, researchers found. There was no difference in rehospitalization rates, and no differences in outcomes by age, sex, race or ethnicity.
Researchers also found no differences based on a patient’s cognition or functional status, with about half of the group having moderate or severe cognitive impairment, and three quarters requiring help with their daily living activities.
Using more secondary prevention medications was associated, however, with a 30 percent relative increase in functional decline in some analyses that excluded antiplatelet drugs. But when antiplatelets were included, more medication use didn’t make much of a difference.
“This disagreement means that the functional outcome results must be interpreted with extra caution,” Zullo said.
The study team also notes that the results have several limitations. It’s possible, for instance, that people with more severe heart attacks received more medication, or that those who were more frail or had a worse prognosis received fewer drugs. The researchers also had no information about medication dosages.
Future studies should investigate the effects of specific combinations of medications, as well as doses and what happens when over-the-counter medicines are added to the mix. Researchers should also follow-up with these patients after a year to understand long-term outcomes, Zullo said.
“Older frail adults are at greater risk of experiencing medication-related harms,” said Susan Bowles of Dalhousie University and the Nova Scotia Health Authority in Halifax, Canada, who wrote a commentary accompanying the study.
Decisions about starting and stopping medications require consideration of potential benefits and risks for patients, including their goals of care, she writes.
“Clinicians and patients are then presented with the quandary of what is the actual benefit of these treatments and if the potential for benefit exceeds the potential risk of harm,” Bowles told Reuters Health by email. “A better understanding of this would assist clinicians and patients in decision making.”