This application aims to investigate the possibility that behavioral and psychological symptoms in dementia (BPSD) increase blood pressure in nursing home (NH) residents with Alzheimer's Disease and related dementias (ADRD), thereby complicating the management and treatment of hypertension in this group. BPSD is common in NH residents with ADRD, affecting at least 80% of patients, and, by causing distress and sympathetic nervous system activation, may increase blood pressure and blood pressure measurement variability. The clinical implication is that NH clinicians may make antihypertensive prescribing decisions based on suboptimal blood pressure measurements, and may intensify antihypertensive treatment of patients with ADRD with unlikely benefit and possible harm.
The aims of this study are exploratory and developmental in that there are no large-scale studies on these questions and findings can inform the design of future studies to examine interactions between BPSD exposures on outcomes in patients with ADRD and hypertension.
Our specific aims are to: 1) Explore the associations between behavioral and psychological symptoms in dementia (BPSD), hypertension, and blood pressure readings in NH residents with ADRD, 2) Examine the association between BPSD and intensity of antihypertensive medication treatment in NH residents with ADRD, and 3) Examine the association between changes in antipsychotic use and blood pressure readings in NH residents with ADRD, controlling for BPSD. We expect that, independent of other factors, BPSD will be associated with increased variability of blood pressure and higher blood pressure in NH residents with ADRD. In addition, we expect that NH residents with ADRD and more severe BPSD will receive more intense medication treatment for high blood pressure. Finally, we expect that antipsychotic medication reduction will be associated with changes in blood pressure that may affect antihypertensive medication management, but the direction of association may differ from individual to individual. To achieve these aims we will utilize 2 cohorts of long-stay NH residents with ADRD: 1) a cohort of veterans served in VA Community Living Centers (VA NHs); and 2) Medicare-enrolled residents of U.S. NHs. Both cohorts will provide information on BPSD, hypertension, and other diagnoses; cognitive and physical function; medication prescribing; and adverse drug effects in large national representative groups. The VA cohort will provide information on blood pressure and will be used in Aims 1, 2 and 3. The Medicare cohort will provide population estimates of antihypertensive and antipsychotic medication treatment among all U.S. nursing home residents and will be used in Aims 2 and 3. We will produce multivariable models that will enable us to test hypothesized relationships between behavioral and psychological symptoms in dementia, blood pressure and blood pressure management.
With progressive function decline and increasing burden from many aspects of usual medical care, nursing home residents with Alzheimer's disease and related dementias and comorbid hypertension may not benefit from more intensive hypertension treatment. This project will produce knowledge that can inform prescribing decisions for nursing home residents with both dementia and hypertension and support avoidance of overtreatment of high blood pressure in this high risk group. Given there are approximately 1.4 million nursing home patients in the U.S. and an estimated 350,000 with both dementia and hypertension, the public health impact of these findings in this population is great.
