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After a heart attack, beta-blockers "yielded a considerable mortality benefit" among older nursing home residents but at the cost of greater functional decline, a Medicare cohort study showed.

Patients started on the guideline-directed therapy after an acute MI hospitalization were 26% less likely to die during follow-up than nonusers (HR 0.74, 95% CI 0.67-0.83), and that association was similar across all patient subgroups in the propensity-matched cohort of 15,720 long-stay nursing home residents examined through national Medicare data.

However, decline on the Morris scale of independence in activities of daily living was worse overall among beta-blocker-treated patients (OR 1.14, 95% CI 1.02-1.28), with a number needed to harm of 52, , of the University of California San Francisco, and colleagues .

"Our results confirm the suspicion of many physicians that poor cognitive and functional status increases the risk for medication-induced harms in older adults," they wrote. "However, they call into question the more general practice whereby older adults are less likely to receive guideline-recommended medications after AMI regardless of their mental or physical abilities."

The beta-blocker associated functional decline was largely among those already substantially impaired:

• 34% elevated risk in users with moderate or severe cognitive impairment
• 32% elevated risk in users with severe functional dependency

"In contrast, little evidence of functional decline due to beta-blockers was found in participants with intact cognition or mild dementia (OR 1.03; 95% CI 0.89-1.20; P=0.03 for effect modification), or in those in the best (OR 0.99; 95% CI 0.77-1.26) and intermediate (OR 1.05; 95% CI 0.86-1.27) tertiles of functional independence (P=0.06 for effect modification)," the researchers noted.

For the more than half of nursing home residents with high levels of functional dependence and two-thirds with moderate or severe cognitive impairment, avoiding further decline might be a bigger concern than prolonging life, Steinman's group noted.

, and , both of the University of Massachusetts Medical School in Worcester, agreed in an accompanying commentary, published as part of the JAMA journals' "Less is More" series.

The study suggested a tipping point, they wrote, once patients have "short-term memory loss and a moderately impaired ability for decision making or an inability to make their needs understood" or need "extensive assistance or total dependence for most, if not all, activity of daily living needs, including dressing, personal hygiene, toileting, ambulation, transferring, bed mobility, and eating."

American Heart Association/American College of Cardiology guidelines in non-ST segment elevation MI already call for individualization of pharmacotherapy for older adults that takes into account preferences, functional and cognitive status, and life expectancy, Tjia and Lapane noted.

"Good prescribing is a balancing act that is as much an art as a science," they wrote. "The present study adds to the science part.

"However, despite its rigorous and careful execution, it remains level B quality of evidence, namely, moderate quality from a well-designed, nonrandomized, observational study ... Specifically, removing the patients at highest risk for poor outcomes (i.e., those who died or were rehospitalized within 14 days of hospital discharge) likely biased the findings toward a positive survival benefit of beta-blockers."