by Todd Neale
Senior Staff Writer, MedPage Today

February 24, 2014

Older adults with multiple chronic health conditions — including hypertension — appear to be at greater risk for sustaining serious fall injuries when treated for high blood pressure, an observational study showed.

During 3 years of follow-up, 9% of adults with an average age of 80 had a serious fall injury, including hip and other major fractures, traumatic head injuries, and joint dislocations, according to Mary Tinetti, MD, of Yale University, and colleagues.

The risk was elevated for those taking antihypertensives at both moderate intensity (HR 1.40, 95% CI 1.03-1.90) and high intensity (HR 1.28, 95% CI 0.91-1.80) compared with those who were not taking any antihypertensives.

The hazards were greatest for patients who had already had a fall injury in the past year (HRs 2.17 and 2.31, respectively), the researchers reported online in JAMA Internal Medicine.

The findings are consistent with previous studies looking at the use of antihypertensives and falls in older adults, and seem to support concerns raised in a 2011 consensus document on managing hypertension in the elderly from the American College of Cardiology and the American Heart Association.

Adam Skolnick, MD, of NYU Langone Medical Center, questioned certain aspects of the study, however, including the lack of a difference in risk of falling between the various classes of antihypertensives and the lack of a dose-response relationship between the intensity of the therapy and the risk of falling.

Previous studies, he noted, have shown that diuretics in particular are associated with falling, “which makes good sense because you might think that someone who is dehydrated with a reduced pre-load might be prone to dizziness and falling.”

What Skolnick took away from the lack of class differences “is that it’s hard for me to believe these findings are valid,” he said in an interview.

He did, however, put more credence into the finding that patients with a previous fall had a greater risk of another.

“So when taking a history and when prescribing a medication that could in theory increase the risk of falls, I think it’s really important to look at the history of falls and use particular caution in prescribing a medication that might increase that risk,” he said.

In an accompanying editorial, Sarah Berry, MD, MPH, and Douglas Kiel, MD, MPH, of Hebrew SeniorLife in Boston, discussed how clinicians should weigh the risk-benefit balance when considering antihypertensive treatment in older patients.

“In the absence of direct data, they should individualize the decision to treat hypertension according to functional status, life expectancy, and preferences of care,” they wrote.

“For some patients, concern about injurious falls may be paramount, whereas other patients fear the complications of untreated hypertension,” they wrote. “Unfortunately, there is no easy way for clinicians to compare these risks; thus, a candid discussion with each patient is advisable.”

“When antihypertensive drug treatment is indicated, using the lowest dose possible to achieve a target blood pressure makes good sense,” they added. “Most important, clinicians should pay greater attention to fall risk in older adults with hypertension in an effort to prevent injurious falls, particularly among adults with a previous injury.”

From the American Heart Association:

• AHA/ACC/CDC Science Advisory: An Effective Approach to High Blood Pressure Control