Antihypertensive drugs associated with risk for serious fall injuries in elderly patients

Antihypertensive drugs may be associated with a higher risk for serious fall injuries in elderly adults, according to a new study.

Researchers used data from the Medicare Current Beneficiary Survey to perform a competing risk analysis in community-living hypertensive adults older than age 70 over 3 years of follow-up. Intensity of exposure to antihypertensive medications was based on the standardized daily dose of each class used by each patient. The study's main outcome measures were serious fall injuries (hip and other major fractures, traumatic brain injuries, and joint dislocations) as determined by CMS claims. The results were published online Feb. 24 by JAMA Internal Medicine.

A total of 4,961 patients were included in the study. The mean age was 80.2 years, and 61.5% were women. Overall, 697 patients (14.1%) did not receive antihypertensive medications, 2,711 (54.6%) received moderate-intensity antihypertensive treatment, and 1,553 (31.3%) received high-intensity antihypertensive treatment. Five hundred three patients had had a previous fall injury. Renin-angiotensin system blockers were the most common antihypertensive drug taken (56.6%), followed by diuretics (54.2%), beta-blockers (45.9%), and calcium-channel blockers (34.2%). Three hundred forty-nine patients (7.0%) took other classes of antihypertensive drugs. Among the patients taking antihypertensive drugs, 1,265 (28.3%) took 1 class, 1,599 (35.8%) took 2 classes and 1,607 (35.9%) took 3 or more classes. The propensity-score matched subcohort included 2,849 patients, 662 (95%) of those not taking medication for hypertension, 1,455 (53.7%) of the moderate-intensity group, and 732 (47.1%) of the high-intensity group.

Over the 3-year follow-up, 446 patients (9.0%) had serious fall injuries and 837 (16.9%) died. Compared with nonusers of antihypertensive drugs, the moderate-intensity and high-intensity groups had adjusted hazard ratios for serious fall injury of 1.40 (95% CI, 1.03 to 1.90) and 1.28 (95% CI, 0.91 to 1.80), respectively. Differences in adjusted hazard ratios did not reach statistical significance across groups, but results were similar in the subcohort of patients matched for propensity scores. Among patients with a history of previous fall injuries, adjusted hazard ratios were 2.17 (95% CI, 0.98 to 4.80) for the moderate-intensity group and 2.31 (95% CI, 1.01 to 5.29) for the high-intensity group.

The researchers noted that they did not find a cause-and-effect relationship in their study, nor a dose-response relationship between intensity or number of drug classes and fall injury risk. In addition, no particular class of antihypertensives was associated with increased risk. The researchers also acknowledged that data on hypertension onset and duration of antihypertensive treatment were not available, among other limitations. However, they concluded that based on their results, antihypertensive medications seem to be associated with increased risk for fall injury among hypertensive elderly patients. “The potential harms vs benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions,” they wrote.

The authors of an accompanying editorial agreed that the study's findings increase the evidence supporting an association between antihypertensive medications and increased risk for fall injuries but pointed out that undertreatment of systolic hypertension might also cause harm. Without more direct data, they said, clinicians should base treatment decisions on individual functional status, life expectancy, and preferences and should discuss risks and benefits “candidly” with each patient.

“When antihypertensive drug treatment is indicated, using the lowest dose possible to achieve a target blood pressure makes good sense,” the editorialists wrote. “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.”