BP Meds Linked to Serious Fall Injuries in Elderly

Larry Hand

February 24, 2014

Taking antihypertensive medications may lead to a significantly increased risk for serious fall injuries among older adults with hypertension and multiple comorbidities, according to an article published online February 24 in JAMA Internal Medicine. The risk may be doubled for those individuals who have had a previous fall in the past year.

Mary E. Tinetti, MD, from the Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, and colleagues analyzed the records of 4961 community-living adults older than 70 years (mean age, 80.2 years) with hypertension who were enrolled in the Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. The study population was enrolled from 2004 to 2007, with a follow-up period through 2009.

Prescription medication data included multiple classes of antihypertensives as well as combination medications. Researchers derived medication exposure intensity by dividing the total defined daily dose (DDD) across all antihypertensive agents by the number of days under observation and then calculated the number of medication classes participants used from 0 to 3 or higher. They then characterized antihypertensive use from none (<0.2 DDD) to moderate intensity (0.2 - 2.5 DDD) to high intensity (>2.5 DDD) and estimated a propensity score using a regression model including 36 covariates. Data on serious fall injuries came from emergency department and inpatient claims.

Of 4961 participants, 697 (14.1%) took no antihypertensives, 2711 (54.6%) were in the moderate-intensity group, and 1553 (31.3%) were in the high-intensity group. Among those who did use antihypertensives, 1265 (28.3%) took 1 class, 1599 (35.8%) took 2 classes, and 1607 (35.9%) took 3 or more classes.

During the study period, 446 (9.0%) of the participants experienced serious fall injuries, including hip fractures, major head injuries, and joint dislocations, with 58 experiencing more than 1 serious injury. The injuries occurred in 52 (7.5%) participants in the no antihypertensives group, 267 (9.8%) in the moderate-intensity group, and 127 (8.2%) in the high-intensity group (P = .058).

However, after adjusting for covariates, the hazard ratios for serious fall injury was 1.40 (95% confidence interval [CI], 1.03 - 1.90) for the moderate-intensity group and 1.28 (95% CI, 0.91 - 1.80) for the high-intensity group compared with nonusers. The researchers found similar results in a subgroup of propensity score-matched participants, but with no statistical significance.

Double Risk

Among a subgroup of 4621 participants for whom a prior fall within a year could be identified, researchers found that the hazard ratio hovered around 2.25 for moderate- and high-intensity users who had experienced a fall compared with about 1.2 for those who had not experienced a fall.

The researchers found no differences in association with serious fall injuries among antihypertensive classes of medications.

The researchers point out that, to their knowledge, this is the first study to assess risk for serious injuries such as brain injury and hip fracture associated with antihypertensive use.

"Although noninjurious falls and minor fall injuries are associated with morbidity, we limited our study to serious fall injuries, which are more clinically equivalent to the cerebrovascular and cardiovascular events that antihypertensive medications are prescribed to prevent," the researchers write.

They also point out, "The morbidity and mortality associated with serious injuries such as hip and head injury are comparable to those associated with cardiovascular events.... The potential harms vs benefits of antihypertensive medications should be weighed in deciding whether to continue antihypertensives in older adults with multiple chronic conditions."

In an accompanying invited commentary, Sarah D. Berry, MD, MPH, and Douglas P. Kiel, MD, MPH, from the Institute for Aging Research, Hebrew Rehabilitation Center, Boston, Massachusetts, write that balancing potential harms and benefits should be done according to individual patients.

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

Integrated Risks

"What this article really brings forward, and it's not unique, is that the benefit of decreased cardiovascular events is completely integrated with the greater risk of falls," Daniel E. Forman, MD, chair of the American College of Cardiology Geriatric Cardiology Section, director of the exercise testing laboratory and cardiac rehabilitation at Brigham and Women's Hospital, and associate professor of medicine at Harvard Medical School in Boston, told Medscape Medical News in a telephone interview.

For blood pressure, he said, "It's not just a number. I think most internists, most cardiologists, most providers rivet on a number."

He continued, "For patients, it's not so simple. Most patients are on 10-plus medicines by the time they're 70, and it's been absolutely, unequivocally shown that when you're on 10-plus meds, the side effects start to creep up. If you fall, your morbidity goes skyrocketing. So anything you gain with blood pressure lowering starts to become eroded with what you lose with the blood pressure falling."

Dr. Forman said he thinks the message from this article is this: "You can't just focus on a number, despite data that are strong, despite all these studies that have been funded in large part by pharma that show that you should lower blood pressure. Despite all the stuff that we've been doing for blood pressure, we're really not there. In many ways, this article argues that the whole concept of geriatric care is really in the early stages."

Complicated Conversations

Dr. Forman said the aging population in the United States mandates that physicians get better at stratifying patients and identifying which would benefit from antihypertensives and which would not. Complicating the issue is the lack of clear data on older adults and the practice of extrapolating from data on younger patients. Other complications include the time spent with patients and the complexities of aging.

He asked, "In 15 minutes, given all the complexities of language, cognition, and multimorbidity — and you're dealing with 10 things at once with your patient to begin with — how do you have this very sophisticated conversation with them and try to work out these details and really make life-prolonging, definitive decisions about health management in that short time period?"

This research was funded by the National Institute on Aging. One coauthor has reported receiving funding from Medtronic and 21st Century Oncology and being on the scientific advisory board of Fair Health Inc. The other study authors have disclosed no relevant financial relationships. Dr. Berry has reported receiving royalties from UptoDate, and Dr. Kiel has reported receiving royalties from UpToDate, grants from Amgen, Lilly, and Merck unrelated to the current commentary, as well as being on the scientific advisory boards of Ammonett Pharma, Merck, Amgen, and Lilly. Dr. Forman has disclosed no relevant financial relationships.

JAMA Intern Med. Published online February 24, 2014. Article abstract, Commentary extract

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