COMMENTARY

Balancing Hypertension Drugs and Fall Risk in the Elderly

Henry R. Black, MD

Disclosures

May 09, 2014

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Hi. I am Dr. Henry Black, Clinical Professor of Medicine at the Langone New York University School of Medicine and a former president of the American Society of Hypertension.

One of the great victories of the past 50-60 years is the success of antihypertensive therapy in preventing strokes, by 30%-40% in every trial when we look at the statistics. More recently, statins have clearly helped to reduce the incidence of myocardial infarction and heart disease.

There are appropriate concerns, especially with the antihypertensive agents, that we might be causing some harm with respect to falls. Falls are a major problem for older individuals, especially individuals with osteoporosis, in whom a hip fracture and subsequent hospitalization carries about a 50% 1-year rate of mortality. If antihypertensive agents are responsible for a patient becoming dizzy, falling down, and breaking a hip, then we have to start thinking about balancing the risk and benefit.

When we look at randomized trials, we don't see any evidence of increased falls. That may be partly related to the people who volunteer to be in randomized trials and how healthy they are. They tend to be healthier than the general population. Mary Tinetti from Yale University (a former colleague of mine), along with a multitude of outstanding statisticians, has tried to get a handle on this issue using Medicare data.[1] They collected data on approximately 7000 individuals who were in that database. They had some inclusion and exclusion criteria, and they used a propensity-matched sample. This is a very interesting new statistical technique. When you don't have a comparative cohort, as you do in a randomized trial, you try to create one using the characteristics of the people in the trial and you try to match them.

They created a propensity sample and then compared the whole cohort of almost 9000 with the propensity sample of almost 4500 to determine whether taking antihypertensive agents mattered in serious falls. [Editor's note: Almost 7000 adults older than 70 years with hypertension met eligibility; the cohort comprised 4961 participants and the propensity sample comprised 2849 participants.] Serious falls, fractured hips -- not just bumping your elbow, but fractures, head trauma, and death. The findings are quite interesting. They used a technique that the World Health Organization (WHO) devised to look at the doses of drugs and how these doses affect outcomes.

Twenty-five percent of the group who experienced a serious fall died compared with 16% of those who didn't have a serious fall. That's not very surprising. If you look at the antihypertensive doses, the people on no medicines had the fewest falls, but the people on increasing doses of medicine, using the WHO technique, didn't show an increase in falls that you would expect in a linear dose-response relationship. This was the case in the whole cohort as well as in the propensity sample. In fact, a group in the middle, who were taking medium doses of antihypertensive medication, had the highest rate of falls: 9.8%. The highest rate of falls did not occur in the group taking the highest doses of antihypertensive drugs. About one-third of people who were on antihypertensive drugs were taking a drug from a single class, one-third were taking drugs from 2 classes, and one-third were taking drugs from 3 classes.

What can we make of this? The important thing is to continue to be vigilant and to warn people about this risk. People who have a likelihood of falling have to be cautioned about this, and sometimes we have to adjust when the medications are taken. No particular class of drugs was associated with an increase in falls. It was the same, regardless of whether patients took a diuretic (which we think of as having this particular problem), a renin-angiotensin system blocker, a calcium channel blocker, or a beta-blocker. They were all about the same.

What are we to do? In the study the mean age was 80 years, and there was no difference between those over and under the age of 85 years in the risk for falls and the relationship with antihypertensive drugs. This is a strange finding, but maybe once you get to age 85, you are healthier than somebody who doesn't make it that far.

So beware, but let's not forget the benefits of antihypertensive therapy, which we have now demonstrated in all age groups that we have studied, especially with respect to strokes and myocardial infarction. Thank you very much.

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