Falls Not a Major Risk in Seniors on BP-Lowering Therapy: Study

Marlene Busko

May 13, 2015

BOSTON, MA — The results of an observational study of more than 500 healthy, elderly seniors suggests that chronic use of antihypertensives may not be as strong a risk factor for falls as previously thought, researchers report. In fact, in this 1-year study of community-dwelling 70- to 97-year-olds, neither standard nor high doses of antihypertensives were linked to falls[1].

Moreover, ACE inhibitors and calcium-channel blockers were associated with a reduced risk of falls, Dr Lewis A Lipsitz (Harvard Medical School, Boston, MA) and colleagues report in the study, published online May 4, 2015 in Hypertension.

"In the treatment of hypertension in older people, it is important to prevent adverse events and it's appropriate to think of adverse effects of the drugs themselves. But when it comes to falls in people who are on chronic use of antihypertensive medication, we need not worry much about precipitating falls, and with ACE inhibitors and calcium-channel blockers, we may actually reduce that risk," Lipsitz told heartwire from Medscape.

The general thinking is that hypertension should be treated, but the most recent guidelines suggest clinicians should be less aggressive and treat to 150/90 mm Hg and below; treating to 120/80 mm Hg is not considered safe, because with lower blood pressure there is lower blood flow to the brain, he continued. However, "we looked at that and found that calcium-channel blockers actually improved [cerebral blood flow]," he noted.

False Fear of Precipitating Falls?

Conflicting data on the relationship between antihypertensives and falls in elderly people may lead to inappropriate undertreatment, Lipsitz and colleagues write.

They aimed to clarify this in 598 hypertensive community-dwelling elderly people who were enrolled in the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly Study in Boston (MOBILIZE Boston Study). These participants had a mean age of 78.4; 62% were women, and three-quarters were white.

Most patients were taking beta-blockers (51.9%), diuretics (47.0%), ACE inhibitors (34.7%), and calcium-channel blockers (29.3%), and fewer were taking angiotensin-receptor blockers (ARBs) (12.8%) or alpha-blockers (7.1%).

During the 1-year follow-up, there were 541 falls.

Just over half of the patients (55.3%) did not report any falls, and the rest (44.7%) reported falling one to 17 times. Of those who fell, 13.7% fell outdoors, 21.2% fell indoors, and 7.4% fell indoors and outdoors.

A quarter of the patients reported injurious falls, which were defined as falls that resulted in physical injury or required treatment in an emergency department or hospital.

Frailest and Most Active People May Fall

"There is a U-shaped relationship: the frailest people tend to fall and the most active people tend to fall—for different reasons," Lipsitz explained. Indoor falls tend to occur in people who are frailer and don't go out much and get caught on furniture or slippery floors or other hazards, whereas outdoor falls tend to occur in very active people. "If you lump them all together you sometimes lose information about what is really going on," he said.

Participants who received ACE inhibitors had a significantly lower 1-year risk of injurious falls (odds ratio [OR] 0.62, 95% CI 0.39–0.96), compared with those not taking these drugs. Although this was a small study, it suggests that ACE inhibitors may improve skeletal muscle function, allowing people to better protect themselves in a fall, the researchers speculate.

Participants using calcium-channel blockers had a decreased risk of all falls (OR 0.62; 95% CI 0.42–0.91) and indoor falls (OR 0.57; 95% CI 0.36–0.91), compared with other participants. Of the six classes of antihypertensives, only calcium-channel blockers were associated with significantly increased cerebral blood-flow velocity, as measured by transcranial Doppler ultrasound. This increased cerebral blood flow may explain the lower risk of falls with this class of drug.

Higher doses of calcium-channel blockers were associated with a lower risk of all falls, and higher doses of ACE inhibitors were associated with a significantly lower risk of outdoor falls.

It is important to prevent falls in the elderly, since "it's a very common problem and it's one that is often the beginning of the end," Lipsitz noted. Yet it is also important to optimally treat hypertension.

"Given the known benefits of treating hypertension in elderly people, the withholding of antihypertensive medications to prevent falls may not be a justifiable medical practice," the researchers conclude.

"Although the acute administration of any hypotensive medication can precipitate a fall or syncope, the careful uptitration and long-term administration of the lowest effective doses of these medications do not seem to increase the risk of falls."

The study was supported by grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke. Lipsitz and some coauthors were supported in part by the Limoges University Foundation, University Hospital Center of Limoges, and Regional Council of Limousin. The authors have no relevant financial relationships.

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