Aggressive BP Lowering Linked to Falls in Older Patients

Fran Lowry

May 09, 2018

ORLANDO — For older people being treated aggressively for hypertension, an easing of blood pressure targets might reduce recurrent falls, new research shows.

Kenneth Boockver

"An increased risk for falls is a concern for older adults who pursue aggressive targets for lowering high blood pressure," said Kenneth Boockvar, MD, from the Icahn School of Medicine at Mount Sinai in New York City.

"I am both a geriatrician and a researcher, and a lot of my research questions come from my own practice," Boockvar said here at the American Geriatrics Society 2018 Annual Scientific Meeting.

"I was seeing this, and teaching that blood pressure treatment might be harmful in some patients, but when you review the literature, it's still a matter of controversy as to how aggressively you should treat blood pressure in older adults," he told Medscape Medical News.

A systolic pressure of 120 mm Hg or below is normally considered an agressive target.

To examine the association between falls and aggressive blood pressure targets, Boockvar and his colleagues examined Veterans Affairs data on 19,297 residents of VA nursing homes who were 65 years and older and had been treated with at least one of the common hypertension drug classes from 2010 to 2015.

The team identified veterans who had fallen in the 3 days after a systolic blood pressure reading no higher than 120 mm Hg, which suggests that they were receiving aggressive blood pressure management.

They then looked at whether treatment had been eased — with a dose decrease or the discontinuation of a medication — in the 7 days after the fall, and assessed the 30-day risk for subsequent falls.

Fall Risk

The median nursing home stay of the 3436 veterans who fell was 611.5 days.

Of the 730 falls that were preceded by a systolic blood pressure reading of 80 to 100 mg Hg, 245 veterans (33.6%) had had their antihypertensive treatment eased.

Of the 1528 falls that were preceded by a systolic reading of 101 to 120 mg Hg, 381 veterans (24.9%) had had their treatment eased.

Age and physical function were similar, whether or not treatments had been changed. However, Elixhauser Comorbidity Index score was higher with medication easing than without (6.4 vs 5.9; P = .004), and the rate of dementia was lower (53% vs 61%; P = .008).

In addition, the risk for 30-day subsequent falls was lower after treatment changes.

Table. Effect of Treatment Reductions on Subsequent Falls

Systolic Pressure (mm Hg) Falls After Eased Treatment, % Falls After No Treatment Change, % Relative Risk P Value
80–100 11.0 18.1 0.61 .013
101–120 12.9 17.6 0.73 .030

 

Alayne Markland

"This study has implications for veterans in long-term care, and may have an impact on residents in other long-term care settings," said Alayne Markland, DO, from University of Alabama at Birmingham.

"However, the findings will need to be replicated in women in long-term care settings, given that veterans are predominately men," she pointed out.

"But clinical trials are expensive, and in the absence of money to do such research, using these administrative data really does give us a great hint about de-escalation," she told Medscape Medical News.

Thuan Ong

Long-term residents of nursing homes "often have functional impairments, frailty, and a high burden of comorbidity," said Thuan Ong, MD, from the University of Washington in Seattle.

"This is an important, vulnerable population that randomized controlled trials exclude. Hence, clinicians have little data to inform their clinical decision making," he told Medscape Medical News.

"Although data on orthostatic blood pressure measurements were not obtainable because of the study design, the study's underpinnings highlight the fact that falls and their consequences can be as catastrophic as a cardiovascular event. Balancing the two clinically important outcomes requires a patient-centric approach," he pointed out.

The study was sponsored by the Donahue Foundation, the National Institute on Aging, and the US Veterans Administration. Boockvar, Markland, and Ong have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2018 Annual Scientific Meeting: Abstract P3. Presented May 3, 2018.

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