Balancing hypertension and fall risk: a delicate dance in older patients

Caution is needed in balancing the risk of falls and fractures with the need to lower blood pressure in older patients living in long-term care facilities, data from the Veterans Health Administration show.

The propensity-matched analysis found that older individuals who started a new antihypertensive drug were more than twice as likely to sustain a fracture within the first 30 days than those who did not, reports Chintan V. Dave, PharmD, PhD (Rutgers The State University of New Jersey, New Brunswick) and colleagues in JAMA Internal Medicine.

“The risk was highest in the 30-day period, but it begins to decline over time (and) is still significant at day 90,” Dave told TCTMD. “So despite the attenuation, there is still a 70% increased risk over 90 days, which is a lot.”

The study also found that patients with dementia were at particularly high risk of fracture.

When considering the consequences of falls that occur in this population, despite staff vigilance and prevention measures such as guardrails, Dave noted to TCTMD that hip fractures alone have been associated with one-year mortality rates of more than 40% in nursing home patients.

“Hip fractures in general are devastating, but nursing home patients in particular are already a highly vulnerable population,” he added.

In an accompanying editorial, Muna Thalji Canales, MD, and Ronald I. Shorr, MD (both of Malcom Randall VA Medical Center, Gainesville, FL), say the data “create a compelling narrative” that lowering blood pressure too quickly can cause hypotension, predisposing the elderly to falls that can lead to serious injury.

They say the data also extends the results of a secondary analysis of the results SPRINT A study suggesting that intensive lowering of systolic blood pressure to less than 120 mm Hg is associated with an increased risk of orthostatic hypotension and possibly syncope.

An important question Canales and Shorr say the new findings raise is whether the “unrealistic goal of not falling” should come at the expense of treating hypertension in patients living in long-term care facilities.

“In addition to race, ethnicity, gender, and socioeconomic status, older nursing home residents represent a heterogeneous, complex population in which we, as healthcare providers, must feel comfortable tailoring therapy to the individual patient’s health care priorities and circumstances,” they write .

Since no two octogenarians are the same, they suggest using prognostic calculators such as eForecast and measuring the risk of hypotension, with the option of accepting higher blood pressure in exchange for avoiding hypotension that could lead to a fall.

Dementia increases the risk of fracture

Dave and colleagues analyzed data from 64,710 propensity-matched nursing home residents (mean age 78 years; 2% women) from Veterans Health Administration facilities. Compared with the control group who did not initiate antihypertensive medications, those who did initiate the medications had higher systolic and diastolic blood pressure, were more likely to be diagnosed with heart failure or MI, and were more likely to be prescribed opioids and benzodiazepines. A quarter of baseline and control patients had recently fallen, with more than 60% in each group having a history of falls. Dementia was present at baseline in 55% of all patients.

At 30 days, the fracture rate in those taking a new antihypertensive drug was 5.4 per 100 person-years, compared with 2.2 in the control groups (adjusted HR 2.42; 95% CI 1.43-4.08). Fractures included non-traumatic pelvic fractures, surgically treated hip fractures, and fractures of the humerus, radius, or ulna requiring intervention.

Patients taking new antihypertensive medications also had a higher risk of serious falls requiring hospitalizations or emergency department visits compared with controls (HR 1.80; 95% CI 1.52-2.13) and a greater risk of syncope (HR 1.69; 95% CI 1.30-2.19). ).

In subgroup analyses, factors associated with an even greater risk of fracture after starting a new antihypertensive drug included dementia (HR 3.28; 95% CI 1.76-6.10), systolic blood pressure of 140 mm Hg or greater (HR 3.12; 95% CI 1.71-5.69). ), diastolic blood pressure of 80 mm Hg or greater (HR 4.41; 95% CI 1.67-11.68), and no recent prior use of an antihypertensive drug (HR 4.77; 95% CI 1.49-15 ,32).

Antihypertensive medications as a modifiable risk factor

In their article, the researchers say that antihypertensive medications may be a prominent modifiable risk factor for fall prevention in this population.

While dementia is in some ways an easier-to-understand risk factor due to underreporting or lack of understanding of symptoms by patients, Dave said the increased risk of fracture at higher systolic or diastolic levels requires a more nuanced interpretation.

“If you start with lower blood pressure to begin with, you don’t have much room to go down. But with higher blood pressure you actually have a greater tendency towards orthostasis. It’s a bit counterintuitive, but it makes sense,” he added.

When it comes to understanding how antihypertensive medications work in the elderly, that too can be unclear, Dave said, because patients in long-term care facilities have been largely excluded from high-resource trials. “We don’t know if these drugs work as well in this patient population,” he noted. “We can still translate an advantage. . . but you also have to weigh that against the special predisposition to certain side effects such as falls and fractures.

Canales and Shorr note that an additional factor to consider in this patient population is how they feel on antihypertensive medications.

“Some nursing home residents simply do not feel well with tight blood pressure control, and feeling good may be the most important thing for that resident,” they write. “A discussion with the patient and their loved ones about the goals of care can help guide the approach to blood pressure management in nursing homes.”