For adults over 70, could the risk of falls due to the effects of antihypertensive medications outweigh the risks of not taking those medications? According to a recent study of nearly 5,000 community-living adults over 70 with hypertension, it's a valid question that should be asked at the individual level.
In an article e-published ahead of print (abstract only available for free) in the February 24 issue of JAMA Internal Medicine, researchers led by Mary Tinetti, MD,concluded that "antihypertensive medications were associated with an increased risk of serious fall injuries," with those taking antihypertensive medications who have already experienced a fall more than twice as likely to experience a subsequent serious fall than those who are not taking the drugs.
"The morbid effects associated with serious fall injuries … which are comparable to those imposed by myocardial infarction and stroke, suggest that treatment decisions should be predicated on maximizing benefit and minimizing harm," the authors wrote.
The study focused on participants in the Medicare Current Beneficiary Survey from 2004 – 2007 who were older than 70, in a community living environment, and were designated as a traditional Medicare beneficiaries (Medicare Advantage beneficiaries were excluded from the research). In all, 4961 participants with a claims-based diagnosis of hypertension were included with a mean age of 80.2 years. Just over 60% were female.
The group was further divided into 3 subgroups, a no-hypertensive medication group (697 participants), a moderate-intensity medication group (2711 participants), and a high-intensity medication group (1553 participants). Researchers then tracked falls incidents for all participants, but limited their review to only serious falls, "which are more clinically equivalent to the cerebrovascular and cardiovascular events that antihypertensive medications are prescribed to prevent."
According to the study, 446 of the 4961 participants experienced a serious fall injury, with 111 of those participants dying during the follow-up period (rates of death were higher for the medication groups, though it was unclear whether death was directly related to the fall). Broken down by subgroup, serious falls were experienced by 52 participants in the no-medication group, 267 in the moderate-intensity group, and 127 in the high-intensity group. When researchers looked further into the histories of the subgroups, they found that for those who had fallen in the year prior, risk of another fall more than doubled for the medication groups. They found no particular class of antihypertensive medication to be more strongly associated with falls risk than another.
"This article highlights some important factors PTs know, but they're ones that bear repeating and should be on our collective radar," says Mindy Renfro, PT, PhD, GCS, research assistant professor at the University of Montana. "Fall risk is multifactorial, and polypharmacy use is high on the list of modifiable risk factors. Cardiovascular medications, including antihypertensive medications, are only surpassed by psychoactive medications in increased risk for falls in all adults—but even more so in older adults. As the profession of choice for falls prevention and management, we need to consider these risk factors."
Authors acknowledged this risk and framed it in light of the relative benefits of antihypertensive medications. "Because most older hypertensive adults have had hypertension and been receiving treatment for many years," they write, "the clinical question is the likely benefit vs harm of continuing medications" at a time when serious falls risk has increased. Researchers wrote that because the morbidity and mortality associated with serious falls-related injuries such as hip fracture and head injury are comparable to morbidity and mortality associated with cardiovascular events, "It is important … to consider the effects of medications not only on the conditions for which the medications are indicated but on coexisting conditions, including fall injury risk."
Renfro pointed out that while health care providers must always be aware of medication effects, particular attention needs to be paid to when a patient begins taking a drug. "PTs and other health professionals should understand that falls due to antihypertensive or psychoactive meds occur most often in the first 2 weeks after a prescription change," she said.
“This research isn’t necessarily news for PTs, but it does point out how important it is for health professionals to recognize the effect that medications can have on a patient’s function, including the very serious risks associated with falls," said Anita Bemis-Dougherty, PT, DPT, MAS, clinical practice director at APTA. "Informing patients of the potential risks of medications and monitoring the effects of the medication on functioning—not just the effect of the medication on the condition being treated—must be considered, particularly in the older adult population."
Authors acknowledged that "although cause and effect cannot be established" through the study, the nationally representative data on older adults suggests an association between the medicines and falls risk strong enough that it should be weighed against the benefits of the drugs on an individual level. "The potential trade-off between serious fall injury and cardiovascular events and mortality suggests that each older adult's prevention priority should drive decision making," they write.
APTA provides continuing education on exercise prescriptions for balance improvement and falls prevention and offers other resources for physical therapists, such as how to develop consumer events on balance, falls, and exercise, information on evidence-based falls programs, and a clinical summary on falls risk in community-dwelling elderly. Members can also access an APTA pocket guide on falls risk reduction (.pdf) as well as an online community where members can share information about falls prevention.
Hypertension clinical practice guidelines and their lack of information on physical activity was the subject of a recent PTNow blog post. Check it out—and join the conversation!
Research-related stories featured in News Now are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.
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