Initiating BP Medication Linked to Higher Fall, Fracture Risks in Nursing Home Residents

Older patients starting medication to manage their blood pressure may be at risk of falling, suggest study findings.¹

Among over 60,000 nursing home residents who initiated antihypertensive medication, rates of excess fractures due to falls per 100 person-years were as high as 5 among certain patient groups, such as those with dementia and high blood pressure.

“The findings of this study have important clinical implications. Despite ongoing efforts, the incidence of fall-related mortality has continued to trend upward in the United States, nearly doubling from 2000 to 2013, from 29.6 to 56.7 deaths per 100,000 adults,” explained the researchers. “Falls are also the primary contributor to fractures, which are associated with worsening global health and a pronounced increase in overall mortality. Notably, among older nursing home residents, hip fractures alone have been linked to 1-year mortality rates exceeding 40%.”

Aecondary analysis of patient data showed that initiating antihypertension medication was associated with an increased risk of severe falls | Image Credit: ibreakstock - stock.adobe.com

Findings from the current study, published in JAMA Internal Medicine, suggest that despite preventive measures already implemented by nursing homes, patients initiating antihypertensive medications have a higher risk of falls and fractures within 30 days of initiation. It’s thought that decreased blood pressure through antihypertensive medication causes orthostatic hypotension, leading to falls.

Using 1:4 propensity score matching, researchers retrospectively analyzed data from 64,710 residents of a long-term care nursing home, part of the Veterans Health Administration, between 2006 and 2019. On average, these patients were aged 78 years. Patients were matched based on 50 relevant variables. The researchers analyzed patient data between the end of 2021 and 2023.

In the primary analysis, the adjusted excess risk rate of fractures for the 12,942 patients initiating antihypertensive medication was 3.1 per 100 person-years compared with the 51,768 residents from the same nursing home. Patients starting antihypertensive medication had a nearly 1.5-fold greater risk of fractures vs their matched counterparts (HR, 2.42; 95% CI, 1.43-4.08).

Secondary analysis of patient data showed that initiation of antihypertension medication was also associated with an increased risk of severe falls that required hospitalization or emergency department visits (HR, 1.80; 95% CI, 1.53-2.13) and fainting (HR, 1.69; 95% CI, 1.30-2.19). The study was not powered to determine differences in fracture risk based on drug class.

Subgroup analyses of patients showed varying levels of elevated risk associated with dementia (HR, 3.28; 95% CI, 1.76-6.10), elevated systolic (HR, 3.12; 95% CI, 1.71- 5.69) and diastolic (HR, 4.41; 95% CI, 1.67-11.68) blood pressures, and no prior use of antihypertensives (HR, 4.77; 95% CI, 1.49-15.32).

Notably, although the findings suggest a potential risk of fracture after these patients initiated the medication, the increases were not statistically significant.

“Patients with dementia have a higher risk of falls and fractures due to a variety of factors, including impaired cognition, gait abnormalities, and use of other medications that are associated with fall risk (eg, benzodiazepines),” the study authors wrote. “This risk could be further exacerbated in this subgroup during antihypertensive medication initiation due to poorer reporting of subjective symptoms associated with orthostasis and falls (eg, dizziness).”

In an accompanying editorial,² a pair of researchers reflected on the implications of these study findings, offering several recommendations for the initiation of antihypertensive medications in older patients while emphasizing the importance of personalized approaches to treating this heterogenous and complex group of patients.

General guidance for the initiation of antihypertensive medications in these older patients provided by the pair included these suggestions:

• Start with the lowest dose available when initiating treatment
• Monitor orthostatic vitals the week of initiation or when there is a change in dose
• Avoid rapid intensification of treatment and allow at least a month for acclimating to a new drug or dose in alignment with the SPRINT protocol

References

1.Dave C, Li Y, Steinman M, et al. Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. JAMA Intern Med. Published online April 22, 2024. doi:10.1001/jamainternmed.2024.0507

2.Canales M, Shorr R. Blood pressure management and falls in nursing home residents—a matter of balance. JAMA Intern Med. Published online April 22, 2024. doi:10.1001/jamainternmed.2024.0506