Antihypertensive medication initiation and intensification was associated with a short-term increased risk of serious fall injuries among older adults, according to results of a retrospective cohort study published in Circulation: Cardiovascular Quality and Outcomes.

While antihypertensive medication has reduced cardiovascular disease risk, older adults are prone to the adverse side effects associated with these agents, including postural hypotension, balance and gait impairment, dizziness, and electrolyte disturbances—all of which may increase serious fall injury risk.

Researchers used a case-crossover study model, which means only individuals who experience an outcome are analyzed and each case serves as their own control. Based on emergency department and inpatient claims, they were able to evaluate 90 127 Medicare beneficiaries who were older than 65 years of age who experienced a serious fall injury between 2007 and 2012. Of those beneficiaries, 65 210 met the inclusion criteria.


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Exposures were obtained the 15 days prior to the fall (case period) and an additional six 15-day earlier periods (control periods). In total, 272 beneficiaries initiated therapy, 1508 beneficiaries added a new class of antihypertensive medication, and 3113 beneficiaries titrated therapy within 15 days of serious fall injury. During the 15 days after medication initiation, the odds for a serious fall injury were increased (odds ratio [OR]: 1.36; 95% confidence interval [CI]: 1.19-1.55). After adding a new class of medication, the OR was 1.16 (95% CI: 1.10-1.23) and after titration, the OR was 1.13 (95% CI: 1.08-1.18). 

Of the 65 210 beneficiaries, 186 (0.29%) experienced a serious fall injury within 15 days after antihypertensive medication initiation.

Loop diuretic initiation was more common in the 15-day case period compared with the control periods while initiation with other classes of antihypertensive medication was similar between the case and control periods. Approximately 20% of beneficiaries in the case period initiated more than 1 antihypertensive class compared with 17.4% of beneficiaries in the control periods.

These results were similar when the definition of initiation required 1 or more diagnoses of hypertension and when the patient population was restricted to Medicare beneficiaries without a recent hospitalization.

In the 30 to 44 days, 60 to 74 days, or 90 to 104 days prior to a fall, there was no association present between initiating antihypertensive medications, and, separately adding a new class, and risk for a subsequent fall injury. A serious fall injury associated with titration within 30 to 44 days, 60 to 74 days, or 90 to 104 days carried odds ratios of 1.04, 1.05, and 1.04 respectively (95% CI: 1.00-1.09; 95% CI: 1.00-1.09; and 95% CI: 1.00-1.09, respectively).

Researchers pointed out that the recent clinical trial, SPRINT (Systolic Blood Pressure Intervention Trial) did examine the risks of hypotension, syncope, and electrolyte abnormalities in both conventional and intensive treatment arms. SPRINT investigators found that the intensive group experienced more of those side effects, but not injurious falls. “However, when adverse events were classified as possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment arm (0.8% vs 0.5%; P=.05),” researchers noted.

Ultimately, the SPRINT findings were consistent with the present study in that the risk of serious fall injuries was short and not long-term.

Researchers concluded that clinicians should discuss fall risks, as well strategies for risk reduction, with their older patients when initiating or intensifying antihypertensive treatment.

Reference

Shimbo D, Bowling B, Levitan EB, et al. Short-term risk of serious fall injuries in older adults initiating and intensifying treatment with antihypertensive medication. Circ Cardiovasc Qual Outcomes. 2016. doi: 10.1161/CIRCOUTCOMES.115.002524.