Falls in Elderly People: The Role of Blood Pressure Drugs

Recent studies have confirmed that a significant cause of falls in the elderly is medication (and often overmedication) with drugs for high blood pressure, resulting in blood pressures low enough to increase the risk of falling — with attendant fractures and head injuries. In addition, last year, national recommendations increased the minimum blood pressure level for initiating treatment for hypertension (high blood pressure) in people 60 or older.

Studies on blood pressure drugs and falls

Researchers at Yale and Oregon State universities, in a study published in 2014, collected information on almost 5,000 U.S. community-living people older than 70 with hypertension, 86 percent of whom were taking antihypertensive drugs. The researchers assessed the occurrence, during a three-year follow-up, of serious fall injuries, including hip and other major fractures, traumatic brain injuries, and joint dislocations. They examined the relationship between these injuries and the use of antihypertensive drugs.[1]

During the three years, 446 people (9 percent) had at least one serious fall injury. The injuries included 107 hip fractures, 345 other major fractures, 72 major head injuries and 16 major joint dislocations. Fifty-eight people experienced more than one type of serious injury with a fall. In comparison with people not using any antihypertensive drug, those who used either moderate- or high- intensity antihypertensive drugs had an increased risk of these more serious fall injuries. The increased risk was most dramatic for the 503 people who had a fall injury during the previous year. In this group, for those using antihypertensive drugs the risk of another serious fall injury during the subsequent three years was more than twice that of non-users.

Having stated, “The effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of [the prevented] cardiovascular events,” the authors of the study concluded, “The potential harms [versus] benefits of antihypertensive medications should be weighed in deciding whether to continue antihypertensives in older adults with multiple chronic conditions.”

In a second study, also published in 2014, 409 randomly selected Australians, ages 60 to 86, were followed for 12 months to study the relationship between any subsequent falls — not just those causing a serious injury — and the use of antihypertensive drugs. In this study, which was not limited to people with hypertension, 54 percent were using antihypertensive drugs.[2]

In the 12 months, 161 subjects (39 percent) fell, and people using higher daily doses of antihypertensive medications and those with a history of strokes had a higher risk of falling than those using lower doses or no such medications. This was especially the case among those using the highest daily doses of the drugs and in patients with a history of stroke.

The study’s authors concluded that “it is important to be mindful of the dose of antihypertensive medications prescribed to older people. … Some older people may be taking more antihypertensive medication than necessary … creating an opportunity to intervene to reduce their risk of falls.” They asserted that reduction in antihypertensive medication appears feasible and might decrease fall risk in older people who have previously fallen.

This feasibility was demonstrated in a 2007 Dutch study in which people with previous falls who had been using fall-risk-increasing drugs, the second most common of which were antihypertensive drugs, either were taken off these drugs or had their dosage decreased. People whose doses were reduced or who stopped taking these drugs were significantly less likely to have subsequent falls than those who continued their previous treatment.[3]

Guidelines on blood pressure treatment

In 2014, a National Institutes of Health-funded group of experts known as the JNC 8 published new recommendations for treatment of hypertension. The first recommendation, most relevant to the issue of antihypertensive medication in the elderly, stated:
 

In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at systolic blood pressure (SBP) of 150mmHg or higher or diastolic blood pressure (DBP) of 90mmHg or higher and treat to a goal SBP lower than 150mmHg and goal DBP lower than 90mmHg. Strong Recommendation [There is high certainty based on evidence that the net benefit is substantial.][4]

This level represents an increase from the previous (JNC 7) recommendation for this age group, which advised initiating treatment at lower blood pressure levels of 140 for SBP and 90 for DBP.[5] The JNC 8 exceptions to the newer general 150/90 recommendation for older patients are for those with diabetes or chronic kidney disease, who should initiate treatment at 140/90.

In addition, the JNC 8 experts, referring to older people already being treated for high blood pressure, stated:
 

In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140mmHg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.

The JNC 8 authors concluded:
 

Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

What You Can Do

If you are 60 or older, do not have diabetes or chronic kidney disease, and are diagnosed with hypertension in the future, you should discuss with your doctor the new recommendation of not initiating treatment if your blood pressure is below 150/90. As indicated above, this discussion should be individualized, should consider the benefits and risks of antihypertensive drugs, and also should occur if you already have had falls while using blood pressure drugs.

Steps for preventing falls in older adults include:[6]
 

• Modification of home environment, including removal or modification of identified hazards, installation of safety devices such as handrails and grab bars, and improvements in lighting.
• Withdrawal or minimization of medications that increase the risk of falls in the elderly, including sedatives, sleeping pills and antidepressants.
• Management of postural hypotension (decreased blood pressure when arising from bed or standing): initiating both of these actions more slowly, first counting to at least 10; maintaining better hydration; and using elastic stockings.
• Treatment of vision impairment.
• Management of foot problems and footwear.
• Exercise, particularly balance, strength and gait training (an excellent description of these can be found at: http://go4life.nia.nih.gov/exercises).

References

[1] Tinetti M, Han L, Lee D, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588-595.

[2] Callisaya ML, Sharman JE, Close J, Lord SR, Srikanth VK. Greater daily defined dose of antihypertensive medication increases the risk of falls in older people — a population-based study. J Am Geriatr Soc. 2014;62:1527-1533.

[3] Van der Velde N, Stricker BH, et al. Risk of falls after withdrawal of fall-risk-increasing drugs: A prospective cohort study. Br J Clin Pharmacol. 2007;63:232-237.

[4] James P, Oparil S, Carter B, et al. Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the eighth Joint National Committee (JNC8). JAMA. 2014;311:507-520.

[5] National Institutes of Health. National Heart, Lung, and Blood Institute. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Reference card. http://www.nhlbi.nih.gov/files/docs/guidelines/phycard.pdf. Accessed March 20, 2015.

[6] Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59:148-157.