Association of Antihypertensive Medication Use With Fracture Risk in Older Veterans Health Administration Nursing Home Residents
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents.
OBJECTIVE
To assess the association between antihypertensive medication initiation and risk of fracture.
DESIGN, SETTING, AND PARTICIPANTS
This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023.
EXPOSURE
Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.
MAIN OUTCOME AND MEASURES
The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.
RESULTS
Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]).
CONCLUSIONS AND RELEVANCE
Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.
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Additional Info
Disclosure statements are available on the authors' profiles:
Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents
JAMA Intern Med 2024 Apr 22;[EPub Ahead of Print], CV Dave, Y Li, MA Steinman, SJ Lee, X Liu, B Jing, LA Graham, ZA Marcum, KZ Fung, MC OddenFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The results of this retrospective database review study involving 29,648 older long-term care nursing home residents, with an average age of 78 years, in the Veterans Health Administration showed an incidence rate of fractures per 100 person-years among residents initiating antihypertensive medication of 5.4 compared with 2.2 among the control group (aHR, 2.42; 95% CI, 1.43–4.08). Residents initiating antihypertensives had a higher risk of severe falls requiring hospitalization and syncope. Subgroups with a higher risk of fracture included residents with dementia (HR, 3.28; 95% CI, 1.76–6.10), systolic blood pressure (BP) of 140 mm Hg or higher (HR, 3.12; 95% CI, 1.71–5.69), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41; 95% CI, 1.67–11.68), and no recent antihypertensive medication use (HR, 4.77; 95% CI, 1.49–15.32).
The benefit of this study is that the controlled nursing home environment allowed for reliable reporting of fractures, medication administration, BP measurements, and dementia and falls reporting as part of the minimum data set (MDS) that is collected by CMS.
Results from other studies have shown an increased risk of fracture and falls within the first month of starting an antihypertensive.1,2 These findings might explain why individuals with higher baseline BP values had a greater risk of falls and fractures. This is because the drop in BP in these individuals following antihypertensive initiation was greater than that of patients with less severe hypertension. The body has to adapt to the new BP and possibly decreased perfusion, and, until it achieves homeostasis, the risk of falls and fractures is increased.
When my patients called and reported dizziness as a side effect of their blood pressure medication, I instructed them to increase their fluid intake for 3 days after starting or increasing the dose of an antihypertensive medication. The fluid intake compensated for the hypovolemia from the vasodilation the medications caused and led to reduced side effects.
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