Initiating and Intensifying Antihypertensives Associated With Short-Term Fall Risk in Older Adults
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Antihypertensive medication use has been associated with an increased risk of falls in some but not all studies. Few data are available on the short-term risk of falls after antihypertensive medication initiation and intensification.
METHODS AND RESULTS
We examined the association between initiating and intensifying antihypertensive medication and serious fall injuries in a case-crossover study of 90 127 Medicare beneficiaries who were ≥65 years old and had a serious fall injury between July 1, 2007, and December 31, 2012, based on emergency department and inpatient claims. Antihypertensive medication initiation was defined by a prescription fill with no fills in the previous year. Intensification was defined by the addition of a new antihypertensive class, and separately, titration by the addition of a new class or increase in dosage of a current class. Exposures were ascertained for the 15 days before the fall (case period) and six 15-day earlier periods (control periods). Overall, 272, 1508, and 3113 Medicare beneficiaries initiated, added a new class of antihypertensive medication or titrated therapy within 15 days of their serious fall injury. The odds for a serious fall injury was increased during the 15 days after antihypertensive medication initiation (odds ratio, 1.36 [95% confidence interval, 1.19-1.55]), adding a new class (odds ratio, 1.16 [95% confidence interval, 1.10-1.23]), and titration [odds ratio, 1.13 [95% confidence interval, 1.08-1.18]). These associations were attenuated beyond 15 days.
CONCLUSIONS
Antihypertensive medication initiation and intensification was associated with a short-term, but not long-term, increased risk of serious fall injuries among older adults.
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Additional Info
Disclosure statements are available on the authors' profiles:
Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication
Circ Cardiovasc Qual Outcomes 2016 May 01;9(3)222-229, D Shimbo, C Barrett Bowling, EB Levitan, L Deng, JJ Sim, L Huang, K Reynolds, P MuntnerFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This study of 90,127 Medicare beneficiaries with serious falls compared various 15-day increments and showed increased risk within 15 days of starting or increasing the dose of blood pressure (BP) medications. While recent randomized controlled trials, namely SPRINT 1 and ACCORD 2,1,2 have shown no increased risk of falls with tight blood pressure control, this study adds a time cut-off component that appears to be important.
Blood pressure medications cause vasodilation, and this leads to a relative hypovolemia. The cross-linking of elastin and collagen in older adults, which is most apparent in the wrinkling of aging skin, also occurs in the veins of lower extremities and causes pooling of blood upon arising. This leads to widened pulse pressure with aging and further relative hypovolemia, often noticed as lightheadedness. To counteract this relative intravascular volume deficit, I encourage my patients to double their fluid intake for the first 3 days after starting or increasing blood pressure meds. This study also found the strongest correlation of falls with diuretics, especially loop diuretics, which deplete body fluids.
We should not shy away from aggressive blood pressure control in older adults at risk for falls, but should caution our patients of the early increased falls risk and encourage increased fluid intake. In the long run, intensive blood pressure control, especially with ACE inhibitors and calcium channel blockers, has been shown to decrease falls in the MOBILIZE 3 study,3 probably through improved brain perfusion with long-term blood pressure control found with intensive ACE inhibitors angiotensin receptor blockers, and calcium channel blockers.
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