Today hypertension affects approximately two-thirds of people above the age of 60. With clinicians forced to balance the benefits of antihypertensive medicine with the potential adverse effects on an aging population, a new study published Feb. 24 in JAMA Internal Medicine sought to investigate the risk of falls associated with the treatment and found an association between antihypertensive medications and serious fall injuries in the elderly.

The study, led by Mary Tinetti, MD, section of geriatrics, department of internal medicine, Yale School of Medicine, performed an analysis drawn from participants (with a mean age of 80) enrolled from 2004 to 2007 in the Medicare Current Beneficiary Survey. From a sample of 4,961 people receiving at least one antihypertensive medication, the study found that after a three-year follow-up 446 individuals (nine percent) experienced a serious fall injury. These injuries included 107 hip fractures, 345 other major fractures in 312 individuals, 72 major head injuries, and 16 major joint dislocations. Fifty-eight participants endured more than one type of serious injury in a single fall. A total of 837 participants (16.9 percent) died during the follow-up, including 111 (24.9 percent) of the 446 participants who experienced a fall injury.

Accounting for the competing risk of mortality, antihypertensive medication use was associated with an increased risk of experiencing a serious fall injury. In subgroup analyses, a fall injury in the prior year was associated with more than doubling the risk of subsequent serious fall injuries with moderate and high intensity antihypertensive use compared without any antihypertensive use. The authors conclude that moving forward, "the potential harms vs. benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions."

In a related editorial comment, Sarah Berry, MD, MPH and Douglas Kiel, MD, MPH, offer several theories as to why antihypertensive medications might cause an elevated risk of injurious falls: "first, the association between antihypertensive medications and injurious fall may be mediated by specific drug classes that lead to injury through their effect on bone and fracture risk. Loop diuretics are an obvious example; they promote renal calcium excretion and decrease bone mineral density, yet they have not been consistently associated with an elevated fracture risk. In contrast, calcium channel blockers and angiotensin receptor blockers do not affect bone mineral density, but they may increase the risk of injurious falls." Another possibility is not the medications themselves but rather "the underlying hypertensions or overall burden of illness. Individuals with treated hypertension may have more vascular disease or comorbid conditions that place them at an increased risk of falling," they add. A final possibility is that "antihypertensive drug increase the risk of injurious fall through their effect on blood pressure and orthostasis ... In the study by Tinetti et al, most users of antihypertensive medications (71.7 percent) were prescribed two or more antihypertensive drugs. Moderate to high exposure to multiple antihypertensive drugs is likely to result in greater reductions in systolic blood pressure, which could lead to an injurious fall."

While direct cause and effect cannot be established from Tinetti’s observational study, Berry and Kiel believe that it is the responsibility of the each clinician to individualize their decisions, treating hypertension according to functional status, life expectancy and preferences of care.

Keywords: Angiotensin Receptor Antagonists, Risk, Follow-Up Studies, Geriatrics, Life Expectancy, Craniocerebral Trauma, Vascular Diseases, Fractures, Bone, Blood Pressure, Sodium Potassium Chloride Symporter Inhibitors, Cost of Illness, Calcium Channel Blockers, Bone Density, Hip Fractures, Medicare, Hypertension