By |Published On: May 19th, 2024|Categories: Fall Prevention|Tags: , , |

Falls and fall-related injuries are the biggest risks with antihypertension therapies because they can cause dizziness and fainting. Falls can lead to broken bones, concussions, and other serious or even life-threatening injuries.

If an elderly person has hypotension, preventing falls and providing fall recover solutions should be one of a clinician’s biggest priorities. Postural hypotension is when the blood pressure drops in a patient when transferring from lying down to sitting up, or from sitting to standing. This can make a person dizzy and more likely to fall.

Rapidly decreasing blood pressure in nursing home residents by prescribing a new antihypertensive drug may cause orthostatic hypotension, which similarly increases the risk of falling, resulting in fractures. Both circumstances are reasonable eventualities that require consideration in determining fall recovery solutions in patient’s homes and clinical settings.

The following synopsis illustrates why fall recovery is an important part of the therapeutic equation: A summary titled “Balancing Hypertension and Fall Risk: A Delicate Dance in Elderly Patients” was recently published by L.A. McKeown, a Senior Medical Journalist for TCTMD1. She writes, in part:

“Caution is needed in balancing fall risk and fractures with the need to lower blood pressure for elderly patients living in long-term care facilities, data from the Veterans Health Administration show.

In the propensity-matched analysis, older individuals starting on a new antihypertensive medication were more than twofold likely to suffer a fracture within the first 30 days than those who did not, report Chintan V. Dave, PharmD, PhD, and colleagues in JAMA Internal Medicine2. The study also found that patients with dementia were at particularly high risk for a fracture.

In accompanying editorial, Muna Thalji Canales, MD, and Ronald I. Shorr, MD, say the data “create a compelling narrative” that lowering BP too rapidly may induce hypotension, predisposing elderly adults to falls that can lead to serious injury3.

A key question that Canales and Shorr say the new findings raise is whether the “unrealistic goal of no falls” should come at the expense of treating hypertension in patients living in long-term care homes.

Since no two octogenarians are alike, they suggest using prognostic calculators like ePrognosis and gauging hypotension risk, with the option to accept a higher BP in exchange for avoiding hypotension that could lead to a fall.

Fall Risk

Dementia Amplifies Fracture Risk

Dave and colleagues analyzed data from 64,710 propensity score-matched long-term care nursing home residents (mean age 78 years; 2% women) from Veterans Health Administration facilities. Compared with controls not initiating antihypertensives, those who did start the drugs had higher systolic and diastolic blood pressures, were more likely to be diagnosed with heart failure or MI and were more often prescribed opioids and benzodiazepines. One-quarter of initiation and control patients had a recent fall, with more than 60% in each group having some history of falls. Dementia was present at baseline in 55% of all patients.

Patients on new antihypertensives also had a higher risk of serious falls requiring hospitalizations or visits to the emergency department compared with controls and a greater likelihood of syncope.

Antihypertensives as a Modifiable Risk Factor

In their paper, the investigators say antihypertensive medications may represent a prominent modifiable risk factor for fall prevention in this population.

While dementia is in some ways an easier to grasp risk factor due to underreporting or lack of understanding of symptoms by patients, Dave said the increased risk of fractures at higher systolic or diastolic levels requires a more-nuanced interpretation.”

The Bottom Line

Hypertension is the most common comorbidity associated with orthostatic hypotension, and its presence and commonality complicate the management of both conditions for clinicians and caregivers within in-home settings. It is common practice to use antihypertensives in patients hospitalized for orthostatic hypotension.

However, the problem of fall management and fall recovery cannot be ignored, especially when treatment programs have to be devised for patients living at home or in clinical settings4,5. Besides antihypertensive drugs, other drugs need avoidance as well including, diuretics, central sympatholytics, and alpha blockers in the management of hypertension. This is a huge issue for health care systems focused on finding solutions to independent living while delivering quality care.

References

1 L.A. McKeown, Balancing Hypertension and Fall Risk: A Delicate Dance in Elderly Patients, www.tctmd.com/news/balancing-hypertension-and-fall-risk-delicate-dance-elderly-patients, April 22, 2024.

2  Dave CV, Li Y, Steinman MA, et al. Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. JAMA Intern Med. 2024;Epub ahead of print.

3  Canales MT, Shorr RI. Blood pressure management and falls in nursing home residents—a matter of balance. JAMA Intern Med. 2024.

4  A Gangavati, I Hajjar, L Quach, et al, Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study, J Am Geriatr Soc, 59 (3) (2011), pp. 383-389

5  SP Juraschek, J-R Hu, JL Cluett, et al, Effects of intensive blood pressure treatment on orthostatic hypotension: a systematic review and individual participant–based meta-analysis, Ann Intern Med, 174 (1) (2021), pp. 58-68

Fall Risk and Fall Recovery

Fall RiskFalls and fall-related injuries are the biggest risks with antihypertension therapies because they can cause dizziness and fainting. Falls can lead to broken bones, concussions, and other serious or even life-threatening injuries.

If an elderly person has hypotension, preventing falls and providing fall recover solutions should be one of a clinician’s biggest priorities. Postural hypotension is when the blood pressure drops in a patient when transferring from lying down to sitting up, or from sitting to standing. This can make a person dizzy and more likely to fall.

Rapidly decreasing blood pressure in nursing home residents by prescribing a new antihypertensive drug may cause orthostatic hypotension, which similarly increases the risk of falling, resulting in fractures. Both circumstances are reasonable eventualities that require consideration in determining fall recovery solutions in patient’s homes and clinical settings.

The following synopsis illustrates why fall recovery is an important part of the therapeutic equation: A summary titled “Balancing Hypertension and Fall Risk: A Delicate Dance in Elderly Patients” was recently published by L.A. McKeown, a Senior Medical Journalist for TCTMD1. She writes, in part:

“Caution is needed in balancing fall risk and fractures with the need to lower blood pressure for elderly patients living in long-term care facilities, data from the Veterans Health Administration show.

In the propensity-matched analysis, older individuals starting on a new antihypertensive medication were more than twofold likely to suffer a fracture within the first 30 days than those who did not, report Chintan V. Dave, PharmD, PhD, and colleagues in JAMA Internal Medicine2. The study also found that patients with dementia were at particularly high risk for a fracture.

In accompanying editorial, Muna Thalji Canales, MD, and Ronald I. Shorr, MD, say the data “create a compelling narrative” that lowering BP too rapidly may induce hypotension, predisposing elderly adults to falls that can lead to serious injury3.

A key question that Canales and Shorr say the new findings raise is whether the “unrealistic goal of no falls” should come at the expense of treating hypertension in patients living in long-term care homes.

Since no two octogenarians are alike, they suggest using prognostic calculators like ePrognosis and gauging hypotension risk, with the option to accept a higher BP in exchange for avoiding hypotension that could lead to a fall.

Dementia Amplifies Fracture Risk

Dave and colleagues analyzed data from 64,710 propensity score-matched long-term care nursing home residents (mean age 78 years; 2% women) from Veterans Health Administration facilities. Compared with controls not initiating antihypertensives, those who did start the drugs had higher systolic and diastolic blood pressures, were more likely to be diagnosed with heart failure or MI and were more often prescribed opioids and benzodiazepines. One-quarter of initiation and control patients had a recent fall, with more than 60% in each group having some history of falls. Dementia was present at baseline in 55% of all patients.

Patients on new antihypertensives also had a higher risk of serious falls requiring hospitalizations or visits to the emergency department compared with controls and a greater likelihood of syncope.

Antihypertensives as a Modifiable Risk Factor

In their paper, the investigators say antihypertensive medications may represent a prominent modifiable risk factor for fall prevention in this population.

While dementia is in some ways an easier to grasp risk factor due to underreporting or lack of understanding of symptoms by patients, Dave said the increased risk of fractures at higher systolic or diastolic levels requires a more-nuanced interpretation.”

The Bottom Line

Hypertension is the most common comorbidity associated with orthostatic hypotension, and its presence and commonality complicate the management of both conditions for clinicians and caregivers within in-home settings. It is common practice to use antihypertensives in patients hospitalized for orthostatic hypotension.

However, the problem of fall management and fall recovery cannot be ignored, especially when treatment programs have to be devised for patients living at home or in clinical settings4,5. Besides antihypertensive drugs, other drugs need avoidance as well including, diuretics, central sympatholytics, and alpha blockers in the management of hypertension. This is a huge issue for health care systems focused on finding solutions to independent living while delivering quality care.

1 L.A. McKeown, Balancing Hypertension and Fall Risk: A Delicate Dance in Elderly Patients, www.tctmd.com/news/balancing-hypertension-and-fall-risk-delicate-dance-elderly-patients, April 22, 2024.

2 Dave CV, Li Y, Steinman MA, et al. Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. JAMA Intern Med. 2024;Epub ahead of print.

3 Canales MT, Shorr RI. Blood pressure management and falls in nursing home residents—a matter of balance. JAMA Intern Med. 2024.

4 A Gangavati, I Hajjar, L Quach, et al, Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study, J Am Geriatr Soc, 59 (3) (2011), pp. 383-389

5 SP Juraschek, J-R Hu, JL Cluett, et al, Effects of intensive blood pressure treatment on orthostatic hypotension: a systematic review and individual participant–based meta-analysis, Ann Intern Med, 174 (1) (2021), pp. 58-68
Key Word Phrase: Fall Risk, Risk Factors, Fall Recovery

The ResQUp

ResQUp - A recovery device to help you get up from the floor in the case of a fall

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ResQUp - A recovery device to help you get up from the floor in the case of a fall

Graystone