Blood pressure treatment may lead to falls in older patients

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A group of researchers from Yale and the University of Oregon, led by geriatrician Dr. Mary Tinetti, studied the incidence and severity of falls among 4,961 community-dwelling older Americans who had been diagnosed with high blood pressure (HBP). Their goal: to see if HBP treatment was a risk factor for falls with resultant significant injury. The study appears in the current JAMA Internal Medicine.

The study subjects were all over age 70, and were followed for three years, on average. While the results showed some association between HBP treatment and falls, the statistical analysis was far from definitive, and there was no dose-response: in other words, the group of patients on the more intense drug therapy had a 28 percent increased risk of falling, while the group on the less intense treatment had a 40 percent increase the opposite of what one would expect if there was a cause-and-effect. Nine percent (446 patients) sustained serious falls, resulting in fractures of the hip and other major bones, head trauma, joint dislocations, among other injuries. The risk was significantly increased, however, among those subjects who had a history of prior falls with injuries, to a level a bit over twice the risk.

Dr. Adam Skolnick, a cardiologist with academic positions at the NYU-Langone Medical Center, was not impressed at all with these results, as he told MedPage Today. His perspective was that both the lack of dose-response effect and the borderline statistical significance of the data made the whole enterprise suspect as far as detecting a true causal link. He thought it might be wise to avoid dehydrating medications specifically diuretics in patients with a history of falling, as it can contribute to dizziness. "So when taking a history and when prescribing a medication that could in theory increase the risk of falls, I think it's really important to look at the history of falls and use particular caution in prescribing a medication that might increase that risk," he said.

An editorial in the same journal, by Drs. Berry and Kiel of the Institute for Aging Research and Beth Israel-Deaconess Medical Center, respectively, had this commentary: "For some patients, concern about injurious falls may be paramount, whereas other patients fear the complications of untreated hypertension. Unfortunately, there is no easy way for clinicians to compare these risks; thus, a candid discussion with each patient is advisable. When antihypertensive drug treatment is indicated, using the lowest dose possible to achieve a target blood pressure makes good sense. Most important, clinicians should pay greater attention to fall risk in older adults with hypertension in an effort to prevent injurious falls, particularly among adults with a previous injury."