Antihypertensive Medication Linked to Fracture Risk Among Older Adults

Antihypertensive medication is associated with an increased fracture risk among older adults, a new study found.

“Nursing home residents present a unique clinical challenge, as they can often derive benefit from using antihypertensive medication to manage conditions such as heart failure that increase the risk of cardiovascular events while simultaneously being predisposed to experiencing adverse reactions, such as falls and fractures, owing to factors such as frailty,” wrote investigators, led by Chintan V. Dave, PharmD, PhD, from the center for Pharmacoepidemiology and Treatment Science at Rutgers University. “This study focused on clarifying 1 of the risks associated with antihypertensive use in this population.”

Falls encompass two-thirds of the unintentional injuries among older adults—and unintentional injuries are the 5th leading cause of mortality among this age group. Approximately 10% - 15% of falls lead to fractures, hospitalizations, or death.

A previous observational study evaluated the association between antihypertensive therapy initiation and fracture risk among older adults. However, the lack of information on blood pressure values constrained the research.

Since more evidence of the link was needed, investigators conducted a retrospective cohort study with a target trial emulation approach to see if starting antihypertensive medication was linked to an increased fracture risk among older adults. The sample included 29,648 long-term care nursing home residents in the Veterans Health Administration from January 1, 2006, to October 31, 2019, with a mean age of 78 years. Most participants were male (97.7%), and many were White (73.4%), followed by Black (17.2%), missing race (6.9%), and other race (2.4%).

Participants had to be ≥ 65 years old, have no signs of end-stage kidney disease in the last year, and have≥ 1 documented measurement of systolic and diastolic blood pressure within 2 weeks of the start of the trial. Patients had to maintain a stable antihypertensive treatment regimen for 4 consecutive weeks before the index date, indicating they could not change their dose in the preceding 4 weeks.

Dave and colleagues identified episodes of antihypertensive medication initiation and matched 1:4 of the episodes with controls who did not start the medication. The primary outcome was a nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation.

The team analyzed the data from December 1, 2021, to November 11, 2023. The team also analyzed fractures among several subgroups, including residents with dementia, across systolic and diastolic blood pressure thresholds of 140- and 80-mm Hg, respectively, and those who previously used anti-hypertensive therapies. Analyses were adjusted for ≥ 50 covariates.

The incidence rate of fractures per 100 person-years in residents starting hypertensive medication was 5.4 compared with 2.2 in controls (hazard ratio [HR], 2.42; 95% confidence interval [CI], 1.43 – 4.08). Investigators observed an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95 – 6.78).

Furthermore, starting antihypertensive medication was linked to a greater 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 fracture risk was greater among residents with dementia (HR, 3.28; 95% CI, 1.76 – 6.10), systolic blood pressure of ≥ 140 mm Hg (HR, 3.12; 95% CI, 1.71 – 5.69), diastolic blood pressure of ≥ 80 mm Hg (HR, 4.41; 95% CI, 1.67 – 11.68), and no recent antihypertensive medication use (HR, 4.77; 95% CI, 1.49 – 15.32).

Although the findings suggest patients with dementia on antihypertensive medications in patients with dementia have an increased fracture risk, the association did not reach statistical significance and thus could have happened by chance.

A greater risk of falls and fractures among people with dementia could be because of impaired cognition, gait abnormalities, and use of other medications that are linked to fall risk such as benzodiazepines.

“The results of the study by Dave et al remind us that we should at least be cautious when we escalate or initiate antihypertensive therapy in the older adult nursing home population,” said authors Muna Canales, MS, and Ronald Shorr, MD, MS, both from the University of Florida, in a commentary paper.

As Canales and Shorr had put it, “What message should we take back to the nursing home bedside?” Controlling blood pressure is linked to improved cardiovascular, kidney, and cognitive outcomes but falls can also be dangerous. The question remains if it is better in nursing homes to control the falls, which the authors view as an “unrealistic goal,” or treat high blood pressure.

“Ultimately, the question of how to treat blood pressure in older nursing home residents remains one that must be individualized,” Canales and Shorr wrote. “The days of the one-size-fits-all approach to treating common diseases are gone.”

References

1. ^{Dave CV, Li Y, Steinman MA, et al. Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Intern Med. Published online April 22, 2024. doi:10.1001/jamainternmed.2024.0507}
2. ^{Canales MT, Shorr RI. Blood Pressure Management and Falls in Nursing Home Residents-A Matter of Balance. JAMA Intern Med. Published online April 22, 2024. doi:10.1001/jamainternmed.2024.0506}