Study Suggests Initiation of Antihypertensives in Older VA Nursing Home Residents Increases Risk of Fractures and Falls
BACKGROUND:
Falls represent two thirds of unintentional injuries that may lead to mortality. Prescription medications represent a leading modifiable risk factor for falls. Given that the prevalence of diagnosed hypertension among older adults exceeds 70%, blood pressure (BP) lowering therapies are the most frequently used medications in this age group. However, the immediate period after treatment initiation is associated with the greatest risk for orthostatic hypotension, a trigger for falls and subsequent fractures. This retrospective cohort study sought to determine whether initiating antihypertensive treatment increases fracture risk in older VA long-term nursing home residents. Using data on long-term care VA nursing home residents from 2006 to 2019, the target trial cohort included older adults (≥65 years) on a stable BP lowering regimen who were subsequently randomly allocated to receive an additional BP-lowering medication (exposure arm) or continue with their existing treatment (control arm). Medical records from nursing home stays were linked to other data sources, including acute hospital stays, as well as outpatient and emergency department visits. The primary outcome was non-traumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation.
FINDINGS:
- Initiation of antihypertensives was associated with a >2-fold increase in risk of fractures and falls.
- In the propensity-score matched cohort of 64,710 older Veterans (mean age 78 years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensives was 5.4 compared to 2.2 in the control arm.
- Use of an antihypertensive was also associated with an increased risk of severe falls necessitating emergency department visits or hospitalizations.
- Risks of fractures and falls were numerically higher among Veterans with dementia, higher baseline blood pressure values, and those who had not used antihypertensives recently, but did not reach statistical significance.
IMPLICATIONS:
- Caution and additional monitoring are advised when initiating antihypertensives in older Veterans residing in nursing homes.
LIMITATIONS:
- Investigators were unable to assess differences in the risk of fractures across drug classes.
- This study focused on treatment initiation and not dosage escalation – which represents another form of treatment intensification that might be linked to fracture risk.
AUTHOR/FUNDING INFORMATION:
Dr. Dave is with the VA New Jersey Health Care System.
Drs. Li, Odden, and Ms. Liu are part of the VA Palo Alto Health Care System.
Drs. Steinman, Lee, and Mr. Jing and Ms. Fung are with the VA San Francisco Health Care System.
Dr. Graham is part of HSR’s Health Economics Resource Center (HERC), Palo Alto, CA.
Dave C, Li Y, Steinman M, Lee S, Liu X, Jing B, Graham L, Marcum Z, Fung K, and Odden M. Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Internal Medicine. April 22, 2024; e240507, online ahead of print.
