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Original Investigation |

Antihypertensive Medications and Serious Fall Injuries in a Nationally Representative Sample of Older Adults

Mary E. Tinetti, MD1,2; Ling Han, MD, PhD1; David S. H. Lee, PharmD, PhD3; Gail J. McAvay, PhD1; Peter Peduzzi, PhD2; Cary P. Gross, MD1; Bingqing Zhou, PhD2; Haiqun Lin, PhD2
[+] Author Affiliations
1Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
2Yale School of Public Health, New Haven, Connecticut
3Oregon State University, Oregon Health & Science University, College of Pharmacy, Portland
JAMA Intern Med. 2014;174(4):588-595. doi:10.1001/jamainternmed.2013.14764.
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Importance  The effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of cardiovascular events. Concerns have been raised about the risk of fall injuries in older adults taking antihypertensive medications. The low risk of fall injuries reported in clinical trials of healthy older adults may not reflect the risk in older adults with multiple chronic conditions.

Objective  To determine whether antihypertensive medication use was associated with experiencing a serious fall injury in a nationally representative sample of older adults.

Design, Participants, and Setting  Competing risk analysis as performed with propensity score adjustment and matching in the nationally representative Medicare Current Beneficiary Survey cohort during a 3-year follow-up through 2009. Participants included 4961 community-living adults older than 70 years with hypertension.

Exposures  Antihypertensive medication intensity based on the standardized daily dose for each antihypertensive medication class that participants used.

Main Outcomes and Measures  Serious fall injuries, including hip and other major fractures, traumatic brain injuries, and joint dislocations, ascertained through Centers for Medicare & Medicaid Services claims.

Results  Of the 4961 participants, 14.1% received no antihypertensive medications; 54.6% were in the moderate-intensity and 31.3% in the high-intensity antihypertensive groups. During follow-up, 446 participants (9.0%) experienced serious fall injuries, and 837 (16.9%) died. The adjusted hazard ratios for serious fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28 (95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with nonusers. Although the difference in adjusted hazard ratios across the groups did not reach statistical significance, results were similar in the propensity score–matched subcohort. Among 503 participants with a previous fall injury, the adjusted hazard ratios were 2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31 (95% CI, 1.01-5.29) for the high-intensity antihypertensive groups.

Conclusions and Relevance  Antihypertensive medications were associated with an increased risk of serious fall injuries, particularly among those with previous fall injuries. 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.

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Serious Fall Injury Events Among Relevant Subgroups According to Antihypertensive Intensity in Older Adults With Hypertension

Hazard ratios (HR) were estimated using a subdistribution proportional hazards regression model for competing risk analyses. The reference group was the group using no antihypertensive medications. Follow-up was continued for up to 3 years. Antihypertensive intensity is defined in the Methods section. The propensity score–adjusted hazard ratios were adjusted for year of study entry, propensity score as a continuous variable, age, sex, fall injury in past year, use of an assistive device, difficulty walking, obesity, osteoporosis, Parkinson disease, depression, cognitive impairment, severe vision impairment, physical function score, prior myocardial infarction, prior stroke, heart failure, diabetes, psychosis, statin use, number of nonantihypertensive medications, self-perceived health, and blood pressure measured within the past 6 months. Dots represent point estimates for HRs, the width of the horizontal lines represents the 95% CIs, and arrows indicate that the upper limits of 95% CIs exceed 2.50.

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