Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication

Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review

Importance

Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.

Observations

Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.

Conclusions and Relevance

More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association

Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.

Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study

BACKGROUND

Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking.

OBJECTIVE

The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries.

METHODS

This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate.

RESULTS

Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022).

CONCLUSIONS

In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.

Association of low blood pressure and falls: An analysis of data from the Leiden 85-plus Study

BACKGROUND

Falls and consequent injuries are prevalent in older adults. In this group, half of injury-related hospitalizations are associated with falls and the rate of falls increases with age. The evidence on the role of blood pressure and the use of antihypertensive treatment on the risk of falls remains unclear in oldest-old adults (≥85 years).

OBJECTIVES

To examine the association between systolic blood pressure (SBP) and incident falls with medical consequences in oldest-old adults and to analyse whether this association is modified by the use of antihypertensive treatments or the presence of cardiovascular disease.

METHODS

We analysed data from the Leiden 85-plus Study, a prospective, population-based cohort study with adults aged ≥85 years and a 5-year follow-up. Falls with medical consequences were reported by the treating physician of participants. We assessed the association between time-updated systolic blood pressure and the risk of falling over a follow-up period of five years using generalized linear mixed effects models with a binomial distribution and a logit link function. Subgroup analyses were performed to examine the role of antihypertensive treatment and the difference between participant with and without cardiovascular disease.

RESULTS

We analysed data from 544 oldest-old adults, 242 (44.4%) of which used antihypertensives. In 81 individuals (15%) ≥1 fall(s) were reported during the follow-up period. The odds for a fall decreased by a factor of 0.86 (95% CI 0.80 to 0.93) for each increase in blood pressure by 10 mmHg. This effect was specific to blood pressure values above 130mmHg. We did not find any evidence that the effect would be modified by antihypertensive treatment, but that there was a tendency that it would be weaker in participants with cardiovascular disease (OR 0.81, 95% CI 0.72 to 0.90 per 10mmHg) compared to those without cardiovascular disease (OR 0.94, 95% CI 0.84 to 1.05 per 10mmHg).

CONCLUSION

Our results point towards a possible benefit of higher blood pressure in the oldest-old with respect to falls independent of the use of antihypertensive treatments.

Taoist way of a balanced exercise training cocktail for the management of primary hypertension in older persons

High blood pressure is the world's leading risk factor for mortality, affecting nearly half of the global population aged 50-79 years. Physical inactivity is one factor contributing to the prevalence of hypertension. This paper discusses a new concept for the management of hypertension in older persons. We are inclined to fade the current guidelines used in China, the United States, and Europe. Although demonstrating irrefutable benefits for blood pressure regulation, the guidelines fail to address the need to incorporate balance exercises, which are crucial for mitigating the risk of falling. We address three pressing questions regarding the efficacy of various combinations of exercise modes for blood pressure regulation, alongside providing an overview of balance exercises. At the core of our concept, we explicate the challenges inherent in addressing the global pandemic of physical inactivity and hypertension in regular socioeconomic people. No guidelines could change the state of inactivity by jumping between zero and all things, where "zero" symbolizes conditions such as physical inactivity and hypertension, and the concept of "all things" encompasses the ideals of an active lifestyle and healthy aging. We advocate a Taoist way, "zero-one-all things," where "one" in this context refers to an inclusive and culturally diverse exercise training cocktail. The Tao guides us to illuminate an ancient way of overcoming physical inactivity-associated diseases in the present day.

Evaluating the use of methods to mitigate bias from non-transient medications in the case-crossover design: A systematic review

PURPOSE

The case-crossover design is a self-controlled study design used to compare exposure immediately preceding an event occurrence with exposure in earlier control periods. The design is most suitable for transient exposures in order to avoid biases that can be problematic when using the case-crossover design for non-transient (i.e., chronic) exposures. Our goal was to conduct a systematic review of case-crossover studies and its variants (case-time-control and case-case-time-control) in order to compare design and analysis choices by medication type.

METHODS

We conducted a systematic search to identify recent case-crossover, case-time-control, and case-case-time-control studies focused on medication exposures. Articles indexed in MEDLINE and EMBASE using these study designs that were published between January 2015 and December 2021 in the English language were identified. Reviews, methodological studies, commentaries, articles without medications as the exposure of interest, and articles with no available full text were excluded. Study characteristics including study design, outcome, risk window, control window, reporting of discordant pairs, and inclusion of sensitivity analyses were summarized overall and by medication type. We further evaluated the implementation of recommended methods to account for biases introduced by non-transient exposures among articles that used the case-crossover design on a non-transient exposure.

RESULTS

Of the 2036 articles initially identified, 114 articles were included. The case-crossover was the most common study design (88%), followed by the case-time-control (17%), and case-case-time-control (3%). Fifty-three percent of the articles included only transient medications, 35% included only non-transient medications, and 12% included both. Across years, the proportion of case-crossover articles evaluating a non-transient medication ranged from 30% in 2018 to 69% in 2017. We found that 41% of the articles that evaluated a non-transient medication did not apply any of the recommended methods to account for biases and more than half of which were conducted by authors with no previous publication history of case-crossover studies.

CONCLUSION

Using the case-crossover design to evaluate a non-transient medication remains common in pharmacoepidemiology. Researchers should apply appropriate design and analysis choices when opting to use a case-crossover design with non-transient medication exposures.

Risk of adverse events following the initiation of antihypertensives in older people with complex health needs: a self-controlled case series in the United Kingdom

BACKGROUND

We assessed the risk of adverse events-severe acute kidney injury (AKI), falls and fractures-associated with use of antihypertensives in older patients with complex health needs (CHN).

SETTING

UK primary care linked to inpatient and mortality records.

METHODS

The source population comprised patients aged >65, with ≥1 year of registration and unexposed to antihypertensives in the year before study start. We identified three cohorts of patients with CHN, namely, unplanned hospitalisations, frailty (electronic frailty index deficit count ≥3) and polypharmacy (prescription of ≥10 medicines). Patients in any of these cohorts were included in the CHN cohort. We conducted self-controlled case series for each cohort and outcome (AKI, falls, fractures). Incidence rate ratios (IRRs) were estimated by dividing event rates (i) during overall antihypertensive exposed patient-time over unexposed patient-time; and (ii) in the first 30 days after treatment initiation over unexposed patient-time.

RESULTS

Among 42,483 patients in the CHN cohort, 7,240, 5,164 and 450 individuals had falls, fractures or AKI, respectively. We observed an increased risk for AKI associated with exposure to antihypertensives across all cohorts (CHN: IRR 2.36 [95% CI: 1.68-3.31]). In the 30 days post-antihypertensive treatment initiation, a 35-50% increased risk for falls was found across all cohorts and increased fracture risk in the frailty cohort (IRR 1.38 [1.03-1.84]). No increased risk for falls/fractures was associated with continuation of antihypertensive treatment or overall use.

CONCLUSION

Treatment with antihypertensives in older patients was associated with increased risk of AKI and transiently elevated risk of falls in the 30 days after starting antihypertensive therapy.

Long-term Health Outcomes of New Persistent Opioid Use After Surgery Among Medicare Beneficiaries

OBJECTIVE

We examined long-term health outcomes associated with new persistent opioid use after surgery and hypothesized that patients with new persistent opioid use would have poorer overall health outcomes compared with those who did not develop new persistent opioid use after surgery.

BACKGROUND

New persistent opioid use is a common surgical complication. Long-term opioid use increases risk of mortality, fractures, and falls; however, less is known about health care utilization among older adults with new persistent opioid use after surgical care.

METHODS

We analyzed claims from a 20% national sample of Medicare beneficiaries ≥65 years undergoing surgery between January 1, 2009, and June 30, 2019. We estimated associations between new persistent use and subsequent health events between 6 and 12 months after surgery, including mortality, serious fall/fall-related injury, and respiratory or opioid/pain-related readmission/emergency department (ED) visits using a Cox proportional hazards model to estimate mortality and multivariable logistic regression for the remaining outcomes, adjusting for demographic/clinical characteristics. Our primary outcome was mortality within 6 to 12 months after surgery. Secondary outcomes included falls and readmissions or ED visits (respiratory, pain related/opioid related) within 6 to 12 months after surgery.

RESULTS

Of 229,898 patients, 6874 (3.0%) developed new persistent opioid use. Compared with patients who did not develop new persistent opioid use, patients with new persistent opioid use had a higher risk of mortality (hazard ratio 3.44, CI, 2.99-3.96), falls [adjusted odds ratio (aOR): 1.21, 95% CI, 1.05-1.39], and respiratory-related (aOR: 1.67, 95% CI, 1.49-1.86) or pain-related/opioid-related (aOR: 1.68, 95% CI, 1.55-1.82) readmissions/ED visits.

CONCLUSIONS

New persistent opioid use after surgery is associated with increased mortality and poorer health outcomes after surgery. Although the mechanisms that underlie this risk are not clear, persistent opioid use may also be a marker for greater morbidity requiring more care in the late postoperative period. Increased awareness of individuals at risk for new persistent use after surgery and close follow-up in the late postoperative period is critical to mitigate the harms associated with new persistent use.

The association of intensive blood pressure treatment and non-fatal cardiovascular or serious adverse events in older adults with mortality: mediation analysis in SPRINT

AIMS

Randomized clinical trials of hypertension treatment intensity evaluate the effects on incident major adverse cardiovascular events (MACEs) and serious adverse events (SAEs). Occurrences after a non-fatal index event have not been rigorously evaluated. The aim of this study was to evaluate the association of intensive (<120 mmHg) to standard (<140 mmHg) blood pressure (BP) treatment with mortality mediated through a non-fatal MACE or non-fatal SAE in 9361 participants in the Systolic Blood Pressure Intervention Trial.

METHODS AND RESULTS

Logistic regression and causal mediation modelling to obtain direct and mediated effects of intensive BP treatment. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cardiovascular (CVM) and non-CV mortality (non-CVM). The direct effect of intensive treatment was a lowering of ACM [odds ratio (OR) 0.75, 95% confidence interval (CI): 0.60-0.94]. The MACE-mediated effect substantially attenuated (OR 0.96, 95% CI: 0.92-0.99) ACM, while the SAE-mediated effect was associated with increased (OR 1.03, 95% CI: 1.01-1.05) ACM. Similar patterns were noted for intensive BP treatment on CVM and non-CVM. We also noted that SAE incidence was 3.9-fold higher than MACE incidence (13.7 vs. 3.5%), and there were a total of 365 (3.9%) ACM cases, with non-CVM being 2.6-fold higher than CVM [2.81% (263/9361) vs. 1.09% (102/9361)]. The SAE to MACE and non-CVM to CVM preponderance was found across all age groups, with the ≥80-year age group having the highest differences.

CONCLUSION

The current analytic techniques demonstrated that intensive BP treatment was associated with an attenuated mortality benefit when it was MACE-mediated and possibly harmful when it was SAE-mediated. Current cardiovascular trial reporting of treatment effects does not allow expansion of the lens to focus on important occurrences after the index event.

Medications influencing the risk of fall-related injuries in older adults: case-control and case-crossover design studies

BACKGROUND

Medications influencing the risk of fall-related injuries (FRIs) in older adults have been inconsistent in previous guidelines. This study employed case-control design to assess the association between FRIs and medications, and an additional case-crossover design was conducted to examine the consistency of the associations and the transient effects of the medications on FRIs.

METHODS

This study was conducted using a national claims database (2002-2015) in Korea. Older adults (≥ 65 years) who had their first FRI between 2007 and 2015 were matched with non-cases in 1:2 ratio. Drug exposure was examined for 60 days prior to the date of the first FRI (index date) in the case-control design. The hazard period (1-60 days) and two control periods (121-180 and 181-240 days prior to the index date) were investigated in the case-crossover design. The risk of FRIs with 32 medications was examined using conditional logistic regression after adjusting for other medications that were significant in the univariate analysis. In the case-crossover study, the same conditional model was applied.

RESULTS

In the case-control design, the five medications associated with the highest risk of FRIs were muscle relaxants (adjusted odd ratio(AOR) = 1.35, 95% confidence interval (CI) = 1.31-1.39), anti-Parkinson agents (AOR = 1.30, 95%CI = 1.19-1.40), opioids (AOR = 1.23, 95%CI = 1.19-1.27), antiepileptics (AOR = 1.19, 95%CI = 1.12-1.26), and antipsychotics (AOR = 1.16, 95%CI = 1.06-1.27). In the case-crossover design, the five medications associated with the highest risk of FRIs were angiotensin II antagonists (AOR = 1.87, 95%CI = 1.77-1.97), antipsychotics (AOR = 1.63, 95%CI = 1.42-1.83), anti-Parkinson agents (AOR = 1.58, 95%CI = 1.32-1.85), muscle relaxants (AOR = 1.42, 95%CI = 1.35-1.48), and opioids (AOR = 1.35, 95%CI = 1.30-1.39).

CONCLUSIONS

Anti-Parkinson agents, opioids, antiepileptics, antipsychotics, antidepressants, hypnotics and sedatives, anxiolytics, muscle relaxants, and NSAIDs/antirheumatic agents increased the risk of FRIs in both designs among older adults. Medications with a significant risk only in the case-crossover analysis, such as antithrombotic agents, calcium channel blockers, angiotensin II antagonists, lipid modifying agents, and benign prostatic hypertrophy agents, may have transient effects on FRIs at the time of initiation. Corticosteroids, which were only associated with risk of FRIs in the case-control analysis, had more of cumulative than transient effects on FRIs.

Discontinuation of Renin-Angiotensin System Inhibitors During the Early Stage of the COVID-19 Pandemic

BACKGROUND

In March and April 2020, medical societies published statements recommending continued use of renin-angiotensin system (RAS) inhibitors despite theoretical concerns that these medications could increase COVID-19 severity. Determining if patients discontinued RAS inhibitors during the COVID-19 pandemic could inform responses to future public health emergencies.

METHODS

We analyzed claims data from US adults with health insurance in the Marketscan database. We identified patients who filled a RAS inhibitor and were persistent, defined by not having a ≥30-day gap without medication available, and high adherence, defined by having medication available on ≥80% of days, from March 2019 to February 2020. Among these patients, we estimated the proportion who discontinued their RAS inhibitor (i.e., had ≥30 consecutive days without a RAS inhibitor available to take) between March and August 2020. For comparison, we estimated the proportion of patients that discontinued a RAS inhibitor between March and August 2019 after being persistent with high adherence from March 2018 to February 2019.

RESULTS

Among 816,380 adults who were persistent and adherent to a RAS inhibitor from March 2019 to February 2020, 10.8% discontinued this medication between March and August 2020. Among 822,873 adults who were persistent and adherent to a RAS inhibitor from March 2018 to February 2019, 11.7% discontinued this medication between March and August 2019. The multivariable-adjusted relative risk for RAS inhibitor discontinuation in 2020 vs. 2019 was 0.94 (95% CI 0.93-0.95).

CONCLUSIONS

There was no evidence of an increase in RAS inhibitor discontinuation during the early stage of the COVID-19 pandemic.

Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization

AIMS

To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established.

METHODS AND RESULTS

We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3.

CONCLUSIONS

Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.

Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021

Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.

Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication

BACKGROUND

Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported.

METHODS

Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls.

RESULTS

Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers.

CONCLUSIONS

Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.

Treatment of Hypertension Among Non-Cardiac Hospitalized Patients

PURPOSE OF REVIEW

This review provides a contemporary perspective and approach for the treatment of hypertension (HTN) among patients hospitalized for non-cardiac reasons.

RECENT FINDINGS

Elevated blood pressure (BP) is a common dilemma encountered by physicians, but guidelines are lacking to assist providers in managing hospitalized patients with elevated BP. Inpatient HTN is common, and management remains challenging given the paucity of data and misperceptions among training and practicing physicians. The outcomes associated with intensifying BP treatment during hospitalization can be harmful, with little to no long-term benefits. Data also suggests that medication intensification at discharge is not associated with improved outpatient BP control. Routine inpatient HTN control in the absence of end-organ damage has not shown to be helpful and may have deleterious effects. Since routine use of intravenous antihypertensives in hospitalized non-cardiac patients has been shown to prolong inpatient stay without benefits, their routine use should be avoided for inpatient HTN control. Future large-scale trials measuring clinical outcomes during prolonged follow-up may help to identify specific circumstances where inpatient HTN control may be beneficial.

Effects of Antihypertensive Deprescribing Strategies on Blood Pressure, Adverse Events, and Orthostatic Symptoms in Older Adults: Results From TONE

BACKGROUND

The Trial of Nonpharmacologic Interventions in the Elderly (TONE) demonstrated the efficacy of weight loss and sodium reduction to reduce hypertension medication use in older adults. However, the longer-term effects of drug withdrawal (DW) on blood pressure (BP), adverse events, and orthostatic symptoms were not reported.

METHODS

TONE enrolled adults, ages 60-80 years, receiving treatment with a single antihypertensive and systolic BP (SBP)/diastolic BP <145/<85 mm Hg. Participants were randomized to weight loss, sodium reduction, both, or neither (usual care) and followed up to 36 months; ~3 months postrandomization, the antihypertensive was withdrawn and only restored if needed for uncontrolled hypertension. BP and orthostatic symptoms (lightheadedness, feeling faint, imbalance) were assessed at randomization and throughout the study. Two physicians independently adjudicated adverse events, masked to intervention, classifying symptomatic (lightheadedness, dizziness, vertigo), or clinical events (fall, fracture, syncope).

RESULTS

Among the 975 participants (mean age 66 years, 48% women, 24% black), mean (±SD) BP was 128 ± 9/71 ± 7 mm Hg. Independent of assignment, DW increased SBP by 4.59 mm Hg (95% confidence interval [CI]: 3.89, 5.28) compared with baseline. There were 113 adverse events (84 symptomatic, 29 clinical), primarily during DW. Compared with usual care, combined weight loss and sodium reduction mitigated the effects of DW on BP (β = -4.33 mm Hg; 95% CI: -6.48, -2.17) and reduced orthostatic symptoms long term (odds ratio = 0.62; 95% CI: 0.41, 0.92), without affecting adverse events (hazard ratio = 1.81; 95% CI: 0.90, 3.65). In contrast, sodium reduction alone increased risk of adverse events (hazard ratio = 1.75; 95% CI: 1.04, 2.95), mainly during DW.

CONCLUSIONS

In older adults, antihypertensive DW may increase risk of symptomatic adverse events, highlighting the need for caution in withdrawing their antihypertensive medications.

CLINICAL TRIALS REGISTRATION

Trial Number NCT00000535.

Time to benefit for stroke reduction after blood pressure treatment in older adults: A meta-analysis

Background

Hypertension treatment in older adults can decrease mortality, cardiovascular events, including heart failure, cognitive impairment, and stroke risk, but may also lead to harms such as syncope and falls. Guidelines recommend targeting preventive interventions with immediate harms and delayed benefits to patients whose life expectancy exceeds the intervention's time to benefit (TTB). Our objective was to estimate a meta‐analyzed TTB for stroke prevention after initiation of more intensive hypertension treatment in adults aged ≥65 years.

Methods

Studies were identified from two Cochrane systematic reviews and a search of MEDLINE and Google Scholar for subsequent publications until August 31, 2021. We abstracted data from randomized controlled trials comparing standard (untreated, placebo, or less intensive treatment) to more intensive treatment groups in older adults (mean age ≥ 65 years). We fit Weibull survival curves and used a random‐effects model to estimate the pooled annual absolute risk reduction (ARR) between control and intervention groups. We applied Markov chain Monte Carlo methods to determine the time to ARR thresholds (0.002, 0.005, and 0.01) for a first stroke.

Results

Nine trials (n = 38,779) were identified. The mean age ranged from 66 to 84 years and study follow‐up times ranged from 2.0 to 5.8 years. We determined that 1.7 (95%CI: 1.0–2.9) years were required to prevent 1 stroke for 200 persons (ARR = 0.005) receiving more intensive hypertensive treatment. Heterogeneity was found across studies, with those focusing on tighter systolic blood pressure control (SBP < 150 mmHg) showing longer TTB. For example, in the SPRINT study (baseline SBP = 140 mmHg, achieved SBP = 121 mmHg), the TTB to avoid 1 stroke for 200 patients treated was 5.9 years (95%CI: 2.2–13.0).

Conclusions

More intensive hypertension treatment in 200 older adults prevents 1 stroke after 1.7 years. Given the heterogeneity across studies, the TTB estimates from individual studies may be more relevant for clinical decision‐making than our summary estimate.

See related Editorial by Mark A. Supiano in this issue.

Predictors of poor medication adherence of older people with hypertension

Aims

To explore the risk factors for poor medication adherence in older people with hypertension.

Design

A cross‐sectional study.

Methods

Participants were administered with a self‐report questionnaire about their demographic characteristics; additionally, their four‐item Morisky Medication Adherence Scale scores were calculated. The STROBE checklist was applied as the reporting guideline for this study (File S1).

Results

Univariate analysis indicated that the following five factors were statistically significantly associated with medication adherence: education level (χ² = 8.073, p = .045), co‐living (χ² = 11.364, p = .010), hypertension complications (χ² = 10.968, p = .001), admission blood pressure (χ² = 8.876, p = .003), and falls (χ² = 6.703, p = .010). Multivariable binary logistic regression analysis showed that there were four statistically significant predictors, such as people who lived with spouses and offspring (OR = 3.004, p = .017), and those who had high admission blood pressure (OR = 1.910, p = .003) had a greater risk of poor medication adherence, whereas those without hypertension complications (OR = 0.591, p = .026) and those without falls (OR = 0.530, p = .046) had a lower risk.

Relevance to clinical practice

We believe that these findings contribute to the identification of high‐risk people with poor adherence, allowing nurses to identify people with poor adherence in a timely manner, and pay attention to the people's medication.

The association between blood pressure variability and hip or vertebral fracture risk: A population-based study

BACKGROUND

The present study evaluated the association between blood pressure variability and the risk of hip/vertebral fractures in middle aged and elderly patients.

METHODS

This was a retrospective observational study of patients attending family medicine outpatient clinics, recruited from 1st January 2000 to 31st December 2003 and were followed up until 31st December 2019. Standard deviation (SD), root mean square (RMS), coefficient of variation (CV) and a variability score (defined as the number of changes in blood pressure (diastolic and systolic) of 5 mm Hg or more) were used as measures of blood pressure variability. The primary outcome was a composite of new onset hip or vertebral fractures.

RESULTS

A total of 57,810 patients were included. Over a median follow-up of 5894 days (interquartile range: 3505-6487), 3285 patients (5.68%) developed new onset hip/vertebral fractures. The crude incidence rates were 4.95%, 5.31%, and 7.2% for diastolic blood pressure-CV and 5.0%, 5.28%, and 7.08% for systolic blood pressure-CV in the first, second, and third tertiles, respectively. Survival analysis demonstrated differences in hip/vertebral fracture amongst the tertiles of systolic and diastolic blood pressure variability (P < 0.0001).

CONCLUSIONS

Measures of blood pressure variability were significantly associated with incident hip/vertebral fractures. They can be incorporated into existing clinical scores to improve risk stratification.

Older Adults with Hypertension: Prevalence of Falls and Their Associated Factors

Falls are prominent health issues among older adults. Among hypertensive older adults, falls may have a detrimental effect on their health and wellbeing. The purpose of this study is to determine the prevalence of falls among hypertensive older adults and to identify the associated factors that contribute to their falls. This was a cross-sectional study conducted among two hundred and sixty-nine hypertensive older adults who were selected via systematic random sampling in two primary health clinics in Kuala Terengganu, Malaysia. Data on their socio-demographic details, their history of falls, medication history and clinical characteristics were collected. Balance and gait were assessed using the Performance Oriented Mobility Assessment (POMA). It was found that 32.2% of participants reported falls within a year. Polypharmacy (adjusted OR 2.513, 95% CI 1.339, 4.718) and diuretics (adjusted OR 2.803, 95% CI 1.418, 5.544) were associated with an increased risk of falls. Meanwhile, a higher POMA score (adjusted OR 0.940, 95% CI 0.886, 0.996) and the number of antihypertensives (adjusted OR 0.473, 95% CI 0.319, 0.700) were associated with a low incidence of falling among hypertensive older adults. Falls are common among hypertensive older adults. Older adults who are taking diuretics and have a polypharmacy treatment plan have a higher incidence of falls. However, older adults taking a higher number of anti-hypertensive medications specifically were not associated with an increased prevalence of falls.

Research on Beers Criteria and STOPP/START Criteria based on the FDA FAERS database

PURPOSE

Inappropriate medication criteria for the elderly have played an important role in ensuring the safety of medications for the elderly. Too few drugs included in the criteria cannot guarantee the safety of medication for the elderly. Too many drugs included in the criteria will result in less selective medication for the elderly. This paper uses real-world data to evaluate the relationship between antihypertensive drugs and falls, so as to provide references for experts and scholars to revise the criteria of potentially inappropriate medications for the elderly and clinical safe medication.

METHOD

We use the US Food and Drug Administration Adverse Event Reporting System (FDA FAERS) to evaluate the association between specific antihypertensive drugs in six categories (alpha-1 receptor blockers (α-1 blockers), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-receptor blockers (β-blockers), and diuretics) and falls by data mining algorithms, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), Medicines and Healthcare Products Regulatory Agency (MHRA), and the empirical Bayes geometric mean (EBGM) and compared with the relevant drugs included in the Beers Criteria and STOPP/START Criteria.

RESULT

There are a total of 5,157,172 co-occurrences found in 973,447 reports aged 65 years or older from 2016 to 2019 in the FDA FAERS database, and the number of co-occurrences of falls is 5917 for the six categories of 51 antihypertensive drugs. Four kinds of mining methods overlap detection of 12 kinds of positive signal drugs, none of which are not included in the Beers Criteria and 7 drugs are included in the STOPP/START Criteria; 1-3 kinds of mining methods overlap detection of positive signal drugs, a total of 12 kinds, and one drug is included in the Beers Criteria and 5 drugs are included in the STOPP/START Criteria; 22 drugs have fall adverse events, but no positive signal is detected, and 13 drugs are included in STOPP/START Criteria; and 5 drugs have no fall adverse events and 3 drugs are included in the STOPP/START Criteria.

CONCLUSION

The FAERS database was used to confirm the potential connection between some antihypertensive drugs and fall adverse events through data mining algorithms. The Beers Criteria did not clearly indicate the antihypertensive drugs that caused falls, and the antihypertensive drugs included in the STOPP/START Criteria were too extensive and did not include β-blockers and diuretics. It is recommended that experts and scholars use real-world data (such as FAERS, EudraVigilance, WHO VigiBase, and so on) to further explore the relationship between specific antihypertensive drugs and falls in the elderly, so as to revise and improve the criteria for inappropriate medications for the elderly.

Sub-acute hyponatraemia more than chronic hyponatraemia is associated with serious falls and hip fractures

BACKGROUND

Falls and hip fractures among older people are associated with high morbidity and mortality. Hyponatraemia may be a risk for falls/hip fractures, but the effect of hyponatraemia duration is not well understood.

AIMS

To evaluate individuals with periods of sub-acute and chronic hyponatraemia on subsequent risk for serious falls and/or hip fractures.

METHODS

Retrospective cohort study in the period 1 January 1998 to 14 June 2016 within an integrated health system of individuals aged ≥55 years with ≥2 outpatient serum sodium measurements. Hyponatraemia was defined as sodium <135 mEq/L with sub-acute (<30 days) and chronic (≥30 days) analysed as a time-dependent exposure. Multivariable Cox proportional-hazards modelling was used to estimate hazard ratios (HR) for serious falls/hip fractures based on sodium category.

RESULTS

Among 1 062 647 individuals totalling 9 762 305 sodium measurements, 96 096 serious falls/hip fracture events occurred. Incidence (per-1000-person-years) of serious falls/hip fractures were 11.5, 27.9 and 19.8 for normonatraemia, sub-acute and chronic hyponatraemia. Any hyponatraemia duration compared to normonatraemia had a serious falls/hip fractures HR (95%CI) of 1.18 (1.15, 1.22), with sub-acute and chronic hyponatraemia having HR of 1.38 (1.33, 1.42) and 0.91 (0.87, 0.95), respectively. Examined separately, the serious falls HR was 1.37 (1.32, 1.42) and 0.92 (0.88, 0.96) in sub-acute and chronic hyponatraemia, respectively. Hip fracture HR were 1.52 (1.42, 1.62) and 1.00 (0.92, 1.08) for sub-acute and chronic hyponatraemia, respectively, compared to normonatraemia.

CONCLUSIONS

Our findings suggest that early/sub-acute hyponatraemia appears more vulnerable and associated with serious falls/hip fractures. Whether hyponatraemia is a marker of frailty or a modifiable risk factor for falls remains to be determined.

Blood Pressure Control Among Older Adults With Hypertension: Narrative Review and Introduction of a Framework for Improving Care

Although antihypertensive medications are effective, inexpensive, and recommended by clinical practice guidelines, a large percentage of older adults with hypertension have uncontrolled blood pressure (BP). Improving BP control in this population may require a better understanding of the specific challenges to BP control at older age. In this narrative review, we propose a framework for considering how key steps in BP management occur in the context of aging characterized by heterogeneity in function, multiple co-occurring health conditions, and complex personal and environmental factors. We review existing literature related to 4 necessary steps in hypertension control. These steps include the BP measure which can be affected by the technique, device, and setting in which BP is measured. Ensuring proper technique can be challenging in routine care. The plan includes setting BP treatment goals. Lower BP goals may be appropriate for many older adults. However, plans must take into account the generalizability of existing evidence, as well as patient and family's health goals. Treatment includes the management strategy, the expected benefits, and potential risks of treatment. Treatment intensification is commonly needed and can contribute to polypharmacy in older adults. Lastly, monitor refers to the need for ongoing follow-up to support a patient's ability to sustain BP control over time. Sustained BP control has been shown to be associated with a lower rate of cardiovascular disease and multimorbidity progression. Implementation of current guidelines in populations of older adults may be improved when specific challenges to BP measurement, planning, treating, and monitoring are addressed.

Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis

BACKGROUND

Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH).

PURPOSE

To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions.

STUDY SELECTION

Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing.

DATA EXTRACTION

2 investigators independently abstracted articles and rated risk of bias.

DATA SYNTHESIS

5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged.

LIMITATIONS

Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available.

CONCLUSION

Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).

Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older Adults

BACKGROUND

Despite increasing numbers of older adults undergoing surgery and the known risks of opioids, little is known about the potential association between opioid prescribing and serious falls and fall-related injuries after surgery.

OBJECTIVE

To determine the incidence and risk factors of serious falls and fall-related injuries after elective, outpatient surgery.

DESIGN

Retrospective cohort study of 20% national sample of Medicare claims among beneficiaries ≥ 65 years of age with Medicare Part D claims and who underwent elective outpatient surgery from January 1, 2009, through December 31, 2014.

PARTICIPANTS

Opioid-naïve patients ≥ 65 years undergoing elective, minor, outpatient surgical procedures. The exposure was opioid prescription fills in the perioperative period (i.e., 30 days before up until 3 days after surgery) converted to total oral morphine equivalents (OME) over a period 30 days prior to and 30 days after surgery.

MAIN MEASURES

Serious falls and fall-related injuries within 30 days after surgery, examined through Poisson regression analysis with reported fall and fall-related injury rates adjusted for potential confounders.

KEY RESULTS

Among 44,247 opioid-naïve surgical patients, 76.3% filled an opioid prescription in the perioperative period. Overall, 0.62% of patients suffered a serious fall or fall-related injury within 30 days after surgery. Risk factors for serious falls or fall-related injuries after surgery included older age (80-84 years: RR 1.64, 95% CI 1.12-2.40; 85 years and older: RR 1.81, 95% CI 1.25-2.86), female sex (RR 3.04, 95% CI 2.29-4.05), Medicaid eligibility (RR 1.63, 95% CI 1.17-2.26), and higher amounts of opioids filled following surgery (≥ 225 OME: RR 2.29, 95% CI 1.72-3.07).

CONCLUSIONS

Serious falls after elective, outpatient surgery are uncommon, but correlated with age, sex, Medicaid eligibility, and the amount of opioids filled in the perioperative period. Judicious prescribing of opioids after surgery is paramount and is an opportunity to improve the safety of surgical care among older individuals.

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

IMPORTANCE

Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.

OBJECTIVE

To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.

EXPOSURES

Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.

MAIN OUTCOMES AND MEASURES

The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.

RESULTS

The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).

CONCLUSIONS AND RELEVANCE

Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Subclinical Cardiovascular Disease and Fall Risk in Older Adults: Results From the Atherosclerosis Risk in Communities Study

BACKGROUND/OBJECTIVES

Falls are frequent and often devastating events among older adults. Cardiovascular disease (CVD) is associated with greater fall risk; however, it is unknown if pathways that contribute to CVD, such as subclinical myocardial damage or wall strain, are related to future falls. We hypothesized that elevations in high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), measured in older adults, would be associated with greater fall risk.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Atherosclerosis Risk in Communities Study participants without known coronary heart disease, heart failure, or stroke.

MEASUREMENTS

We measured hs-cTnT or NT-proBNP in 2011 to 2013. Falls were identified from hospital discharge International Classification of Diseases, Ninth Revision (ICD-9), codes or Centers for Medicare and Medicaid Services claims. We used Poisson models adjusted for age, sex, and race/study center to quantify fall rates across approximate quartiles of hs-cTnT (less than 8, 8-10, 11-16, and 17 or greater ng/L) and NT-proBNP (less than 75, 75-124, 125-274, and 275 or greater pg/mL). We used Cox models to determine the association of cardiac markers with fall risk, adjusted for age, sex, race/center, and multiple fall risk factors.

RESULTS

Among 3973 participants (mean age = 76 ± 5 years, 62% women, 22% black), 457 had a subsequent fall during a median follow-up of 4.5 years. Incidence rates across quartiles of hs-cTnT and NT-proBNP were 17.1, 20.0, 26.2, and 36.4 per 1000 person-years and 12.8, 22.2, 28.7, and 48.4 per 1000 person-years, respectively. Comparing highest vs lowest quartiles of either hs-cTnT or NT-proBNP demonstrated a greater than two-fold higher fall risk, with hazard ratios of 2.17 (95% confidence interval {CI} = 1.60-2.95) and 2.34 (95% CI = 1.73-3.16), respectively. In a joint model, the relationships of hs-cTnT and NT-proBNP with falls were significant and independent.

CONCLUSION

Subclinical elevations of cardiac damage and wall strain were each associated with a higher fall risk in older adults. Further research is needed to determine whether interventions that lower hs-cTnT or NT-proBNP also lower fall risk. J Am Geriatr Soc 67:1795-1802, 2019.

Serious Fall Injury History and Adverse Health Outcomes After Initiating Hemodialysis Among Older U.S. Adults

Background

Although older adults with predialysis chronic kidney disease are at higher risk for falls, the prognostic significance of a serious fall injury prior to dialysis initiation has not been well described in the end-stage renal disease population.

Methods

We examined the association between a serious fall injury in the year prior to starting hemodialysis and adverse health outcomes in the year following dialysis initiation using a retrospective cohort study of U.S. Medicare beneficiaries ≥ 67 years old who initiated dialysis in 2010-2012. Serious fall injuries were defined using diagnostic codes for falls plus an injury (fracture, joint dislocation, or head injury). Health outcomes, defined as time-to-event variables within the first year of dialysis, included four outcomes: a subsequent serious fall injury, hospital admission, post-acute skilled nursing facility (SNF) utilization, and mortality.

Results

Among this cohort of 81,653 initiating hemodialysis, 2,958 (3.6%) patients had a serious fall injury in the year prior to hemodialysis initiation. In the first year of dialysis, 7.6% had a subsequent serious fall injury, 67.6% a hospitalization, 30.7% a SNF claim, and 26.1% died. Those with versus without a serious fall injury in the year prior to hemodialysis initiation were at higher risk (hazard ratio, 95% confidence interval) for a subsequent serious fall injury (2.65, 2.41-2.91), hospitalization (1.11, 1.06-1.16), SNF claim (1.40, 1.30-1.50), and death (1.14, 1.06-1.22).

Conclusions

For older adults initiating dialysis, a history of a serious fall injury may provide prognostic information to support decision making and establish expectations for life after dialysis initiation.

Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 1

Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and facilitate the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for internists and subspecialty cardiologists not otherwise focused on cardiovascular prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to both primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist, with particular focus on recent society guideline updates. In Part 1 we highlight developments in cardiovascular risk assessment tools, summarize important recent aspirin trials, discuss prevention considerations in atrial fibrillation, and review guidelines for blood pressure categorization, goals, and therapy.

Blood Pressure Lowering With Nilvadipine in Patients With Mild-to-Moderate Alzheimer Disease Does Not Increase the Prevalence of Orthostatic Hypotension

Background Hypertension is common among patients with Alzheimer disease. Because this group has been excluded from hypertension trials, evidence regarding safety of treatment is lacking. This secondary analysis of a randomized controlled trial assessed whether antihypertensive treatment increases the prevalence of orthostatic hypotension (OH) in patients with Alzheimer disease. Methods and Results Four hundred seventy-seven patients with mild-to-moderate Alzheimer disease were randomized to the calcium-channel blocker nilvadipine 8 mg/day or placebo for 78 weeks. Presence of OH (blood pressure drop ≥20/≥10 mm Hg after 1 minute of standing) and OH-related adverse events (dizziness, syncope, falls, and fractures) was determined at 7 follow-up visits. Mean age of the study population was 72.2±8.2 years and mean Mini-Mental State Examination score was 20.4±3.8. Baseline blood pressure was 137.8±14.0/77.0±8.6 mm Hg. Grade I hypertension was present in 53.4% (n=255). After 13 weeks, blood pressure had fallen by -7.8/-3.9 mm Hg for nilvadipine and by -0.4/-0.8 mm Hg for placebo ( P<0.001). Across the 78-week intervention period, there was no difference between groups in the proportion of patients with OH at a study visit (odds ratio [95% CI]=1.1 [0.8-1.5], P=0.62), nor in the proportion of visits where a patient met criteria for OH, corrected for number of visits (7.7±13.8% versus 7.3±11.6%). OH-related adverse events were not more often reported in the intervention group compared with placebo. Results were similar for those with baseline hypertension. Conclusions This study suggests that initiation of a low dose of antihypertensive treatment does not significantly increase the risk of OH in patients with mild-to-moderate Alzheimer disease. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02017340.

The new US and European guidelines in hypertension: A multi-dimensional analysis

The Systolic Blood Pressure Intervention Trial (SPRINT) compared the clinical outcomes between target systolic blood pressure (SBP) levels between 140 and 120 mmHg or lower. Both,the 2017 ACC/AHA and the 2018 ESC/ESH guidelines in hypertension are derived from the SPRINT trial and advise initiation and/or intensification of treatment at lower blood pressure thresholds. The ACC/AHA guidance supersedes the 2014 Eight Joint National Committee guideline (JNC-8) which advised initiation of treatment when the BP was 140/90 mmHg or higher; in adults 60 years or over, the target was 150/90 mmHg. Compared to JNC-8, the new guidelines lower the SBP target by 10 mmHg in patients under age of 60 years, and by 20 mmHg in the elderly. We performed a qualitative multi-dimensional analysis in order to answer two key questions: will the new guidelines deliver the stated benefits? and, will translation to the clinic be simple, risk-free, and affordable? A major investment by national healthcare administrations will be necessary for the initiation and support of this program but this decision can only be justified by a valid expectation of clinical benefit. At this time, a definitive answer is not available and a "wait and see" attitude appears appropriate and reasonable. In the interim, efforts are best directed to the immediate problem of untreated hypertension worldwide.

Association between gaps in antihypertensive medication adherence and injurious falls in older community-dwelling adults: a prospective cohort study

OBJECTIVE

Growing evidence suggests that older adults are at an increased risk of injurious falls when initiating antihypertensive medication, while the evidence regarding long-term use of antihypertensive medication and the risk of falling is mixed. However, long-term users who stop and start these medications may have a similar risk of falling to initial users of antihypertensive medication. Our aim was to evaluate the association between gaps in antihypertensive medication adherence and injurious falls in older (≥65 years) community-dwelling, long-term (≥≥1 year) antihypertensive users.

DESIGN

Prospective cohort study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

Consecutive participants presenting a prescription for antihypertensive medication to 106 community pharmacies nationwide, community-dwelling, ≥65 years, with no evidence of cognitive impairment, taking antihypertensive medication for ≥1 year (n=938).

MEASURES

Gaps in antihypertensive medication adherence were evaluated from linked dispensing records as the number of 5-day gaps between sequential supplies over the 12-month period prior to baseline. Injurious falls during follow-up were recorded via questionnaire during structured telephone interviews at 12 months.

RESULTS

At 12 months, 8.1% (n=76) of participants reported an injurious fall requiring medical attention. The mean number of 5-day gaps in medication refill behaviour was 1.47 (SD 1.58). In adjusted, modified Poisson models, 5-day medication refill gaps at baseline were associated with a higher risk of an injurious fall during follow-up (aRR 1.18, 95% CI 1.02 to 1.37, p=0.024).

CONCLUSION

Each 5-day gap in antihypertensive refill adherence increased the risk of self-reported injurious falls by 18%. Gaps in antihypertensive adherence may be a marker for increased risk of injurious falls. It is unknown whether adherence-interventions will reduce subsequent risk. This finding is hypothesis generating and should be replicated in similar populations.

Hypertension Treatment and Control and Risk of Falls in Older Women

BACKGROUND/OBJECTIVES

A lower risk of falls is commonly cited as a reason to treat hypertension conservatively in older individuals. We examined the effect of hypertension treatment and control status and measured blood pressure (BP) level on the risk of falls in older women.

DESIGN/SETTING

Prospective cohort study.

PARTICIPANTS

A total of 5971 women (mean age 79 years; 50.4% white, 33.1% black, 16.5% Hispanic/Latina) enrolled in the Women's Health Initiative and Objective Physical Activity and Cardiovascular Health study.

MEASUREMENTS

BP was measured by trained nurses, and hypertension treatment was assessed by medication inventory. Participants mailed in monthly calendars to self-report falls for 1 year.

RESULTS

Overall, 70% of women had hypertension at baseline (53% treated and controlled, 12% treated and uncontrolled, 5% untreated). There were 2582 women (43%) who reported falls in the 1 year of surveillance. Compared with nonhypertensive women, when adjusted for fall risk factors and lower limb physical function, the incidence rate ratio (IRR) for falls was 0.82 (confidence interval [CI] = 0.74-0.92) in women with treated controlled hypertension (p = .0008) and 0.73 (CI = 0.62-0.87) in women with treated uncontrolled hypertension (p = .0004). Neither measured systolic nor diastolic BP was associated with falls in the overall cohort. In women treated with antihypertensive medication, higher diastolic BP was associated with a lower risk of falls in a model adjusted for fall risk factors (IRR = 0.993 per mm Hg; 95% CI = 0.987-1.000; p = .04). The only class of antihypertensive medication associated with an increased risk of falls compared with all other types of antihypertensive drugs was β-blockers.

CONCLUSION

Women in this long-term research study with treated hypertension had a lower risk of falls compared with nonhypertensive women. Diastolic BP (but not systolic BP) is weakly associated with fall risk in women on antihypertensive treatment (<1% decrease in risk per mm Hg increase). J Am Geriatr Soc, 2019. J Am Geriatr Soc 67:726-733, 2019.

Impact of prescription drugs on second fragility fractures among US Medicare patients

Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture.

INTRODUCTION

Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures.

METHODS

We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture.

RESULTS

Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics).

CONCLUSION

Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.

Individual and Joint Effects of Pulse Pressure and Blood Pressure Treatment Intensity on Serious Adverse Events in the SPRINT Trial

PURPOSE

The objective of this study was to determine individual and joint effects of pulse pressure and blood pressure treatment intensity on serious adverse events in the Systolic Blood Pressure Intervention Trial.

METHODS

Pulse pressure was calculated by subtracting diastolic blood pressure from systolic blood pressure. Blood pressure treatment intensity goal was ≤140mm Hg in the control arm and ≤120mm Hg in the intensive arm. The primary outcome was a 5-point composite of hypotension, syncope, electrolyte abnormalities, acute renal insufficiency, or injurious falls.

RESULTS

In 9361 trial participants, the incident rate for the primary outcome per 1000 person-years increased with higher pulse pressure category: ≤49 mmHg: 20.4 (17.2-24.1), 50-59 mmHg: 24.5 (21.3-28.2), 60-69 mmHg: 31.7 (27.7-36.2), ≥70 mmHg: 44.6 (39.8-49.9; P_trend < .0001; hazard ratio [HR] of pulse pressure [every 10mm Hg] 1.23; 95% confidence interval [CI], 1.18-1.28). The intensive treatment arm had a higher incidence rate of serious adverse events than the control arm (34.2, 95% CI, 31.2-37.3, vs 26.0, 95% CI, 23.4-28.8, P = .0001; HR 1.32; 95% CI, 1.15-1.51). The combined effect was not significant in the relative risk scale (HR 0.97, P_interaction = .48) but was significant in the risk difference scale (P = .027), contributing 2.5 additional serious adverse events per 1000 person-years for every 10mm Hg increase in pulse pressure in excess of the individual effects of pulse pressure and treatment intensity.

CONCLUSIONS

Wider pulse pressure and intensive blood pressure treatment were individually associated with the composite adverse event outcome. A modest effect modification of pulse pressure and treatment intensity led to additional adverse events when both were present. Clinicians should use caution when treating older patients with elevated pulse pressure to an intensive blood pressure treatment target.

Low Systolic Blood Pressure From Treatment and Association With Serious Falls/Syncope

INTRODUCTION

With the growing emphasis on intensive blood pressure control, the potential for overtreatment and treatment-related adverse outcomes has become an area of interest. A large representative population within a real-world clinical environment with successful hypertension control rates was used to evaluate serious falls and syncope in people with low-treated systolic blood pressure (SBP).

METHODS

A cross-sectional study among medically treated hypertensive individuals within the Kaiser Permanente Southern California health system (2014-2015) was performed. Serious fall injuries and syncope were identified using ICD codes based on emergency department and hospitalization diagnoses. SBPs in a 1-year window were used to compare serious falls and syncope among individuals with SBP <110 mmHg vs ≥110 mmHg. Logistic regression was used to evaluate the association between low minimum and mean SBP and serious falls/syncope after adjustment for demographics, comorbidities, and medications.

RESULTS

In 477,516 treated hypertensive individuals, the mean age was 65 (SD=13) years and the mean SBP was 129 (SD=10) mmHg, with 27% having a minimum SBP <110 mmHg and 3% having mean SBP <110 mmHg. A total of 15,419 (3.2%) individuals experienced a serious fall or syncope or both during the observation window (5.7% among minimum SBP <110 mmHg and 5.4% among mean SBP <110 mmHg). The multivariable ORs for serious falls/syncope were 2.18 (95% CI=2.11, 2.25) for minimum SBP <110 mmHg and 1.54 (95%CI=1.43, 1.66) for mean SBP <110 mmHg compared with SBP ≥110 mmHg.

CONCLUSIONS

Among treated hypertensive patients, both minimum and mean SBP less than 110 mmHg were associated with serious falls and syncope. Low treatment-related blood pressures deserve consideration given the emphasis on intensive blood pressure control.

Dangers of Overly Aggressive Blood Pressure Control

PURPOSE OF REVIEW

Recent US guidelines have changed the definition of hypertension to ≥ 130/80 mmHg and recommended more intense blood pressure (BP) targets. We summarize the evidence for intense BP treatment and discuss risks that must be considered when choosing treatment goals for individual patients.

RECENT FINDINGS

The SPRINT study reported that treating to a systolic BP target of 120 mmHg reduces cardiovascular outcomes in high-risk individuals, supporting more intensive BP reduction than previously recommended. However, recent observational studies have placed emphasis on the BP J-curve phenomenon, where low BPs are associated with adverse cardiovascular outcomes, suggesting that overly aggressive BP targets may sometimes be harmful. We attempt to reconcile these apparent contradictions for the clinician. We also review other potential dangers of aggressive BP targets, including syncope, renal impairment, polypharmacy, drug interactions, subjective drug side-effects, and non-adherence. We suggest a personalized approach to BP drug management considering individual risks, benefits, and preferences when choosing therapeutic targets, recognizing that a goal of 130/80 mmHg should always be considered. Additionally, we recommend an intense focus on lifestyle changes and medication adherence.

Recent History of Serious Fall Injuries and Posttransplant Outcomes Among US Kidney Transplant Recipients

BACKGROUND

Serious fall injuries are associated with poor outcomes among dialysis patients, but whether these associations hold in patients with a history of serious fall injury before kidney transplantation is unknown.

METHODS

In national administrative data, 22 474 US adults receiving a first kidney transplant in 2011-2014 with at least 1 year of follow-up before transplant were identified. Serious fall injuries in the year before transplant were identified using diagnostic codes for falls and simultaneous fractures, dislocations, or head trauma in inpatient or outpatient claims. We used multivariable Cox proportional hazards models to estimate associations of incident posttransplant outcomes with serious fall injury in the year before transplant.

RESULTS

A total of 620 (2.8%) recipients had serious fall injuries before transplant and were more likely to be white, female, and have more comorbid conditions than those without a fall injury. Although posttransplant recipient survival did not differ by recent serious fall injuries (hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.78-1.36), these injuries were associated with 33% higher rates of graft failure (HR, 1.33; 95% CI, 1.03-1.72). Patients with serious fall injuries spent 12.1% of posttransplant follow-up hospitalized, a 3.3-fold higher rate than those without a fall, and had nearly 2-fold higher rates of skilled nursing facility utilization (HR, 1.98; 95% CI, 1.52-2.57).

CONCLUSIONS

Serious fall injuries are independently associated with significantly greater resource requirements and lower graft survival. Further study is needed to delineate the relationship between falls and adverse outcomes in transplant and reduce the incidence and deleterious effects of these events.

A Literature Review of Factors Influencing Injurious Falls

Falls pose substantial challenges to health care institutions. This review aims to provide a synthesis and critique of studies that investigated fall injury risk factors and to identify significant risk factors that predispose patients to injurious falls. A comprehensive literature search was conducted in PubMed, COCHRANE, Embase, Cumulative Index to Nursing and Allied Heath Literature, and Scopus. Additional records were searched through Google Scholar and bibliographies of the retrieved articles. Twenty-three primary research studies were included. Demographic, intrinsic, and extrinsic factors have been identified. Demographics include age, gender, and marital status. Intrinsic factors include body mass index, medication, and preexisting conditions, and extrinsic factors include environmental factors. Several factors were found to be inconclusive. These factors should be considered and examined further. Future research may evaluate interventions focusing on targeted risk factors of injurious falls. Clinical guidelines addressing the factors in this review may be considered after further testing and research.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study

Background

This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status.

Methods

Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant.

Results

The mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49–19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23–12.19; p = 0.02). Sensitivity analyses generated consistent findings.

Conclusion

Both ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0871-7) contains supplementary material, which is available to authorized users.

Ambulatory blood-pressure monitoring, antihypertensive therapy and the risk of fall injuries in elderly hypertensive patients

Background

Fall injuries are common among the elderly. The aim of this study was to investigate whether blood-pressure patterns, as measured by 24-h ambulatory blood pressure monitoring (ABPM), or intensification of antihypertensive therapy following the 24-h ABPM, may be associated with fall injuries in hypertensive elderly patients.

Methods

In a retrospective study, community-based elderly patients (age ≥ 70 years) who were referred to 24-h ABPM were evaluated for fall injuries within one-year post-ABPM. We compared the clinical characteristics, 24-h ABPM patterns and the intensification of hypertensive therapy following 24-h ABPM, between patients with and without a fall injury.

Results

Overall 1032 hypertensive elderly patients were evaluated. Fifty-five (5.3%) had a fall injury episode in the year following ABPM. Patients with a fall injury were significantly older, and with higher rates of previous falls. Lower 24-h diastolic blood-pressure (67.3 ± 7.6 vs. 70.7 ± 8.8 mmHg; P < 0.005) and increased pulse-pressure (74.7 ± 14.3 vs. 68.3 ± 13.7 mmHg; P < 0.005), were found in the patients with a fall injury, compared to those without a fall injury. After adjustment for age, gender, diabetes mellitus and previous falls, lower diastolic blood-pressure and increased pulse-pressure were independent predictors of fall injury. Intensification of antihypertensive treatment following the 24-h ABPM was not associated with an increased rate of fall injury.

Conclusions

Low diastolic blood-pressure and increased pulse-pressure in 24-h ABPM were associated with an increased risk of fall injury in elderly hypertensive patients. Intensification of antihypertensive treatment following 24-h ABPM was not associated with an increased risk of fall injury.

Association of Serious Fall Injuries among United States End Stage Kidney Disease Patients with Access to Kidney Transplantation

BACKGROUND AND OBJECTIVES

Serious fall injuries in the setting of ESKD may be associated with poor access to kidney transplant. We explored the burden of serious fall injuries among patients on dialysis and patients on the deceased donor waitlist and the associations of these fall injuries with waitlisting and transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our analytic cohorts for the outcomes of (1) waitlisting and (2) transplantation included United States adults ages 18-80 years old who (1) initiated dialysis (n=183,047) and (2) were waitlisted for the first time (n=37,752) in 2010-2013. Serious fall injuries were determined by diagnostic codes for falls plus injury (fracture, joint dislocation, or head trauma) in inpatient and emergency department claims; the first serious fall injury after cohort entry was included as a time-varying exposure. Follow-up ended at the specified outcome, death, or the last date of follow-up (September 30, 2014). We used multivariable Cox proportional hazards models to determine the independent associations between serious fall injury and waitlisting or transplantation.

RESULTS

Overall, 2-year cumulative incidence of serious fall injury was 6% among patients on incident dialysis; with adjustment, patients who had serious fall injuries were 61% less likely to be waitlisted than patients who did not (hazard ratio, 0.39; 95% confidence interval, 0.35 to 0.44). Among incident waitlisted patients (4% 2-year cumulative incidence), those with serious fall injuries were 29% less likely than their counterparts to be subsequently transplanted (hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80).

CONCLUSIONS

Serious fall injuries among United States patients on dialysis are associated with substantially lower likelihood of waitlisting for and receipt of a kidney transplant.

Association Between Chronic or Acute Use of Antihypertensive Class of Medications and Falls in Older Adults. A Systematic Review and Meta-Analysis

BACKGROUND

Evaluating effect of acute or chronic use of antihypertensives on risk of falls in older adults.

METHODS

Data sources: Systematic search of primary research articles in CINAHL, Cochrane, EBM, EMBASE, and MEDLINE databases from January 1 2007 to June 1 2017. Study selection: Research studies of cohort, case-control, case-crossover, cross-sectional, or randomized controlled trial (RCT) design examining association between antihypertensives and falls in people older than 60 years were evaluated. Data synthesis: Twenty-nine studies (N = 1,234,667 participants) were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). PRISMA and MOOSE guidelines were used for abstracting data and random-effects inverse-variance meta-analysis was conducted on 26 articles examining chronic antihypertensive use, with odds ratios (ORs) and hazards ratios (HRs) analyzed separately. Time-risk analysis was performed on 5 articles examining acute use of antihypertensives. Outcomes: Pooled ORs and HRs were calculated to determine the association between chronic antihypertensive use and falls. For time-risk analysis, OR was plotted with respect to number of days since antihypertensive commencement, change, or dose increase.

RESULTS

There was no significant association between risk of falling and chronic antihypertensive medication use (OR = 0.97, 95% confidence interval [CI] 0.93-1.01, I2 = 64.1%, P = 0.000; and HR = 0.96, 95% CI 0.92-1.00, I2 = 0.0%, P = 0.706). The time-risk analysis demonstrated a significantly elevated risk of falling 0-24 hours after antihypertensive initiation, change, or dose increase. When diuretics were used, the risk remained significantly elevated till day 21.

CONCLUSIONS

There is no significant association between chronic use of antihypertensives and falls in older adults. Risk of falls is highest on day zero for all antihypertensive medications.

The effect of perindopril on postural instability in older people with a history of falls-a randomised controlled trial

Angiotensin converting enzyme inhibitors may improve exercise capacity and muscle function in older people but are often thought to increase falls risk. We investigated the effect of perindopril on postural stability in older people with a history of falls.

Blood Pressure, Antihypertensive Polypharmacy, Frailty, and Risk for Serious Fall Injuries Among Older Treated Adults With Hypertension

Antihypertensive medication and low systolic blood pressure (BP) and diastolic BP have been associated with an increased falls risk in some studies. Many older adults have indicators of frailty, which may increase their risk for falls. We contrasted the association of systolic BP, diastolic BP, number of antihypertensive medication classes taken, and indicators of frailty with risk for serious fall injuries among 5236 REGARDS study (Reasons for Geographic and Racial Difference in Stroke) participants ≥65 years taking antihypertensive medication at baseline with Medicare fee-for-service coverage. Systolic BP and diastolic BP were measured, and antihypertensive medication classes being taken assessed through a pill bottle review during a study visit. Indicators of frailty included low body mass index, cognitive impairment, depressive symptoms, exhaustion, impaired mobility, and history of falls. Serious fall injuries were defined as fall-related fractures, brain injuries, or joint dislocations using Medicare claims through December 31, 2014. Over a median of 6.4 years, 802 (15.3%) participants had a serious fall injury. The multivariable-adjusted hazard ratio for a serious fall injury among participants with 1, 2, or ≥3 indicators of frailty versus no frailty indicators was 1.18 (95% confidence interval, 0.99-1.40), 1.49 (95% confidence interval, 1.19-1.87), and 2.04 (95% confidence interval, 1.56-2.67), respectively. Systolic BP, diastolic BP, and number of antihypertensive medication classes being taken at baseline were not associated with risk for serious fall injuries after multivariable adjustment. In conclusion, indicators of frailty, but not BP or number of antihypertensive medication classes, were associated with increased risk for serious fall injuries among older adults taking antihypertensive medication.

Serious Fall Injuries Before and After Initiation of Hemodialysis Among Older ESRD Patients in the United States: A Retrospective Cohort Study

BACKGROUND

Because initiation of dialysis therapy often occurs in the setting of acute illness and may signal worsening health and functional decline, we examined whether rates of serious fall injuries among older hemodialysis patients differ before and after dialysis therapy initiation.

STUDY DESIGN

Retrospective cohort study of claims data from the 2 years spanning dialysis therapy initiation among patients initiating dialysis therapy in 2010 to 2012.

SETTING & PARTICIPANTS

Claims from 81,653 Medicare end-stage renal disease beneficiaries aged 67 to 100 years.

PREDICTOR

Post- versus pre-dialysis therapy initiation periods, defined as on or after versus before dialysis therapy initiation.

OUTCOMES

Serious fall injuries were defined using diagnostic codes for falls in combination with fractures, brain injuries, or joint dislocation. Incidence rate ratios (overall and stratified) for post- versus pre-dialysis therapy initiation periods were estimated using generalized estimating equation models with a negative binomial link.

RESULTS

Overall, 12,757 serious fall injuries occurred in the pre- and post-dialysis therapy initiation periods. Annual rates of serious fall injuries were 64.4 (95% CI, 62.7-66.2) and 107.8 (95% CI, 105.4-110.3) per 1,000 patient-years, respectively, in the pre- and post-dialysis therapy initiation periods (incidence rate ratio, 1.62; 95% CI, 1.56-1.67). Relative rates of serious fall injuries in the post- vs pre-dialysis initiation periods were of greater magnitude among patients who were younger (<75 years), had pre-end-stage renal disease nephrology care, had albumin levels > 3g/dL, were able to walk and transfer, did not need assistance with activities of daily living, and were not institutionalized compared with relative rates among their counterparts.

LIMITATIONS

Potential misclassification due to the use of claims data and survival bias among those initiating hemodialysis therapy.

CONCLUSIONS

Among older Medicare beneficiaries receiving hemodialysis, serious fall injuries are common, the post-dialysis initiation period is a high-risk time for falls, and dialysis therapy initiation may be an important time to screen for fall risk factors and implement multifactorial fall prevention strategies.