Starting antihypertensives increases fracture risk in older nursing home residents

Long-term care residents are a highly vulnerable population with substantial multimorbidity, polypharmacy and frailty. The majority of residents will experience a fall in any given year. More than a quarter of falls lead to a serious injury, and 10%–15% result in fractures, hospitalization or death.Hypertension is diagnosed in more than 70% of older adults and antihypertensives are the most frequently used medications in this age group. However, orthostatic hypotension is a frequent complication of antihypertensive use and the trigger for many falls. The greatest risk occurs in the period immediately after treatment initiation.Only limited evidence is available on the association between starting antihypertensive medication and the risk of fractures in older long-term nursing home residents. Most clinical trial and observational data have been derived from community-dwelling patients.To examine this issue, US researchers assessed the association between the initiation of antihypertensive medication and risk of fracture in older long-term care nursing home residents. The retrospective cohort study used data derived from older long-term care nursing home residents (97.7% male) in the Veterans Health Administration from 2006–2019. Then investigators identified episodes of antihypertensive medication initiation; these were matched with comparable controls who did not initiate therapy.The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, by blood pressure thresholds, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.Results showed the following:In the propensity score–matched cohort of 64,710 residents (mean age, 77.9 years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43–4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95–6.78).Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalization or an emergency department visit (HR, 1.80 [95% CI, 1.53–2.13]) and syncope (HR, 1.69 [95% CI, 1.30–2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76–6.10]), baseline systolic blood pressure ≥ 140 mmHg (HR, 3.12 [95% CI, 1.71–5.69]), baseline diastolic blood pressure ≥ 80 mmHg (HR, 4.41 [95% CI, 1.67–11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49–15.32]).The authors concluded that starting antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressure values, and no recent antihypertensive medication use. They advise caution and additional monitoring when initiating antihypertensive medication in older long-term care nursing home residents. The authors point out that their study predominantly involved male nursing home patients, which could limit the generalizability of their findings to other nursing home populations. Also, the study did not assess differences in the risk of fracture according to antihypertensive drug class.Reference:1. Dave CV, Li Y, Steinman MA, et al. Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. JAMA Intern Med 2024; published online April 22, 2024. (accessed April 23, 2024).

Starting antihypertensives increases fracture risk in older nursing home residents

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