Nursing home patients who take blood pressure drugs have a higher than normal risk of life-threatening bone fractures, which can then often trigger a downward health spiral, suggests a recent cohort study.
After analysing records from nearly 30 000 nursing home residents on BP medication, Rutgers Health research found they had more than double the risk of fractures, stemming from the drugs’ tendency to impair balance.
They said these patients are particularly vulnerable when they first stand up and temporarily experience low blood pressure, which deprives the brain of oxygen.
Interactions with other drugs and low baseline balance in many nursing home patients compound the problem, they wrote in their findings, which were published in JAMA Internal Medicine.
“Bone fractures often start nursing home patients on a downward spiral,” said Chintan Dave, academic director of the Rutgers Centre for Health Outcomes, Policy and Economics and lead author of the study.
“Roughly 40% of those who fracture a hip die within the next year, so it’s truly alarming to find that a class of medications used by 70% of all nursing home residents more than doubles the bone-fracture risk.”
While many patients have high enough blood pressure that the benefits of treatment outweigh these dangers, he added that such patients require careful observation, particularly when treatment begins, “and that’s not happening”.
“Caregivers think of BP medication as very low risk, and that’s not true in this patient population.”
Dave’s team analysed Veterans Health Administration data from 29 648 elderly patients in long-term care facilities from 2006 to 2019, comparing the 30-day risk of fractures to the hip, pelvis, humerus (upper arm) radius or ulna (forearm) for patients who began using blood pressure medications with similar patients who didn’t.
To maximise the chance that medication use – and not some other factor – drove the different outcomes, they adjusted for more than 50 baseline covariates, such as patient demographics and clinical history.
The 30-day fracture risk for residents who began BP medication was 5.4 per 100 people per year, and 2.2 per 100 people per year for patients who took no blood pressure drugs.
Further analysis showed drug usage predicted particularly elevated fracture risk in certain subgroups. Patients with dementia, systolic blood pressure above 139 (the first number in the blood pressure reading), diastolic blood pressure above 79 (the second number) or no recent use of blood pressure medication all experienced at least triple the fracture risk of un-medicated patients.
About 2.5m Americans live in nursing homes or assisted living facilities. Up to 50% fall in any given year, and up to 25% of those falls will result in serious injury.
The Rutgers Health study indicates that BP medication causes many of those falls and that a combination of less medication and better support could significantly reduce the problem.
“Caregivers can’t strike this right balance of risk and reward if they don’t have accurate data about the risks,” Dave said.
Study details
Antihypertensive medication and fracture risk in older veterans health administration nursing home residents
Chintan Dave, Yongmei Li, Michael Steinman, Michelle Odden et al.
Published in JAMA Internal Medicine on 15 May 2024.
Key Points
Question
Is initiating antihypertensive medication associated with increased fracture risk among older long-term Veterans Health Administration nursing home residents?
Findings
In a 1:4 propensity score–matched cohort of 64 710 residents, initiation of antihypertensive medication was associated with increased fracture risk and adjusted excess risk per 100 person-years. This risk was numerically higher in subgroups of residents with dementia or with systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 80 mm Hg or higher.
Meaning
Findings from this cohort study suggest that caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.
Abstract
Importance
Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents.
Objective
To assess the association between antihypertensive medication initiation and risk of fracture.
Design, Setting, and Participants
This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analysed from 1 December 2021 to 11 November 2023.
Exposure
Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.
Main Outcome and Measures
The primary outcome was non-traumatic 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, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.
Results
Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score–matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] 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 finding 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 hospitalisations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]).
Conclusions and Relevance
Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.
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