First do no harm? Antihypertensives and fracture risk

Frank is 79 years old and has been in a care home for a couple of years. He is getting a little more forgetful, and is certainly a bit more unsteady on his legs, although hasn’t had a fall in the last year. The nursing team phone up as they are worried about his blood pressure, which is creeping up and is now 165/80. Should he have some medication to bring this down? 

This is a common scenario - a highish BP in a frail older adult. We know leaving the BP may lead to a higher cardiovascular risk over the coming few years, but we’re also concerned about the more immediate risk of giving him antihypertensives and causing him to fall and break something.

‘First do no harm’ is an important principle in medicine, but balancing potential benefits and harms is often tricky. Hypertension management in older frailer adults is a classic case in point. Where lies the greater harm? Not treating the hypertension and increasing CVD risk or treating the hypertension and risking hypotension, falls and a fracture? 

The fracture risk is the one that I’m sure we all worry about, especially in someone like Frank. A fall resulting in a fracture is a devastating episode, often life limiting, if not life ending. But are we right to worry about antihypertensives due to his risk of falls and fracture, or are we actually unnecessarily denying him treatment that will reduce his CVD risk? There is evidence of CVD benefits with antihypertensives for adults aged >80 if systolic >160 from the HYVETT study (although even that excluded people from nursing homes or with dementia), and there has been limited evidence to support or refute the concern over falls and fractures in frail older people, in large part due to the fact that most hypertension studies exclude this group. 

So this recently published study in JAMA (JAMA Intern Med. 2024;184(6):661-669) is an important one to help fill the evidence gap. It was a retrospective cohort study of almost 30,000 older long-term nursing home residents (heavily biased to men as it was a veterans cohort) which looked at exposure to antihypertensive medication and fracture risks. The primary outcome was fracture of pelvis, humerus, hip, radius or ulna within 30 days of antihypertensive initiation. 

There was more than double the risk in the group exposed to antihypertensives vs controls (HR 2.42, 95% CI = 1.43-4.08) which equates to an adjusted excess fracture risk of ~3 per 100 patient/years (i.e. an excess of 3 fractures per 100 patients per year). There were also significant increased risks of falls requiring hospitalisation or ED attendance (HR 1.80, 95% CI = 1.53-2.13). Fracture risk was even higher in those with dementia. 

Although this is observational data with the usual caveats about confounding, this is quite a big study and gives pretty good evidence that using antihypertensives in frail elderly people does increase falls, fractures and ED visits. The authors conclude that if we do consider treating hypertension in frail elderly people ‘caution and additional monitoring is advised when initiating antihypertensive medication’.

So this study suggests we are right to be wary of initiating antihypertensives in frail older people due to the risks of falls and fractures, and are left (as is often the way) with pros and cons to both intervening or not. But this is not new territory for us in primary care. Discussion on the individual risks and benefits of either treating his hypertension, or not, will be needed for Frank. 

It’s worth remembering NICE recommend we check for postural hypotension in those at risk and if >20 mm/Hg drop in systolic BP to use standing, not sitting, BPs. Even if they don’t meet that threshold there is an argument for using standing BPs in frail older adults with any degree of postural hypotension. If we do initiate antihypertensives for Frank we should get carers to monitor his BP closely and ask them to watch carefully for any symptoms or signs of postural hypotension. 

Whilst on the subject of Hypertension, we are currently in the process of putting together our next set of presentations for the new Autumn/Winter 2024 Hot Topics course - one of the subjects we will cover is the new British and Irish Hypertension Society statement which has a couple of important changes in practice that we shall cover, so do join us on the upcoming courses!