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Osteoporosis International

, Volume 24, Issue 10, pp 2649–2657 | Cite as

The risk of falls on initiation of antihypertensive drugs in the elderly

  • D. A. ButtEmail author
  • M. Mamdani
  • P. C. Austin
  • K. Tu
  • T. Gomes
  • R. H. Glazier
Original Article

Abstract

Summary

Antihypertensive drugs are associated with an immediate increased falls risk in elderly patients which was significant during the first 14 days after receiving a thiazide diuretic, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, calcium channel blocker, or beta-adrenergic blocker. Fall prevention strategies during this period may prevent fall-related injuries.

Introduction

The purpose of this study is to evaluate if initiation of the common antihypertensive drugs is associated with the occurrence of falls.

Methods

This population-based self-controlled case series study used healthcare administrative databases to identify new users of antihypertensive drugs in the elderly aged 66 and older living in Ontario, Canada who suffered a fall from April 1, 2000 to March 31, 2009. The risk period was the first 45 days following antihypertensive therapy initiation, further subdivided into 0–14 and 15–44 days with control periods before and after treatment in a 450-day observation period. We calculated the relative incidence (incidence rate ratio, IRR), defined as the rate of falls in the risk period compared to falls rate in the control periods.

Results

Of the 543,572 new users of antihypertensive drugs among community-dwelling elderly, 8,893 experienced an injurious fall that required hospital care during the observation period. New users had a 69 % increased risk of having an injurious fall during the first 45 days following antihypertensive treatment (IRR = 1.69; 95 % CI, 1.57–1.81). This finding was consistent for thiazide diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-adrenergic blockers but not angiotensin II receptor antagonists. There was also an increased falls risk during the first 14 days of antihypertensive drug initiation (IRR = 1.94; 95 % CI, 1.75–2.16), which was consistent for all antihypertensive drug classes.

Conclusions

This study suggests that initiation of antihypertensive drugs is a risk factor for falls in the elderly. Fall prevention strategies during this period may reduce injuries.

Keywords

Antihypertensive drugs Elderly Falls Self-controlled case series 

Notes

Acknowledgments

We thank Dr. Paddy Farrington (PhD, Division of Statistics, Open University, Milton Keynes, England) for his contribution to the study design and analytical assistance. This work was funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The sponsor did not participate in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review or approval of the manuscript. The opinions, results, and conclusions are those of the authors and no endorsement by the MOHLTC or by the Institute for Clinical Evaluative Sciences is intended or should be inferred. Dr. Austin was supported by a Career Investigator Award from the Heart and Stroke Foundation of Ontario. Dr. Tu was supported by a Canadian Institutes of Health Research Fellowship Award in Primary Care.

Conflicts of interest

Dr. Butt, Dr. Glazier, Dr. Austin, Dr. Tu, and Tara Gomes declare no conflict of interest. Dr. Mamdani reported that he is a consultant for Hoffman LaRoche, Glaxo-Smith Kline, Pfizer, Novartis, and Lilly.

References

  1. 1.
    Anonymous (2001) Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 49:664–672CrossRefGoogle Scholar
  2. 2.
    Peel NM (2011) Epidemiology of falls in older age. Can J Aging 30:7–19CrossRefGoogle Scholar
  3. 3.
    Speechley M, Tinetti M (1991) Falls and injuries in frail and vigorous community elderly persons. J Am Geriatr Soc 39:46–52PubMedGoogle Scholar
  4. 4.
    Jarvinen TL, Sievanen H, Khan KM, Heinonen A, Kannus P (2008) Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 336:124–126PubMedCrossRefGoogle Scholar
  5. 5.
    Alexander BH, Rivara FP, Wolf ME (1992) The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 82:1020–1023PubMedCrossRefGoogle Scholar
  6. 6.
    Kannegaard PN, van der Mark S, Eiken P, Abrahamsen B (2010) Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival. Age Ageing 39:203–209PubMedCrossRefGoogle Scholar
  7. 7.
    Wolf-Maier K, Cooper RS, Banegas JR et al (2003) Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 289:2363–2369PubMedCrossRefGoogle Scholar
  8. 8.
    Vasan RS, Beiser A, Seshadri S et al (2002) Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA 287:1003–1010PubMedCrossRefGoogle Scholar
  9. 9.
    Neutel CI, Campbell NR (2007) Antihypertensive medication use by recently diagnosed hypertensive Canadians. Can J Cardiol 23:561–565PubMedCrossRefGoogle Scholar
  10. 10.
    Huang A, Mallet L, Rochefort C, Eguale T, Buckeridge D, Tamblyn R (2012) Medication-related falls in the elderly: causative factors and preventive strategies. Drug Aging 29:360–376CrossRefGoogle Scholar
  11. 11.
    Campese V, Schneider EL (2010) Reevaluating the use of antihypertensive medications, a first step toward reducing polypharmacy in very old patients. J Clin Hypertens 12:621–624CrossRefGoogle Scholar
  12. 12.
    Kamaruzzaman S, Watt H, Carson C, Ebrahim S (2010) The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study. Age Ageing 39:51–56PubMedCrossRefGoogle Scholar
  13. 13.
    Shannon RP, Wei JY, Rosa RM, Epstein FH, Rowe JW (1986) The effect of age and sodium depletion on cardiovascular response to orthostasis. Hypertension 8:438–443PubMedCrossRefGoogle Scholar
  14. 14.
    Poon IO, Braun U (2005) High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther 30:173–178PubMedCrossRefGoogle Scholar
  15. 15.
    Capewell S, Capewell A (1991) ‘First dose’ hypotension and venodilatation. Br J Clin Pharmacol 31:213–215PubMedCrossRefGoogle Scholar
  16. 16.
    Slavachevsky I, Rachmani R, Levi Z, Brosh D, Lidar M, Ravid M (2000) Effect of enalapril and nifedipine on orthostatic hypotension in older hypertensive patients. J Am Geriatr Soc 48:807–810PubMedGoogle Scholar
  17. 17.
    Pool JL, Glazer R, Chiang YT, Gatlin M (1999) Dose–response efficacy of valsartan, a new angiotensin II receptor blocker. J Hum Hypertens 13:275–281PubMedCrossRefGoogle Scholar
  18. 18.
    Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS (1992) Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension 19:508–519PubMedCrossRefGoogle Scholar
  19. 19.
    Burton L, Norton M, Newton JL (2004) Are some antihypertensives more prone to induce hypotensive side effects than others? Age Ageing 33:626–628PubMedCrossRefGoogle Scholar
  20. 20.
    Gribbin J, Hubbard R, Gladman J, Smith C, Lewis S (2011) Risk of falls associated with antihypertensive medication: self-controlled case series. Pharmacoepidemiol Drug Saf 20:879–884PubMedCrossRefGoogle Scholar
  21. 21.
    Gribbin J, Hubbard R, Gladman JR, Smith C, Lewis S (2010) Risk of falls associated with antihypertensive medication: population-based case–control study. Age Ageing 39:592–597PubMedCrossRefGoogle Scholar
  22. 22.
    Butt DA, Mamdani M, Austin PC, Tu K, Gomes T, Glazier RH (2012) The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med 172:1739–1744PubMedCrossRefGoogle Scholar
  23. 23.
    Tinetti ME, Kumar C (2010) The patient who falls: “it’s always a trade-off”. JAMA 303:258–266PubMedCrossRefGoogle Scholar
  24. 24.
    Tinetti ME, Speechley M, Ginter SF (1988) Risk factors for falls among elderly persons living in the community. N Engl J Med 319:1701–1707PubMedCrossRefGoogle Scholar
  25. 25.
    Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ (2007) Will my patient fall? JAMA 297:77–86PubMedCrossRefGoogle Scholar
  26. 26.
    Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE (2012) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 9:CD007146. doi: 10.1002/14651858.CD007146.pub3 PubMedGoogle Scholar
  27. 27.
    Gill TM, Desai MM, Gahbauer EA, Holford TR, Williams CS (2001) Restricted activity among community-living older persons: incidence, precipitants, and health care utilization. Ann Intern Med 135:313–321PubMedCrossRefGoogle Scholar
  28. 28.
    Woolcott JC, Richardson KJ, Wiens MO et al (2009) Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169:1952–1960PubMedCrossRefGoogle Scholar
  29. 29.
    Levy AR, O’Brien BJ, Sellors C, Grootendorst P, Willison D (2003) Coding accuracy of administrative drug claims in the Ontario Drug Benefit database. Can J Clin Pharmacol 10:67–71PubMedGoogle Scholar
  30. 30.
    Whitaker HJ, Farrington CP, Spiessens B, Musonda P (2006) Tutorial in biostatistics: the self-controlled case series method. Stat Med 25:1768–1797PubMedCrossRefGoogle Scholar
  31. 31.
    Schoofs MW, van der Klift M, Hofman A et al (2003) Thiazide diuretics and the risk for hip fracture. Ann Intern Med 139:476–482PubMedCrossRefGoogle Scholar
  32. 32.
    Gibson JE, Hubbard RB, Smith CJ et al (2009) Use of self-controlled analytical techniques to assess the association between use of prescription medications and the risk of motor vehicle crashes. Am J Epidemiol 169:761–768PubMedCrossRefGoogle Scholar
  33. 33.
    Lamb SE, Jorstad-Stein EC, Hauer K, Becker C, Prevention of Falls Network Europe and Outcomes Consensus Group (2005) Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus. J Am Geriatr Soc 53:1618–1622PubMedCrossRefGoogle Scholar
  34. 34.
    Williams J, Young W (1996) A summary of studies on the quality of healthcare administrative databases in Canada. In: Goel V, Williams JI, Young W, Anderson GM, Blackstein-Hirsch P, Fooks C, Naylor CD (eds) Patterns of health care in Ontario: the ICES practice atlas, 2nd edn. Canadian Medical Association, Ottawa, pp 339–346Google Scholar
  35. 35.
    LeMier M, Cummings P, West TA (2001) Accuracy of external cause of injury codes reported in Washington State hospital discharge records. Inj Prev 7:334–338PubMedCrossRefGoogle Scholar
  36. 36.
    Luther SL, French DD, Powell-Cope G, Rubenstein LZ, Campbell R (2005) Using administrative data to track fall-related ambulatory care services in the Veterans Administration Healthcare system. Aging Clin Exp Res 17:412–418PubMedGoogle Scholar
  37. 37.
    Leipzig RM, Cumming RG, Tinetti ME (1999) Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 47:30–39PubMedGoogle Scholar
  38. 38.
    Musonda P, Farrington CP, Whitaker HJ (2006) Sample sizes for self-controlled case series studies. Stat Med 25:2618–2631PubMedCrossRefGoogle Scholar
  39. 39.
    Shuto H, Imakyure O, Matsumoto J et al (2010) Medication use as a risk factor for inpatient falls in an acute care hospital: a case-crossover study. Br J Clin Pharmacol 69:535–542PubMedCrossRefGoogle Scholar
  40. 40.
    Berry SD, Zhu Y, Choi H, Kiel DP, Zhang Y (2013) Diuretic initiation and the acute risk of hip fracture. Osteoporos Int 24:689–695PubMedCrossRefGoogle Scholar
  41. 41.
    Hamdy RC, Hudgins LB, Compton R (1993) Management of hypertension in older patients. South Med J 86:2S1–2S6PubMedGoogle Scholar
  42. 42.
    Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA (1990) Hip fracture incidence among the old and very old: a population-based study of 745,435 cases. Am J Public Health 80:871–873PubMedCrossRefGoogle Scholar
  43. 43.
    Mulrow C, Lau J, Cornell J, Brand M (2000) Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev 2:CD000028. doi: 10.1002/14651858.CD000028 PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  • D. A. Butt
    • 1
    • 2
    Email author
  • M. Mamdani
    • 3
  • P. C. Austin
    • 4
  • K. Tu
    • 4
    • 5
  • T. Gomes
    • 4
  • R. H. Glazier
    • 4
    • 6
  1. 1.Department of Family and Community Medicine, The Scarborough HospitalUniversity of TorontoTorontoCanada
  2. 2.Ellesmere Health Care CentreScarboroughCanada
  3. 3.Applied Health Research CentreLi Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  4. 4.Institute for Clinical Evaluative SciencesTorontoCanada
  5. 5.Department of Family and Community Medicine, Toronto Western Hospital Family Health TeamUniversity of TorontoTorontoCanada
  6. 6.Department of Family and Community Medicine, St. Michael’s Hospital, University of TorontoTorontoCanada

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