Are Blood Pressure Drugs Worth the Falls?

Source from the The New York Times, Written By PAULA SPAN

Are Blood Pressure Drugs Worth the Falls?

For older Americans, high blood pressure is a fact of life. By one common estimate, more than 70 percent of those over age 70 contend with it. That means medication to lower blood pressure has become a fact of life, too.

Diuretics, beta blockers, calcium channel blockers, the unpronounceable renin-angiotensin system blockers — in a study looking at a national sample of almost 5,000 Medicare beneficiaries with hypertension, more than 85 percent were taking at least one of these classes of blood pressure drugs. Most took two or three, or more.

They did so because randomized clinical trials, the supposed gold standard of medical research, have shown that these drugs reduce heart failure, heart attacks and stroke without scary side effects. “The prevailing notion is that these medications are safe, with very few adverse effects,” said Dr. Mary Tinetti, chief of geriatrics at the Yale School of Medicine, and lead author of the study.

But the people enrolled in clinical trials, she pointed out, are typically healthier than older adults in general. Investigators often exclude people who have other medical problems — “co-morbidities,” in doctor-speak — or who are taking several other medications. Yet the great majority of the older people who show up at doctors’ offices do have multiple chronic conditions and are taking lots of prescription drugs.

So Dr. Tinetti and her team have been looking into whether anti-hypertensive drugs might be causing problems in the real world beyond clinical trials. They followed those 5,000 older people (average age: 80) with hypertension for up to three years, and the results of their study are disturbing: The risk of serious fall injuries — fractured bones, brain injuries or dislocated joints — was significantly higher among those who took anti-hypertensives than among those who didn’t.

Over the three-year follow-up, 9 percent of the subjects were badly hurt by falls, which can have a devastating effect. “The outcomes are just as serious as the strokes and heart attacks for which we give these medications,” Dr. Tinetti told me in an interview. “Serious fall injuries are as likely to lead to death or lasting functional disability.”

More than half of the people in the study group were classified as moderate users of anti-hypertensives based on the number and doses of the drugs they took. In that category, serious fall injuries were 40 percent higher than among people who didn’t take anti-hypertensives.

In the group considered high-intensity users, serious injuries from falls were 28 percent higher than among non-users. And the risk more than doubled among drug users who’d already had a serious fall injury in the previous year.

Although this study doesn’t prove that taking the drugs led to the falls, anti-hypertensive medications are among the logical suspects. “They can drop people’s blood pressure too much when they stand,” Dr. Tinetti said. “They can make them fatigued, confused, dizzy. Those are all risk factors for falls.”

(Medical authorities already advise relaxing the goals for lowered blood pressure among older patients. The most recent guidelines from an expert panel say that patients over age 60 with hypertension, but without diabetes or kidney disease, should aim for 150/90. The previous recommendation had been 140/90, but more recent research suggests that was unreasonably low — though patients who reached those numbers without problems need not change their regimens. The 140/90 target holds for those with diabetes or kidney disease.)

The Yale findings, which were published this month in JAMA Internal Medicine, mean that blood pressure management enters one of those increasingly common medical gray zones, in which individuals and caregivers have to ask a lot of questions and balance the trade-offs.

Do you avoid a heart attack by using drugs associated with an almost equal risk of breaking a hip or injuring your brain? Especially since another Yale study using the same sample found that use of anti-hypertensive drugs didn’t reduce the rate of cardiovascular events, though it did reduce mortality among those who suffered them?

The Yale team actually asked that leading question of a small group of 123 people over age 70 who had high blood pressure and were at risk for falls. Given that doctors could not magically reduce their cardiovascular risk without increasing fall risk and medication side effects, what was most important to them?

About half the group said their priority was reducing cardiovascular risk over reducing serious fall injuries and medication symptoms. The other half placed greater importance on fewer falls and side effects.

It’s a question millions of older people now have to ask themselves, and not only themselves. “It’s time to ask your doctor, ‘Knowing all my other conditions and my fall risks, do I need all these medications?’” Dr. Tinetti said. “’Are they doing me more harm than good?’”

I wondered aloud how many physicians were prepared to have this possibly lengthy discussion. Dr. Tinetti answered, “It’s really up to patients and their caregivers to make it clear: ‘This is something important to me.’”