Falls Risk Assessment

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Anti-hypertensives

Consider whether the patient is experiencing any dizziness, fatigue, light-headedness, syncope and/or orthostatic hypotension (OH) as a result of anti-hypertensives.

In long-term antihypertensive therapy (≥ 1 year), high doses of antihypertensive medications have been shown to increase fall risk, especially in high fall risk patients; reduce antihypertensive dose when possible.1,2,3

Avoid the following anti-hypertensives as they have been shown to increase the risk of falls:

  • Loop diuretics, α peripheral vasodilators (α-blockers) have high risk of OH.4
  • Centrally acting α2 receptor agonists such as clonidine cause sedation and postural hypotension.5
  • Thiazide and loop diuretics have been associated with a significant increase in fall incidents and loss of plasma potassium and sodium levels leading to muscle weakness.6 Thiazide diuretics can still be kept for patients with isolated systolic hypertension and heart failure that cannot be controlled on other preferred agents.7

Ensuring close monitoring of OH in patients taking three or more antihypertensive medications; reduce the number of antihypertensive medications when possible.5,7

Choice:

  • Switching diuretics/ alpha blockers/ vasodilators to ACE inhibitor or calcium channel blocker.7
    • The chronic use of ACE, angiotensin receptor blockers or calcium channel blockers is less associated with postural hypotension in comparison to other antihypertensive classes.1,8
  • Switching α blockers to selective α -1 blocker if the above is not feasible. 5

Other:

  • Consider taking α blocker medication at bedtime; this can also reduce the risk of OH in patient with multiple anti-hypertensives. 5
  • Consider splitting the dose or changing administration time, so that peak drug effects do not happen at the same time for all antihypertensive medications.3
  • When a new antihypertensive is indicated, start with a low dose and titrate slowly while ensuring close monitoring of OH in high fall risk patients; within the first 42-45 days of commencing the treatment. 1,8,9
    • When de-prescribing is appropriate, ensure tapering the dose gradually to avoid rebound hypertension.8

References

  1. Butt D, Harvey P. Benefits and risks of antihypertensive medications in the elderly. Rev J Intern Med. 2015; 278(6):599–626.

  2. Callisaya L, Sharman E, Close J, Lord R, Srikanth K. Greater daily defined dose of antihypertensive medication increases the risk of falls in older people—a population‐based Study. J Am Geriatr Soc. 2014;62(8):1527-33.

  3. Bulat T, Castle SC, Ruthledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly—part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract. 2008; 20(2):55-62.

  4. Poon I, Braun U. High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther (2005);30(2): 173–8.

  5. kamaruzzaman S, Watt H, Carson C, Ebrahim S. The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study. Age Ageing. 2010;39 (1): 51–6. 

  6. Boyle N, Naganathan V, Cumming R. Medication and falls: risk and optimization. Clin Geriatr Med. 2010;26(4):583-605.

  7. Lewis A, Lipsitz A, Habtemariam D, Gagnon M, Iloputaife I, Sorond F, et al. Reexamining the Effect of Antihypertensive Medications on Falls in Old Age Novelty and Significance.  J Hypertens. 2015;66(1):183-9.

  8. Parekh N, Page A, Ali K, Davies K, Rajkumar C. A practical approach to the pharmacological management of hypertension in older people. Rev Ther Adv Drug Saf. 2017;8(4):117–132. 

  9. Arnold A, Shibao C. Current concepts in orthostatic hypotension management. Curr Hypertens Rep. 2013; 15(4):304–312

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