Have you had any concerns about an older person falling, or being at risk for a broken hip?
A new clinical research study relevant to millions of older adults was just featured in the news.
The study, completed by a team of geriatrics researchers at Yale, found that in older adults aged 70 or older, taking blood pressure medication was linked to a higher risk of serious falls. (Serious falls as in, falls that caused an ER visit for a fracture, a dislocated joint, or a brain bleed. Serious stuff indeed!)
So, if the person you care for has a diagnosis of hypertension, and if you’ve had any concerns regarding falls or near-falls, these study results should be of interest to you.
In this post, I’ll review the key results of this study. Then I’ll tell you what I think are the most important practical take-aways for family caregivers.
This post will also include some practical tips to help you minimize the risk of your loved one experiencing a serious fall.
Key results of the high blood pressure medications and falls study
One of the many good things about the study is that it used the Medicare records of a “real-world” group of 4961 people aged 70 or older. (This is important because many clinical trials of BP medication are done with patients recruited specifically for the study; there are advantages to this but it means that often patients in clinical trials are healthier than the aging adults that you and I are caring for.)
To be included in this “real-world” study, the patients had to have a diagosis of high blood pressure, they had to be living at home or in assisted-living, and they had to be in Medicare fee-for-service (no Medicare Advantage patients).
The researchers then examined three years worth of these patients’ Medicare records. Here’s what they found:
- Overall, 9% of these older people experienced a serious fall injury.
- When people were classified based on how much BP medication they were taking, the percentages of aging adults having a serious fall within 3 years were:
- No medication: 7.5%
- Moderate-intensity BP medication: 9.8%
- High-intensity BP medication: 8.2%
Next the researchers used some statistical adjustments, to compare older adults with similar levels of illness burden. (It’s important to do this adjustment, because otherwise it could be that some people have no BP medication because they are so sick and frail that doctors have stopped their medications.) In this adjusted group, the percentages of older adults having a serious fall over 3 years were:
- No medication: 7.1%
- Moderate-intensity BP medication: 8.6%
- High-intensity BP medication: 8.5%
The researchers also found that in those people who’d had a serious fall injury within the previous year, being on BP medication was linked to an especially high chance of another serious fall.
What you should take away from this study
I consider this study very important, because most clinical research focuses on benefits of medication, rather than studying the potential harms and downsides of medication. It’s probably not a coincidence that the main author is a geriatrician; we tend to feel that a little goes a long way when it comes to medications in aging adults!
Key take-aways for family caregivers:
- Serious falls are a fair possibility in all older adults aged 70+. Over 3 years, 9% of these Medicare patients had a fall involving a fracture, a dislocation, or a brain bleed. It’s probably reasonable for you to assume that your loved one has at least a roughly 10% chance of a serious fall within a few years. This risk is higher if your loved one has already had a serious fall.
- Consider learning practical approaches to reducing fall risk in your loved one. Along with learning to be careful with medications, there is lots more that you can do! Visit our fall prevention topic page to see all our articles on this topic.
- Consider a plan or system to call for help in the event of a fall. This is especially important for those independent older adults who live alone! Last year I saw a patient who lay at home with a broken hip for 2 days before he was found 🙁
- Home sensors and/or a personal emergency response system can help alert a care circle when an older person falls.
- Being on blood pressure (BP) medication raises the risk of a serious fall. This doesn’t mean your loved one shouldn’t take any medication for high BP. But it does mean that you should be thoughtful about weighing the benefits and the risks, and you probably want to aim for the lowest doses possible. In my experience, regular doctors tend to not think of the risks of BP medications in aging adults. So here are some specific things YOU can do:
- Be careful if your loved one’s BP is often below the new recommended target of 150/90. Read “What the New Blood Pressure Guidelines Mean for Older Adults” for more info.
- Ask the doctors to help you understand how much benefit to expect from the BP treatment. Note that often the expected chance of benefit (e.g. avoiding a stroke or heart attack) is about the same as the risk of harm that was found in this research study.
- Seniors who’ve had a previous serious fall are at extra high risk. Be extra careful about blood pressure and over-treatment if your loved one has already had a serious fall. These are the older adults for whom it’s most important to make sure that they aren’t on more medication than is absolutely necessary.
- Know that in general, the most benefit from treating high blood pressure in seniors comes from getting a systolic blood pressure (SBP; that’s the top number that a monitor reports) from 170 or higher, down to 140s-150s.
- Once elderly people are treated to a SBP below 140, the chance of harm can easily become bigger than the chance of benefit.
- Get a home blood pressure machine if you’re concerned about falls and your loved one is on medication. Don’t just leave it to the doctors to monitor things and take action. When properly done, home BP measurements can be more accurate than occasional office measurements, and can lead to better care. For more on this topic, here are some posts I wrote last fall:
Do you have any questions about how to reduce the chance of falls and injuries in aging adults?
Please post them below in the comments section.
ZombieDad says
My Dad is turning into a zombie because his BP is currently around 74/60. He has a pacemaker and had fluid in lungs the other week, so in addition to the Lisinopril and Coreg, he is now taking Lasix. He has lost 40 pounds over the past 8 months and is too weak to do anything. He also seem very confused and debilitated. His doctor keeps doing all these tests and says that he does have heart failure, but we don’t think it is at the extreme level.
He is at the point where he says that he is willing to risk a stroke or heart attack if he could just feel halfway normal again. He is 95 and had been fairly active until he started on the medicines. Everyone has noticed a big change in him.
Would an opinion from another doctor be a good idea?
Unfortunately we have no geriatric specialists in our town.
Seems like anything that the drug reps bring in ends up being given to him and we are starting to feel like he is an experiment.
Leslie Kernisan, MD MPH says
BP can difficult to manage in heart failure. That said, BP 74/60 is really quite low!
So yes, I would definitely recommend you get a second opinion regarding your father’s health. He has lost quite a lot of weight, and everything you are describing sounds concerning. You could try consulting with a good generalist, or perhaps a cardiologist. However, a large weight loss like that is often not just due to heart problems, so a cardiologist may not be able to provide you with all the answers you need.
Another good idea would be to consult with a palliative care clinician. Palliative care consults are more easily available during hospitalization, but some health systems offer outpatient palliative care consultations as well. This specialty focuses on helping people feel better and also helps patients understand the big picture of their health, so this would be a good fit for your father. You can learn more about how palliative care helps families here:
What Is Palliative Care?
ZombieDad says
Thank you for your reply. I did contact Palliative Care and they are sending a doctor this week to talk to him and work with his family doctor. Cannot understand why the cardiologist is not concerned about his low BP?
We made the decision to cut out one BP medicine and his readings are much better than before. Family doctor is in agreement. We are wondering if the Lisinopril is also causing him to lose so much weight. I bought some high calorie drink mix, but the doctors all note the weight loss but never give any ideas as the the cause. Hoping this new doctor will be more helpful in that way.
Leslie Kernisan, MD MPH says
My own experience has been that cardiologists are inordinately concerned about high BP and usually much less concerned about low BP, even though our experience in geriatrics is that older adults often feel light-headed when BP is too low. I would encourage you to keep bringing up your concerns with the cardiologist. You could also ask what is the highest BP the cardiologist would consider acceptable.
It also sounds like you will need to keep politely insisting that the doctors address the weight loss. They really should be explaining to you what might be causing it, and how they are going to investigate the possible causes. Anything is possible with medications, but it would be unusual for lisinopril to cause that much weight loss.
I have been meaning to write an article on this site about investigating weight loss, but until I do, here’s one I wrote about for another website a few years ago:
When to Worry About Weight Loss and Poor Nutrition
Judith Wallace says
THAT SITE SAYS IT DOES NOT EXIST
Nicole Didyk, MD says
Hi Judith. Sorry that there’s a broken link in the article. We’ll take a look at that and let you know when it’s fixed.
Why3BPmeds says
I was so mad I forgot to mention it.. I checked with an Omron I have at home… her BP in the past few days has been around 105/50 or 109/60, so I don’t care what the doc says I’m cutting her BP pills in half for a week. You need not publish that if you think it’s dangerous, but I wanted you to know… I’m fed up with this bs. She has only a few years, I don’t want her confused and dizzy.
Leslie Kernisan, MD MPH says
Wow, what a story. Sorry you and your mother have had to go through this. 105/50 does sound on the low side, esp for an older person who has been falling, but I can’t truly judge without knowing more about her other health conditions.
I would certainly encourage you to document all the BPs you record. Be sure to note the pulse as well, as that’s crucial to interpreting BP, and also log the time of day. If you check BP in anything other than a sitting position, note that as well.
Generally I feel obligated to tell people to not change medications on their own and instead ask to speak to a clinician. It is often possible to reduce the dosage of BP meds, and usually it makes more sense to go from three meds to two, rather than to be on small doses of three medications.
Good luck! It’s great for your mom that you are being proactive about her health.
Why3BPmeds says
I’m so grateful to you for your reply. She’s napping today a bit more than usual. The first couple of days “home” she wanted to do “everything” like walk too far, climb stairs, sit in the sun… etc, everything she couldn’t do. I think I’d probably do the same if I felt trapped like that. I kept her safe while letting her have a really good time. We had a good hug moment too, something that doesn’t happen much in nursing facilities I imagine. I’m so glad she’s here. Since the facility has come up with an indisputable compromise to get her back on site but also allow me to care for her for the next month (the maximum allowable “guest” period of time), I will seek a local GP over there to help us reduce these drugs safely, but offsite. I am calmer now. Your site is so incredibly helpful I will be using it to make her master plan when I eventually do have her home with me, but that’s not yet. Another quality of life bonus to her will be that, although I am not personally religious, I will make sure she gets to church every Sunday. She is the daughter of a Missionary preacher who traveled the world and it’s vital to her identity. I wouldn’t take that away from her. The nurses said something very nasty about her religious nature that offended me not because I’m religious (I’m not) but because it was a denial of her identity. In any case, thank you for your reply and I appreciate your taking the time to help educate caregivers. I wish I had had this when I was caring for another relative much earlier in my life. Back then, the internet was all Archie and only Yahoo was an aggregator. I’m very thankful to find your site.
Leslie Kernisan, MD MPH says
I’m glad the information here has been helpful. I’m even happier to hear that you are thinking about things that nourish your mother’s heart and soul; it’s very insightful of you to think of what helps her feel like her best self. Good luck working things out!
Why3BPmeds says
I am angry right now, so take it into consideration. But I can hardly feel any other way and be rational I think. My mom wanted a break from her “nursing home” actually one of those expensive places with “estates” on it where you are given a nice apartment as a teaser and they never have assisted living space so you end up in the nursing home area. Long story short, she was given a leave of absence with me. Of course they give me her medications and instructions with them. I bring her home to find she is on 3 BP meds. And each one is a different type. Beta blocker, ACE and calcium channel blocker. She has never even had a heart attack or a stroke. The worst thing she has ever had is hypothyroidism and arthritis/osteoporosis.
The reason she wanted a break? They are telling her she can’t live in her apartment anymore because she is a falling risk now. The first thing she says to me is “they’re giving me too much medication.” The first thing they are telling me is “the family needs to make decisions for her because she is no longer functional cognitively.” Hah. I’d say she’s very sharp.
I really don’t know what to do, but one of our relatives is a lawyer and I’m calling her tonight to find out how to break this contract and get her home with us. I think they’re trying to make her sick so they can resell her apartment. Claiming she’s nuts is the last straw for me. Unbelievable. I’m angry partly because of what they’re doing to her and partly because I’m scared someone will do it to me someday. It might be better to put all my money in a trust before I’m dead so nobody gets notions about it. This sort of event really makes you think. Sorry if I rambled.
Chetan Pandya says
Very informative article for elderly people and the question and answer parts are very helpful to understand one’s real condition. Many thanks
Jenny Williams says
When I read this story I realized just how similar it was to my husband’s condition. He had uncontrolled blood pressure for years and the doctors kept doing the same tests over and over, and when they couldn’t figure out what to do next they just gave him more medication. After discovering some natural remedies, his BP came down from 200/140 to 130/80 in just 3 weeks. The difference in his health and general wellbeing has been phenomenal. All he did was follow the advice in this website: [deleted]
Leslie Kernisan, MD MPH says
It’s true that changes to diet and lifestyle can often improve blood pressure. I deleted the website you linked to as it was quite “salesy.”
For those interested in learning more about nutrition and supplements for blood pressure, I recommend NutritionFacts.org, which is non-profit and seems to have high-quality information.
kitty says
Thank you for writing this article. My 85 year old father’s blood pressure has always been low, but during the last two doctor’s yearly visits, his diastolic blood pressure was a little high at 140. His diastolic is normal at 78. The nurse mentioned it was high, the doctor didn’t mention anything, but tonight, as I’ve got the phone call from the mail order pharmacy confirming the prescriptions (new medicare requirement for the patient to approve before shipping), I was surprised to find out that the doctor dialed a blood pressure medication, a diuretic, hydrochlorothiazide. I went and measured my father’s blood pressure at home and it was 134/68. I am aware that the recommendations for the elderly is only to treat at 150, and given that my father’s blood pressure is normal at home, I am afraid that this medication will cause it to drop dangerously low and lead to falls.
I am going to call the office and find out why the medication was prescribed, if there was something on a blood test that caused the doctor to result it. Note, that other than the blood test (I didn’t get results in the mail yet), there was no other tests done, and my father didn’t complain of any symptoms.
Leslie Kernisan, MD MPH says
I’m glad you are helping your father double-check his medical care.
Many doctors either don’t know or disagree with a systolic BP treatment goal of 150. Having reviewed the literature extensively, I believe that for most people in their 80s or older, a systolic BP in the 130s or 140s is a good range, and I only try to treat to a lower goal if there are other medical conditions (such as advanced heart failure) that warrant it.
Some scientific evidence does suggest that there’s a small decrease in cardiovascular risk if you treat to a lower blood pressure. However, as I note in my post reviewing the SPRINT trial, the chance of benefit for an individual is small, whereas treating BP more aggressively means taking more pills, spending more money on medication, and running an increased risk of falls and orthostatic symptoms.
Also, we do know that a single office-based BP measurement often misclassifies a person’s hypertension, and it’s much better to get several readings from home, as you are doing. So it’s great that you checked at home and that you’ll be informing the doctor of this information.
Good luck and let us know if you have more questions.
anne-marie says
Hi my Dad has started to have lot of falls which have resulted in him being hospitalised as they cannot work out the reason. In July he went into hospital as his blood pressure was really high. The consultant at the hospital decided to change his blood pressure tablets to amoplodine and ramipril 5mg. Since then his falls have got progressively worse and he cannot walk without the aid of a zimmer and a person holding him to ensure he doesn’t fall. He leans to the right and just goes. He cannot sit on a bed without falling sideways either.
Do you think his blood pressure tablets are causing he problem. His average bp is 120/80.
Leslie Kernisan, MD MPH says
I’d be surprised if it’s only his blood pressure tablets causing the problems, especially since you mention he began having a lot of falls much earlier in the summer. The leaning over and worsening course of things sounds like something more than over-treatment with BP meds.
If you are concerned about the impact of his BP meds right now, I would encourage you to check his blood pressure sitting and standing for several days in a row. Bring this information to the doctors and discuss it with them. You might also want to ask them what is their goal BP for him and why. They may be open to trying to dial back his medications a little so that his average BP is in the 130s and 140s, but obviously online I cannot tell you what his goal BP should be, I can only recommend you discuss it with his doctors and see if aiming for a little higher goal is possible. You can then see if that seems to improve the falls.
Good luck, I hope you find some answers soon, and I especially hope that the situation gets better for your father and your family.
CATHERINE LEWIS says
I AM ALMOST 81 Y/O & FOR THE PAST 18 MOS HAVE HAD FAIRLY FREQUENT FALLS. NO SEVERE DAMAGE YET, BUT I WORRY ABOUT MY LUCK RUNNING OUT.
I HAVE ANOTHER VISIT WITH INTERNEST SCHEDULED FOR LATE THIS MONTH ( JULY, 2015).
Up to now have not mentioned many of my falls to her, however, before visits I usually email
my concerns, sort of a “heads-up”. Currently on Norvasc & Cozzar, & will make no changes prior to seeing her, but secondary to this article from your blog, will be sure to have this concern at top of my list.
Frankly I was seriously considering medications but NEVER even thought of BP studies.
You may have done another MITZVAH today. Many thanks,
Catherine
Leslie Kernisan, MD MPH says
Fairly frequent falls, yikes! I’m glad you haven’t been seriously injured, but yes, your luck could run out, so I hope you can get some help figuring out what’s causing your falls.
I would highly recommend you bring it up to your internist. Generally falls in seniors are due to multiple causes. Overtreatment of blood pressure is a common factor that probably contributes to many falls, but there may be other issues as well. Since many PCPs don’t have the time or expertise to do a careful fall evaluation, I would encourage you to take a look at what we have listed on our fall prevention topic page. Good luck and take care!
sally says
My 91 year old mother with Alzheimer’s has a BP of 120/56 with 20 mg lisinopril. I am afraid that is putting her at risk of falls. She has been very unsteady on her feet with balance the last several years. I notified her Dr’s office and the geriatric nurse practioner who even visits her in her home and they tell me her numbers are “great.” Should I be concerned?
Leslie Kernisan, MD MPH says
I do think it’s quite reasonable for you to be concerned. Is that BP sitting or standing? If it’s a sitting BP, it’s quite possible that your mother is experiencing a drop when she stands.
You don’t say how advanced her Alzheimer’s is, but if she is 91 and often seems unsteady, then it would be very reasonable to try cutting back her BP medication a bit. She will still be at fairly high risk for falls, but at least you’ll have addressed one of the risk factors that can be changed. And who knows, she may either feel better or look steadier on a lower dose of medication.
Research generally hasn’t proven that 91 year old women have a higher stroke risk if their BP is 140 rather than 120. Some things you can do:
– check your mother’s BP standing and sitting, or ask the clinicians to do it
– try getting a few more BP measurements at home. BP is constantly fluctuating a bit, so I generally recommend people get several readings over a week if they are considering making a medication change.
– Tell the doctor and nurse that you’ve heard about the recent information regarding goal BP being in the 140s for aging adults. Let them know you really want to do everything possible to reduce fall risk, you’re worried because her balance seems poor, and you’d really like to discuss the possibility of reducing the lisinopril a bit.
Good luck!
Sonia Pressman Fuentes says
Dear Dr. Kernisan:
A retired doctor friend of mine sent me your recent article about blood pressure meds, falls, and seniors. I am an 85-year-old woman and recently went off Losartan because I couldn’t take the side effects, including falling when I awoke at night. (I’d previously gone off other BP meds because I couldn’t take the side effects.) Since I went off Losartan, for unexplained reasons, my BP has been in the acceptable range. But I am concerned that my BP cuff at home and those I use at the Y and the supermarket may not be accurate.
You recommended in your article that one get a good BP cuff. What do you recommend?
Best,
Sonia
Leslie Kernisan, MD MPH says
Hi Sonia,
Sorry to hear you experienced falls; I hope those are better now that you’ve changed your medication.
If you have a BP monitor already and are concerned about its accuracy, you may want to start by bringing it to your doctor’s office. You can ask the staff to compare your monitor’s reading to the office cuff’s reading.
Regarding the purchase of a new home BP monitor, I would look at a website like Amazon (or another site where there are lots of customer reviews) and pick one that has a lot of positive reviews. Measuring BP in the upper arm tends to be more accurate than measuring at the wrist.
If you want to purchase a cuff that makes it easy for you to track the data, and share it with a doctor or caregiver, your options will depend on whether you are able to use a mobile device, and what kind of device you have. I do encourage families to consider these types of cuffs, but they are newer and so they have less of a track record at this time. (See my blog post on Choosing & Using a Blood Pressure Monitor for more info.)
I’m currently trying to find a suitable blood pressure monitor for an older person in assisted living. Since she doesn’t have a smartphone or tablet, we are considering a BP monitor that uses wi-fi, like this one. But I have never had a patient use a wireless-enabled cuff, so I can’t yet tell you if I recommend it.
Good luck and I hope you’ll let us know if you find a new BP cuff that you like!
Vanessa says
Hello my grandma recently fell and landed on her knees and hit her head on the table she now has black and purple eyes very swollen and dr said they saw a small blood spot on the lower part of her head a part of her head that wasn’t hit on the table what could this be please I’m very worried I feel like she’s leaving something out to not worry me but now I’m even more worried than ever
Leslie Kernisan, MD MPH says
Sorry to hear of your grandmother’s fall. I’m not sure what the “small blood spot on the lower part of the head” might be. If you are worried, you could try asking your grandmother for permission to discuss this with her doctors, so you can ask more questions. I hope she feels better soon. Good luck!