Antihypertensive Prescribing in Older Adults: Are We Prescribing Correctly?

Introduction

Hypertension is highly prevalent among older adults and is a major contributor to cardiovascular morbidity, mortality, and cognitive decline. While the HYVET trial demonstrated benefits of antihypertensive treatment in older populations, the SPRINT trial highlighted increased adverse events with intensive blood pressure control. This highlights the importance of ensuring antihypertensive prescribing in older people is appropriate and evidence-based, particularly in those presenting with falls.

Method

A retrospective observational review was conducted of 60 adults aged over 75 years who presented following a fall while prescribed antihypertensive medication. Data were extracted from electronic records, including demographics, timing and location of falls, mobility status, documentation of lying and standing blood pressure (LSBP), postural hypotension, prescribing patterns, electrolyte abnormalities, medication adjustments, and fall-related injuries. Prescribing practice was benchmarked against NICE guidance. Patients who were bedbound, paraplegic, or had undergone lower limb amputation were excluded.

Results

Of the 60 patients reviewed, 39 (65%) were females and 21 (35%) males. Falls occurred most frequently in the morning and predominantly within the home. 51 patients (85%) received antihypertensive medication exclusively in the morning, while 5 (8.3%) received twice-daily dosing. LSBP was documented in 36 patients (60%), with postural hypotension identified in 17 (28.3%). Injuries included fractures in 9 patients (15%), soft tissue injuries in 5 (8.3%), and one extracranial haematoma (1.7%). Electrolyte abnormalities were identified in 17 patients (28.3%).

Conclusion

Morning antihypertensive dosing was common and frequently associated with postural hypotension and fall-related injury. Medication timing represents a modifiable risk factor. Routine LSBP assessment, cautious titration, and individualised targets are essential. Evening or bedtime dosing, particularly in those on multiple anti-hypertensive agents, may reduce morning hypotension and risk of falls