Enfermería: Cuidados Humanizados, 14(1)
january - june 2025
10.22235/ech.v14i1.4333
Original articles
Fear and Risk of Falling in Older Hypertensive Individuals Undergoing Medication Treatment
Miedo y riesgo de caída en personas mayores hipertensas en tratamiento farmacológico
Medo e risco de queda em idosos hipertensos em tratamento medicamentoso
Aelem Cristina Apolicena Dantas1 ORCID: 0000-0002-9501-3431
Maria Luiza Nunes Pires2 ORCID: 0009-0003-0237-2860
Aliny de Lima Santos3 ORCID: 0000-0002-4392-4452
Lucas França Garcia4 ORCID: 0000-0002-5815-6150
José Roberto Andrade do Nascimento Júnior5 ORCID: 0000-0003-3836-6967
Grazieli Covre da Silva6 ORCID: 0000-0002-6030-6357
Eduardo Quadros da Silva7 ORCID: 0000-0002-5041-993X
Daniel Vicentini de Oliveira8 ORCID: 0000-0002-0272-9773
1Centro Universitário Cesumar, Brazil
2Centro Universitário Cesumar, Brazil
3Centro Universitário Cesumar, Brazil
4Centro Universitário Cesumar, Brazil
5Centro Universitário Cesumar, Brazil
6Centro Universitário Cesumar, Brazil
7Centro Universitário Cesumar, Brazil
8Centro Universitário Cesumar, Brazil, d.vicentini@hotmail.com
Abstract:
Introduction: Falls are a major concern among
hypertensive older adults, as they can lead to severe injuries and reduced
quality of life. Understanding the impact of antihypertensive medication use on
fall risk and fear of falling is essential for improving patient care and fall
prevention strategies.
Objective: To investigate the associations between antihypertensive
medication use and the risk and fear of falling in hypertensive older adults.
Methods: A quantitative and cross-sectional study was conducted with 70
hypertensive older adults from a medical specialty center in the municipality
of Sapezal, Brazil. The Timed Up and Go test and the Falls Efficacy Scale were
applied. Data were analyzed using the Chi-square test, binary logistic
regression, and the Hosmer-Lemeshow test. A significance level of p < 0.05
was considered.
Results: Older adults using two or more antihypertensive medications
have significantly higher chances of fall risk (48.167 times) and fear of
falling (15.007 times) compared to those using only one medication.
Additionally, those taking medications for one to four years and over four
years have 6.679 and 13.444 times greater chances of experiencing fear of
falling with recurrent falls compared to those using them for less than one
year.
Conclusion: There is an association between the quantity and duration of
medication use with a higher risk and fear of falling in hypertensive older
adults.
Keywords: aging; antihypertensive therapy; falls; fear of falling; fall risk.
Resumen:
Introducción: Las caídas son una preocupación
importante entre los adultos mayores hipertensos, ya que pueden provocar
lesiones graves y una reducción en la calidad de vida. Comprender el impacto
del uso de medicamentos antihipertensivos en el riesgo de caída y el miedo a
caer es fundamental para mejorar la atención al paciente y las estrategias de
prevención de caídas.
Objetivo: Investigar las asociaciones entre el uso de medicamentos
antihipertensivos y el riesgo y miedo a caer en adultos mayores hipertensos.
Métodos: Estudio cuantitativo y transversal, realizado con 70 personas
mayores hipertensas de un centro de especialidades médicas del municipio de
Sapezal, Brasil. Se aplicaron la prueba Timed Up and Go y la Escala de Eficacia
de Caídas. Los datos se analizaron mediante la prueba de chi-cuadrado,
regresión logística binaria y la prueba de Hosmer-Lemeshow. Se consideró un
nivel de significancia de p < 0.05.
Resultados: Las personas mayores que utilizan dos o más medicamentos
antihipertensivos tienen significativamente mayores probabilidades de riesgo de
caída (48,167 veces) y miedo de caer (15,007 veces) en comparación con aquellas
que utilizan solo un medicamento. Además, aquellas que usan medicamentos
durante uno a cuatro años y más de cuatro años tienen 6,679 y 13,444 veces más
probabilidades de experimentar miedo de caer con caídas recurrentes, en
comparación con aquellas que los usan por menos de un año.
Conclusión: Existe una asociación entre la cantidad y la duración del
uso de medicamentos con un mayor riesgo y miedo de caer en personas mayores
hipertensas.
Palabras clave: envejecimiento; terapia antihipertensiva; caídas; miedo a caer; riesgo de caídas.
Resumo:
Introdução: As quedas são uma preocupação
importante entre os idosos hipertensos, pois podem causar lesões graves e
reduzir a qualidade de vida. Compreender o impacto do uso de medicamentos
anti-hipertensivos no risco de queda e no medo de cair é fundamental para
melhorar o cuidado ao paciente e as estratégias de prevenção de quedas.
Objetivo: Analisar os fatores associados ao risco e medo de cair em
idosos hipertensos em tratamento medicamentoso.
Métodos: Estudo quantitativo e transversal, realizado com 70 idosos
hipertensos de um centro de especialidades médicas do município de Sapezal,
Brasil. Foram aplicados o teste Timed Up and Go e a Escala de Eficácia de
Quedas. Os dados foram analisados pelo teste qui-quadrado, regressão logística
binária e teste de Hosmer-Lemeshow. Um nível de significância de p < 0,05
foi considerado.
Resultados: Idosos que utilizam dois ou mais medicamentos
anti-hipertensivos apresentam chances significativamente maiores de risco de
queda (48,167 vezes) e medo de cair (15,007 vezes) em comparação com aqueles que
utilizam apenas um medicamento. Além disso, aqueles que fazem uso de
medicamentos por um a quatro anos e por mais de quatro anos têm 6,679 e 13,444
vezes mais chances de experimentar medo de cair com quedas recorrentes, em
comparação com aqueles que os utilizam por menos de um ano.
Conclusão: Há uma associação entre a quantidade e a duração do uso de
medicamentos com maior risco e medo de cair em idosos hipertensos.
Palavras-chave: envelhecimento; terapia anti-hipertensiva; quedas; medo de cair; risco de quedas.
Received: 30/10/2024
Accepted: 12/03/2025
Introduction
Systemic arterial hypertension (SAH) is a chronic, multifactorial, non-communicable disease considered the leading risk factor for other cardiovascular diseases and one of the leading causes of death worldwide. (1-3) In older adults, SAH is particularly prevalent due to various factors, including the natural aging of the cardiovascular system, such as arterial stiffness and the accumulation of atheromatous plaques over time. (4, 5) Adequate control is essential to prevent complications, so it is important to follow medical advice regarding the proper use of medications. (5, 6)
It is important to consider drug interactions, especially in older adults who often use multiple medications for various health conditions, to avoid harmful interactions3. Older adults are more susceptible to medication side effects, such as falls, dizziness, and balance disturbances. Some patients report feeling dizzy or fearful of falling when using antihypertensive drugs, especially when getting up quickly. (7-9)
Understanding specific risk factors for falls in older hypertensive individuals can help identify areas where preventive interventions may be most effective. This is important for developing targeted and personalized fall prevention strategies for this vulnerable population. Thus, this study aimed to investigate the associations between antihypertensive medication use and the risk and fear of falling in hypertensive older adults.
Methods
This study employed a quantitative, observational, and cross-sectional design, adhering to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. It was approved by the Research Ethics Committee of Cesumar University (UniCesumar) under protocol No. 6.301.362.
Participants
A non-probabilistic, intentional, and convenience-based sampling approach was used to select 70 independent community-dwelling older adults (aged 60 years or older) of both genders, all diagnosed with systemic arterial hypertension (SAH) and undergoing treatment at a Medical Specialties Center in the municipality of Sapezal, Mato Grosso, Brazil. The diagnosis of SAH and antihypertensive medication use were confirmed through electronic health records at the healthcare facility.
Participants were excluded if they:
- Used benzodiazepines, due to their mild nervous system inhibition, which includes anticonvulsant, sedative, muscle relaxant, and tranquilizing effects.
- Had osteoarticular diseases or injuries that prevented them from performing the required physical tests.
- Presented cognitive impairments that hindered accurate completion of the questionnaires.
- Had clinical evidence of pre-renal or post-renal hepatic or thyroid dysfunction.
Instruments
The authors developed a semi-structured questionnaire to assess the sociodemographic and health profiles of the older participants. The questionnaire included items on age, age group, sex, income in minimum wages, occupational status, retirement, education level, marital status, use of antihypertensive medication, use of medications in general, presence of comorbidities, history of falls and history of near falls.
Fall risk was assessed using the Timed Up and Go (TUG) test, a widely used tool to evaluate functional mobility and fall risk in older adults. In this test, participants rose from a chair, walked three meters, turned around, and returned to the chair. Individuals underwent assessment only after familiarization with the task. A predictive value of ≥ 12.47 seconds indicated high fall risk, while ≤ 12.47 seconds indicated low fall risk. (10)
Fear of falling was evaluated using the Falls Efficacy Scale-International (FES-I), a validated questionnaire designed to assess fear of falling in daily activities. It consists of 16 items covering different daily tasks, with responses ranging from 1 (not at all concerned) to 4 (extremely concerned). The total score ranges from 16 to 64, with higher scores indicating greater fear of falling. Cutoff points were used to categorize participants: < 23 – no fear of falling; ≥ 23 – occasional fear of falling; ≥ 31 – recurrent fear of falling. (11)
Procedures
Permission for the study was obtained from the Municipal Health Regulation Center of Sapezal-MT. The center arranged appointments for specialized consultations in Cardiology and Orthopedics, allowing patients to be referred to the Medical Specialties Center for consultations scheduled in advance. This facilitated contact with older individuals diagnosed with (or without) SAH and access to their medical records.
Eligible participants were identified through their scheduled consultations and invited to participate in the study. Those who met the inclusion criteria and agreed to participate signed an informed consent form (ICF), after which data collection was conducted by the researcher between September and November 2023.
Data análisis
Data analysis was performed using SPSS software version 25.0. Descriptive and inferential statistics were applied. Frequency and percentage were used as descriptive measures for categorical variables. The Chi-square test compared proportions of fall risk and fear of falling with time since SAH diagnosis, duration of antihypertensive use, and number of antihypertensive drugs used. Binary Logistic Regression (both crude and adjusted analyses) examined associations of SAH diagnosis, duration of antihypertensive use, and number of antihypertensive medications used (independent variables) with presence of fall risk and fear of falling associated with recurrent falls (dependent variables). Only variables showing significance levels of p ≤ 0.05 in the Chi-square test for association with fall risk and fear of falling were included in the regression analysis. Model fit was assessed using the Hosmer-Lemeshow test. A significance level of p < 0.05 was considered.
Results
Among the 70 older hypertensive individuals, a predominance of women was observed (67.1 %), aged between 60 and 70 years (64.3 %), without a partner (58.6 %), with a monthly income ranging from more than one to two minimum wages (64.3 %), retired (77.1 %), and inactive in occupational status (85.7 %). A majority reported regular health perception (67.1 %), regularly used three to four medications (71.4 %), and had no history of falls in the last six months (61.4 %). Most older individuals use two or more antihypertensive medications regularly (72.9 %), were diagnosed with SAH within the last five years (65.7 %) and have been using antihypertensive medications for at least one year (70.0 %).
The majority of older hypertensive individuals showed a presence of fall risk (71.4 %) and fear of falling associated with recurrent falls (60.0 %). A significant difference was found between groups regarding the number of antihypertensive medications (p < 0.001) and duration of antihypertensive use (p = 0.012), highlighting a higher proportion of older individuals using two or more antihypertensive medications and having had SAH diagnosed for more than four years, who also showed fall risk.
A significant difference was found between groups regarding the number of antihypertensive medications (p < 0.001), duration of antihypertensive use (p = 0.012), and time since SAH diagnosis (p = 0.004), indicating a higher proportion of older individuals using two or more antihypertensive medications, diagnosed with SAH for more than five years, and using antihypertensive medications for more than four years, who also reported fear of falling associated with recurrent falls.
For logistic regression analysis modeling, only variables with a significance level < 0.20 in the Chi-square test for the presence of fall risk and fear of falling (Tables 1 and 2) were considered. Table 1 presents the factors associated with fall risk. In the crude analysis, the following factors individually showed significant association with the presence of fall risk: number of antihypertensive medications (p < 0.001) and duration of antihypertensive use (p = 0.047). When the analysis was adjusted for all variables in the model, only the number of antihypertensive medications remained significantly associated (p < 0.05) with the presence of fall risk. It is noteworthy that older individuals using two or more antihypertensive medications have a 48.167 (95 % CI = 5.361-432.771) times higher chance of experiencing fall risk compared to those using only one antihypertensive medication.
Table 1: Factors associated with the presence of risk of falls in older individuals. Sapezal, Brazil, 2023.
*Significant association - p < 0.05: binary logistic regression. Alternatively, adjusted for all variables of the model. OR: Odds Ratio; CI: Confidence Interval.
Table 2 presents the factors associated with fear of falling and recurrent falls. In the crude analysis, all variables individually showed significant association with the presence of fear of falling associated with recurrent falls (p < 0.05). When the analysis was adjusted for all variables in the model, only the number of antihypertensive medications and duration of antihypertensive use remained significantly associated (p < 0.05) with fear of falling associated with recurrent falls. It is noteworthy that older individuals using two or more medications have a 15.007 (95 % CI = 2.920-77.115) times higher chance of experiencing fear of falling associated with recurrent falls compared to those using only one antihypertensive medication. Additionally, older individuals using antihypertensive medications for between one to four years and more than four years have, respectively, 6.679 (95 % CI = 1.374-33.357) and 13.444 (95 % CI = 1.387-130.305) times higher chances of experiencing fear of falling associated with recurrent falls compared to those using antihypertensive medications for less than one year.
Table 2: Factors associated with the fear of falling in older individuals. Sapezal, Brazil, 2023.
*Significant association – p < 0.05: binary logistic regression. Alternatively, adjusted for all variables. OR: Odds Ratio; CI: Confidence Interval.
Discussion
We found that older hypertensive individuals using two or more antihypertensive medications have a higher likelihood of experiencing fall risk and greater fear of falling compared to those using only one antihypertensive. Gomes et al. (12) emphasize that the use of multiple medications is associated with a higher risk of side effects and drug interactions. Antihypertensive medications, in particular, can cause symptoms such as dizziness, weakness, blurred vision, and fainting, especially when used in combination. (13) Moreover, the use of multiple antihypertensive medications can result in excessive blood pressure reduction, leading to orthostatic hypotension. (14) Orthostatic hypotension is associated with an increased risk of falls, as it can cause dizziness and fainting in older adults. (15)
We also found that older hypertensive individuals who have been using antihypertensives for more than a year are more likely to experience fear of falling associated with recurrent falls compared to those using antihypertensives for less than a year. This likelihood is even higher for those who have been using antihypertensives for more than four years. This may be because prolonged use of antihypertensive medications is associated with a greater risk of developing side effects and complications from the treatment. These side effects can include dizziness, muscle weakness, imbalance, and orthostatic hypotension, which increase the risk of falls. (16) Older individuals who have been using antihypertensives for a longer period may have an increased perception of vulnerability due to these cognitive and sensory changes, contributing to a greater fear of falling. (17)
A higher proportion of older individuals with a longer duration of SAH diagnosis was found to have a risk of falls and fear of falling associated with recurrent falls. First, according to Fuchs and Whelton, (1) SAH is a chronic condition that can cause progressive damage to blood vessels, the heart, the brain, and other organs over time. This damage can result in health complications affecting cardiovascular function, brain health, and balance and motor coordination, thus increasing the risk of falls. (18, 19)
Another aspect is the psychological impact of living with SAH for an extended period. Older individuals who have had chronic conditions for years may develop persistent concerns about their health and well-being, particularly if they have experienced complications related to SAH in the past, such as severe cardiovascular events. (20) Additionally, the prolonged time since the diagnosis of SAH may be associated with a gradual deterioration in overall health and physical functionality. Older individuals may experience progressive declines in muscle strength, balance, and coordination, heightening their vulnerability to falls and, consequently, their fear of falling. (21)
The study's limitations include selection bias from a non-probabilistic sample, restricting generalizability, and potential information bias from self-reported fall risk and fear data. Unmeasured variables, like health conditions and physical activity, may confound results. The cross-sectional design prevents causal analysis, and findings might be context specific. Another important limitation of this study was the small sample size (N = 70), which may have affected the precision of the statistical estimates. Smaller samples tend to produce wider confidence intervals, indicating greater uncertainty in the odds ratio estimates. This occurs because the limited number of observations reduces the stability of statistical calculations, increasing the variability of the results. Moreover, with a reduced number of participants, detecting statistically significant associations becomes more challenging, particularly when the effects under investigation are subtle or moderate. Expanding the sample size in future studies could provide more robust and precise estimates, reducing uncertainty and improving the generalizability of the findings.
Conclusion
Our findings indicate a significant link between the use of multiple antihypertensive medications and a higher risk of falls, as well as increased fear of falling in older hypertensive adults. Specifically, those using two or more medications are more likely to experience these risks compared to those using a single medication. Additionally, the duration of medication use is associated with fear of falling, as older adults on these drugs for over a year tend to have more recurrent falls, underscoring the need to consider both the quantity and duration of medication.
These findings have important clinical implications, as they highlight the necessity for comprehensive medication reviews in older hypertensive adults to balance blood pressure management with fall prevention strategies. Healthcare providers should assess medication regimens regularly, consider deprescribing strategies when appropriate, and incorporate fall risk assessments into routine care.
Future research should explore longitudinal studies to establish causal relationships and investigate alternative treatment approaches that minimize fall risk while maintaining effective blood pressure control. Additionally, intervention studies focusing on fall prevention programs tailored for hypertensive older adults could provide valuable insights into mitigating these risks.
Bibliographical references:
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Data availability: The data set supporting the results of this study is not available.
How to cite: Apolicena Dantas AC, Nunes Pires ML, De Lima Santos A, França Garcia L, Andrade do Nascimento Júnior JR, Covre da Silva G, Quadros da Silva E, Vicentini de Oliveira D. Fear and Risk of Falling in Older Hypertensive Individuals Undergoing Medication Treatment. Enfermería: Cuidados Humanizados. 2025;14(1):e4333. doi: 10.22235/ech.v14i1.4333
Authors’ contribution (CRediT Taxonomy): 1. Conceptualization; 2. Data curation; 3. Formal Analysis; 4. Funding acquisition; 5. Investigation; 6. Methodology; 7. Project administration; 8. Resources; 9. Software; 10. Supervision; 11. Validation; 12. Visualization; 13. Writing: original draft; 14. Writing: review & editing.
A. A. D. has contributed in 1, 2, 3, 6, 10, 11, 12; M. L. N. P. in 3, 6, 10, 11, 12; A. D. L. S. in 3, 6, 10, 11, 12; L. F: G. in 3, 14; J. R. A. D. N. J. in 3, 14; G. C. D. S. in 11, 12, 13, 14; E. Q. D. S. in 11, 12, 13, 14; D. V. D. O. in 1, 3, 5, 6, 7, 10, 11, 12, 13, 14.
Scientific editor in charge: Dr. Natalie Figueredo.
Enfermería: Cuidados Humanizados, 14(1)
january - june 2025
10.22235/ech.v14i1.4333