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Antihypertensives, orthostatic hypotension and falls

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The pathway from an over-tight blood pressure dose to a broken hip is specific, and it has nothing to do with blood pressure. It runs through orthostatic hypotension.

Before you read on

Never stop or change a prescribed medication without speaking to your own prescriber. Several of the classes described on this site rebound, or cause a withdrawal syndrome, when they are stopped abruptly, and some have to be reduced gradually over weeks or months under supervision. Nothing here is advice about your own medication, and nothing here is a reason to change anything on your own.

The pathway

An over-tight dose produces orthostatic hypotension — a drop in blood pressure on standing. That produces dizziness and, at the extreme, syncope. That produces falls, and in an older adult falls produce fractures and head injuries. The harm at the end of that chain is morbidity that has nothing to do with the condition being treated.

Both major criteria sets single out the same agents. The AGS Beers Criteria and STOPP/START each identify centrally acting antihypertensives and alpha-blockers as not recommended for routine treatment of hypertension in older adults.

What the evidence on withdrawal actually shows — and does not

This is the class where the gap between assumption and evidence is widest, so it is worth being precise.

The 2025 Cochrane review of withdrawing antihypertensive medications in older people pooled six randomized trials covering 1,073 participants aged 50 and over, with follow-up from 4 to 56 weeks. No new studies were found in that update. It reported:

  • Falls: “No studies reported falls.” Falls was a pre-specified secondary outcome and not a single included trial measured it. The review’s future-research section calls for trials measuring “clinically important outcomes such as adverse drug events, falls, and quality of life.”
  • Blood pressure rose after withdrawal — systolic by a mean of 9.75 mmHg (95% CI 7.33 to 12.18) and diastolic by 3.5 mmHg (95% CI 1.82 to 5.18), both low certainty.
  • All-cause mortality odds ratio 2.08 (95% CI 0.79 to 5.46) — little or no difference, low certainty. Stroke 1.44 (95% CI 0.25 to 8.35), low certainty. Hospitalization 0.83 (95% CI 0.33 to 2.10) from one study, low certainty.
  • Adverse drug withdrawal reactions were not specifically assessed by any included study.

The reviewers’ own summary is that these limitations “mean that we cannot draw any firm conclusions about the effect of deprescribing antihypertensives on these outcomes.”

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

What this means in practice

It does not mean the orthostatic pathway is imaginary — it is well described and it is why the criteria sets name specific agents. It means that a specific clinical judgment about a specific person who is having symptomatic hypotension is a different thing from a general policy of reducing antihypertensives to prevent falls, and only the first is supported.

The practical question is not “should this person be on fewer blood pressure medicines.” It is “is this person’s blood pressure dropping when they stand up, and is anyone measuring it.” An orthostatic measurement is cheap, takes three minutes, and is skipped constantly.

Abrupt withdrawal has its own hazard

Several antihypertensive classes rebound. Stopping abruptly can produce a sharp rise in blood pressure, and for some agents a withdrawal syndrome. This is one of the clearest illustrations of why a reduction is a supervised process with a taper and a monitoring window rather than a decision someone makes after reading a website.

What the same evidence says does reduce falls

The 2025 Cochrane review of falls prevention in care facilities — 104 randomized trials, 68,964 participants — found that medication optimization as a single intervention may make little or no difference to the rate of falls (rate ratio 0.92, 95% CI 0.75 to 1.13) and probably little or no difference to the risk of falling (relative risk 0.96, 95% CI 0.89 to 1.03). It found sustained exercise probably reduces the rate of falls (rate ratio 0.68), and that tailored multifactorial programs delivered with staff engagement probably produce a large reduction (rate ratio 0.61) — with medication optimization as one component of those programs.

Which is the shape of the honest answer: review the medication as part of a falls program, not instead of one. Deprescribing and falls.

The other half: undertreatment

It is worth remembering which direction the bigger gap runs in for cardiovascular drugs overall. A national survey analysis of 6,336 US community-dwelling adults aged 65 and over found only 44.3% of those with heart failure receiving an ACE inhibitor or ARB plus a beta blocker, and only 54.0% of those with albuminuria receiving an ACE inhibitor or ARB. STOPP/START exists partly because prescribing omissions are as common as inappropriate prescriptions. STOPP/START.

Common questions

Does reducing blood pressure medication prevent falls?

It has not been shown to. The Cochrane review of antihypertensive withdrawal found that no included trial measured falls at all, and the care-facilities falls review found medication optimization as a single intervention makes little or no difference to falls. Treating symptomatic orthostatic hypotension in a specific person is a different question, and a legitimate one. Deprescribing and falls.

Is it safe to stop a blood pressure medicine?

Not abruptly, and not without the prescriber. Several classes rebound, blood pressure rose measurably after withdrawal in the pooled randomized trials, and no included study specifically assessed adverse withdrawal reactions. Any change is a supervised process with a monitoring window. Tapering principles.

Back to the drug-class library.

References

  1. Gnjidic D, Langford AV, Jordan V, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database of Systematic Reviews. 2025;3(3):CD012572. PMID 40162571 · DOI 10.1002/14651858.CD012572.pub3.
  2. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.
  3. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
  4. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. PMID 37256475 · DOI 10.1007/s41999-023-00777-y. See also the published correction, Eur Geriatr Med. 2023;14(4):633, PMID 37326916.
  5. Pan S, Li S, Jiang S, et al. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011–2020. The Journals of Gerontology Series A. 2024;79(7):glae108. PMID 38644631 · DOI 10.1093/gerona/glae108.
  6. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  7. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.