Published August 2023
When Dr Oliver Todd from the University of Leeds embarked on a Dunhill Medical Trust Research Training Fellowship aimed at finding out whether blood pressure management is linked to an increased risk of falls, it opened up a whole new world of research to improve care for older people.
We’ve already seen the outputs of this research being put to use in shaping European primary care guidance, but the impact of this fellowship has gone far beyond my original research questionDr Oliver Todd
The outlook for frailer older people with a hip fracture can be very poor – only half of people coming into hospital as an emergency admission will survive for six months. At the same time, high blood pressure, or hypertension, is the commonest long term health condition in people over the age of 45, and causes around 7.5 million deaths every year worldwide. As a result, anti-hypertensive drugs are some of the most frequently prescribed medications.
However, while there are clinical guidelines aimed at diagnosing and treating high blood pressure, there is no clear guidance about when these medications should be reviewed or stopped if people’s lives and health change over the years and their blood pressure falls.
Working with older patients during my medical training, my colleagues and I noticed that many people admitted into hospital with hip fractures as a result of falling over had also been suffering from symptoms of low blood pressure, such as dizziness, before their accident. We wondered whether the two could be connected, and that perhaps inappropriate blood pressure management was contributing to an increased risk of falling.
Exploring the connection between blood pressure and falls
To find out whether blood pressure and fall risk were linked, I first carried out a systematic review to aggregate all the existing studies looking at both conditions.
I discovered that for older people who were not classed as frail, having higher blood pressure was associated with poorer outcomes, suggesting that maintaining good blood pressure control is important for this group. This association wasn’t seen in frailer people, indicating that they are at greater risk of harm from falls. However, scientific studies tend to exclude the most frail individuals, such as people living in care homes, so we couldn’t be sure we were getting the full picture.
We followed up this analysis by looking for connections between falls, frailty and blood pressure using real world data from routine health records and national databases. In contrast to the systematic review, a more complicated picture emerged from this deep data dive.
I knew we needed to look beyond the numbers and listen directly to the voices of patients themselves
We found that the more frail someone was, the greater their risk from both falls and the negative health impacts of high blood pressure, such as heart attacks and stroke. At the same time, we also know that the quality of blood pressure measurements can be highly variable in everyday clinical practice, adding a layer of uncertainty to the data. This all made it difficult to draw up hard and fast rules for the best management of these patients.
I also knew we needed to look beyond the numbers and listen directly to the voices of patients themselves. We spoke with 10 older people in the Bradford area from the Care75+ study, asking them about their lives, health and concerns, and how things were changing as the years passed.
We discovered that they placed a negative value on being described as ‘frail’, and were concerned that they might be ‘written off’ by doctors and miss out on treatment that could help them.
Their insights suggest that any guidance aimed at tailoring healthcare in frailer older people, to balance their risks from high blood pressure and falls, would need to be carefully and clearly communicated.
Opening up a new world of research
We’ve already seen the outputs of this research being put to use in shaping European primary care guidance, but the impact of this fellowship has gone far beyond my original research question.
The past three years have been really transformative, opening up new collaborations and opportunities, such as looking at how far we can generalise the results of clinical trials with older people when compared with routine health data. And it has sparked the formation of a national and European network of researchers working together to do data-driven research to improve care for older people.
We’re also still seeking answers to the question of how to balance blood pressure and fall risk in older people. I’m now setting up a new study involving 15,000 older people in Bradford that will link 24-hour blood pressure recordings to routine health data to help predict who is most at risk of falling and how best to care for them.
The past three years have been really transformative, opening up new collaborations and opportunities
This fellowship has been an incredible opportunity to work with expert health data researchers at the University of Oxford and the SAIL databank in Swansea – I could never have learned the data skills I needed to do this work without their help.
Through my fellowship I was also able to visit Professor Ken Rockwood, a renowned specialist in the care of older people at Dalhousie University in Nova Scotia, Canada, and see how they’re integrating research into clinical practice. It was a real eye-opener and I hope will enable me to build a team of my own in the future.
Find out more
You can read a separate blog post about Oly’s work on the Bradford Teaching Hospitals NHS Foundation Trust website.