Risk of falls and syncope across frailty levels in hypertensive older adults: a longitudinal study

In older hypertensive adults, frailty may increase the risk of adverse events associated with blood pressure lowering, including syncope and falls. However, the degree of frailty at which these risks become clinically significant remains uncertain. The study aimed to compare clinical characteristics and the incidence of falls and syncope across different frailty levels among older hypertensive adults. We analyzed data from the longitudinal HYPER-FRAIL study, involving hypertensive outpatients ≥ 75 years undergoing comprehensive geriatric assessment. Frailty was defined according to the Clinical Frailty Scale (CFS). The incidence of a composite outcome of falls and syncope was compared between fit (CFS < 4), mildly frail (CFS = 4-5) and frailer participants (CFS ≥ 6). Among 194 participants (mean age 81 years, 45% male), frailty was absent in 53.6%, mild in 31.4% and moderate-to-severe in 14.9%. A history of falls was more commonly reported among frailer (48.3%) and mildly frail patients (45.9%) compared to fit individuals (21.2%; p < 0.001 for both frailty groups vs fit). Over a median 12-month follow-up, the composite outcome occurred in 13.5% of fit, 31.1% of mildly frail and 31% of frailer participants (p = 0.012 for mild vs absent frailty). Kaplan-Meier curves showed a greater risk in mild frailty (p = 0.003 vs fit participants), with no differences compared to the moderate-to-severe frailty group (p = 0.599). Mild frailty predicted syncope and falls independently of age, prior falls, orthostatic hypotension and depression, but not dementia. Mild frailty (i.e. CFS = 4-5) is common among hypertensive older adults and confers a risk of falls and syncope similar to that of moderate-to-severe frailty.