Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older

The effect of a change in antihypertensive treatment on orthostatic hypotension in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) is common in older adults with hypertension. Antihypertensive treatment (AHT) prevents cardio- and cerebrovascular events. However, physicians are concerned to cause OH, making them hesitant to initiate or augment AHT in older adults with hypertension.

METHODS

We systematically researched electronic databases for trials with older participants (≥65 years) with hypertension and OH assessment after initiating, discontinuing, or augmenting AHT. Study quality was assessed using the ROBINS-I tool. Meta-analyses on OH prevalence and postural blood pressure (BP) drop were performed.

RESULTS

Twenty-five studies (26,695 participants) met inclusion criteria, of which fifteen could be included in the meta-analyses. OH prevalence decreased after AHT initiation or augmentation (risk ratio 0.39 (95 % CI = 0.21-0.72; I2 = 47 %; p < 0.01), n = 6 studies), but also after AHT discontinuation (risk ratio 0.39 (95 % CI = 0.28-0.55; I2 = 0 %; p < 0.01), n = 2 studies). Postural BP drop did not change after initiation or augmentation of AHT (mean difference 1.07 (95 % CI = -0.49-2.64; I2 = 92 %; p = 0.18), n = 11 studies). The main reason for ten studies not to be included in the meta-analyses was absence of baseline OH data. Most of these studies reported OH incidences between 0 and 2 %. Studies were heterogeneous in OH assessment methods (postural change, timing of BP measurements, and OH definition). Risk of bias was moderate to serious in twenty studies.

CONCLUSION

Results suggest that AHT initiation or augmentation decreases OH prevalence, implying that the risk of inducing OH may be overestimated in current AHT decision-making in older adults. However, the overall low level of evidence and the finding that AHT discontinuation reduces OH prevalence limit firm conclusions at present and highlight an important research gap. Future AHT trials in older adults should measure OH in a standardized protocol, adhering to consensus guidelines to overcome these limitations.

Epidemiology and Risk Factors for Orthostatic Hypotension and Its Severity in Residents Aged > 60 years: A Cross-Sectional Study

This cross-sectional study investigated the epidemiology and risk factors associated with orthostatic hypotension (OH) and its severity in older adults residing in the Jizhou community of Tianjin and the Jimei community of Xiamen. The study, conducted from March to September 2019, involved adults aged over 60. A comprehensive questionnaire survey was administered, resulting in the enrolment of 4383 older adults. The overall prevalence of OH was found to be 11.7% (516 out of 4383). Notably, a significant gender difference was observed, with a prevalence of 10% among males (194 out of 1926) and 13.1% among females (322 out of 2457) (P=0.002). Among individuals with OH, 332 exhibited mild symptoms, 64 had moderate OH, 58 had severe OH cases, and 50 have very severe OH. Multivariable logistic regression analysis revealed that being female, widowed, engaging in general social activities, and a history of hypertension, migraines, heart disease, cerebrovascular disease, and mental health conditions (anxiety and depression) were independently associated with OH. Ordinal logistic regression analysis further confirmed that hypertension, migraine, and a history of general anesthesia surgery were independently associated with the severity of OH. This study highlights a relatively high prevalence of OH among older adults in the Jizhou community of Tianjin and the Jimei community of Xiamen, China. The identified risk factors, particularly social activities, and hypertension, significantly influence the severity of OH. Further examination is required to corroborate these findings and investigate potential interventions.

Orthostatic hypotension in the elderly: Prevalence and its management by simple isometric limb tensing exercises

Objective

Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors of OH among the elderly attending a secondary care hospital. Furthermore, we assessed and compared the effectiveness of simple arm and leg tensing exercises, performed just prior to standing, to mitigate the orthostatic fall in blood pressure (BP) in elderly OH patients.

Materials and Methods

A cross-sectional study screened elderly patients (≥65 years) for OH and recruited them into a randomized controlled trial (CTRI/2020/08/027182) of two parallel groups performing either arm tensing or leg tensing exercises just before standing up. We performed an interim analysis of the ongoing trial using paired t-test for within-group comparisons. Patients identified to have OH based on systolic or diastolic fall in BP were analyzed separately. Chi-square analysis compared the improvement in OH status between the two groups.

Results

Nineteen out of 186 screened elderly patients were diagnosed with OH (10.21%, 95% CI: 7.99-12.43). Arm exercise significantly reduced the orthostatic-induced fall in systolic and diastolic BP, while leg exercise effectively reduced only the systolic fall in BP among patients with OH. The proportion of patients with OH after arm exercise (20%) was significantly lower than after leg exercise (77.8%) (P = 0.023, Fischer's exact test).

Conclusion

We found a 10.21% prevalence of OH in our elderly population. Furthermore, we found that simple isometric arm tensing exercise ameliorates the fall in BP on standing up in OH patients.

Association of blood pressure and postural control in older adults with hypertension: an observational study

The study investigated the association of orthostatic hypotension (OH) with functional position change and balance in older adults with hypertension. The presence of OH was assessed with intermittent (OH intermittent) and continuous blood pressure (OH continuous) monitoring. The change in functional position was tested with sitting to standing assessment, balance performance using activity specific balance confidence scale (ABC), and timed up and go test (TUG). Testing unilateral and bilateral standing with and without altered sensory inputs was tested using the Humac balance system. ABC, TUG, and standing up time showed no significant association with OH intermittent and OH continuous. A significant association was found between bilateral standing with eyes closed on foam surface for overall stability index and OH intermittent. Older people with hypertension may be routinely examined for OH and appropriate intervention strategies should be included for comprehensive care.

A community-based cross-sectional survey of orthostatic hypotension among elderly from south India

BACKGROUND

Orthostatic hypotension (OH) increases the risk of falls and associated morbidity and mortality in elderly. Hence, determining the prevalence of OH and its associated factors is important, especially in understudied LMIC settings.

METHODS

A community-based cross-sectional study was conducted among randomly selected 240 community-dwelling elderly from Thiruvananthapuram, Kerala. The OH symptoms were assessed by standard clinical measurements and frailty was assessed by modified Fried frailty phenotype. Logistic regression analysis was conducted to assess the factors associated with OH.

RESULTS

The prevalence of OH and frailty among participants was 9.6 and 29.2 percent respectively. In the first minute, OH was associated with increased odds of falls (OR = 1.97 [95%CI = 1.05, 3.72]). Increase in number of co-morbidities (OR_adj = 1.82 [95%CI = 1.36, 2.48]), number of medicines used (OR_adj = 1.73 [95%CI = 1.28, 2.34]), and orthostatic intolerance (OR_adj = 3.67 [95%CI = 1.13, 11.94]) increased the odds of having OH. Elderly with diabetes (OR_adj = 4.81 [95%CI = 1.57, 14.77]), hypertension (OR_adj = 4.97 [95%CI = 1.01, 24.46]) and cognitive impairment (OR_adj = 5.01 [95%CI = 1.40, 18.51]) were at a higher odds of having OH.

CONCLUSIONS

OH and frailty are prevalent in community dwelling elderly in Thiruvananthapuram district. Frailty may be a risk factor for OH in the first minute. The number of co-morbidities may be an independent risk factor for OH. Hence, elderly people with comorbidities and cognitive impairment may be actively assessed for OH to prevent falls and associated injuries.

Orthostatic hypotension following posterior spinal fusion surgeries for spinal deformity correction in adolescents: prevalence and risk factors

Study design

Retrospective case series.

Objectives

This study aimed to determine the prevalence and risk factors for orthostatic hypotension (OH) in adolescents undergoing posterior spinal fusion for spinal deformity correction.

Methods

The data of 282 consecutive adolescents who underwent posterior spinal fusion for spinal deformity correction in our center over 12 months were retrieved. Patient characteristics, including whether laminectomy or osteotomy was performed during the surgery, the occurrence of postoperative nausea and vomiting (PONV), perioperative hemoglobin albumin changes, perioperative blood transfusion, length of bed rest, willingness to ambulate, length of postoperative exercises of the lower limbs, and length of hospital stay, were collected and compared statistically between patients who did and did not develop postoperative OH.

Results

Of 282 patients, 197 (69.86%) developed OH postoperatively, and all cases completely resolved 5 days after the first out-of-bed exercises. Significant differences in the incidence of PONV, the willingness to ambulate and the length of postoperative exercises of the lower limbs were observed. The mean length of hospital stay of the patients with OH was longer than that of the patients without OH.

Conclusion

Our study suggests that temporary OH is a common manifestation following posterior spinal fusion for spinal deformity correction in adolescents. Postoperative OH may increase the length of hospital stay in these patients. Patients with PONV, who are not willing to ambulate and who perform postoperative lower limb exercises for a shorter time are more likely to have OH.

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.

Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis

BACKGROUND

Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.

METHODS

Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.

RESULTS

One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2 = 99%) for 34 community cohorts, 19% (15-25%; I2 = 98%) for 23 primary care cohorts and 31% (15-50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16-23%; I2 = 98%) with hypertension (20 cohorts), 21% (16-26%; I2 = 92%) with diabetes (4 cohorts), 25% (18-33%; I2 = 88%) with Parkinson's disease (7 cohorts) and 29% (25-33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12-17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04).

CONCLUSIONS

PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.

PROSPERO

CRD42017075423.

Does arterial stiffness affect orthostatic hypotension among high-altitude Tibetans?

OBJECTIVE

This study aimed to investigate the association between arterial stiffness and orthostatic hypotension (OH) and orthostatic blood pressure (BP) changes among Tibetans living at high altitude.

METHODS

A total of 630 high-altitude Tibetans were included (56.53 ± 10.16 years; 246 men). Arterial stiffness was assessed by brachial-ankle pulse wave velocity (baPWV). OH was defined as a decrease in systolic BP (SBP) >20 mmHg or a decrease in diastolic BP (DBP) >10 mmHg after 1 min or 3 min of moving from supine to standing position.

RESULTS

The prevalence of OH in this population was 6.3%. Compared with subjects without OH, the subjects with OH had a higher baPWV (P < 0.001). Multiple logistical regression found that baPWV was significantly associated with the occurrence of OH (OR 1.147, CI 95% 1.028-1.280, P = 0.014). Spearman correlation analysis showed that baPWV was negatively associated with orthostatic changes in SBP and DBP(r = -0.256, P < 0.001 and r = -0.194, P < 0.001, respectively). Further multiple stepwise linear regression analysis showed that baPWV was independently correlated with orthostatic BP changes (SBP: β = -0.599, P < 0.001; DBP: β = -0.333, P < 0.001). Moreover, increased baPWV was correlated with attenuation of orthostatic heart rate changes. No significant association was observed between hematocrit or hemoglobin concentration and OH.

CONCLUSION

BaPWV was significantly associated with the occurrence of OH and orthostatic changes in the SBP and DBP, which suggests that arterial stiffness may be a potential mechanism of impaired hemodynamic response to orthostatic challenges among high-altitude Tibetans.

The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis

BACKGROUND

Orthostatic hypotension (OH) is associated with increased risk of falls, cognitive impairment and death, as well as a reduced quality of life. Although it is presumed to be common in older people, estimates of its prevalence vary widely. This study aims to address this by pooling the results of epidemiological studies.

METHODS

MEDLINE, EMBASE, PubMed, Web of Science, and ProQuest were searched. Studies were included if participants were more than 60 years, were set within the community or within long-term care and diagnosis was based on a postural drop in systolic blood pressure (BP) ≥20 mmHg or diastolic BP ≥10 mmHg. Data were extracted independently by two reviewers. Random and quality effects models were used for pooled analysis.

RESULTS

Of 23,090 identified records, 20 studies were included for community-dwelling older people (n = 24,967) and six were included for older people in long-term settings (n = 2,694). There was substantial variation in methods used to identify OH with differing supine rest duration, frequency and timing of standing BP, measurement device, use of standing and tilt-tables and interpretation of the diagnostic drop in BP. The pooled prevalence of OH in community-dwelling older people was 22.2% (95% CI = 17, 28) and 23.9% (95% CI = 18.2, 30.1) in long-term settings. There was significant heterogeneity in both pooled results (I2 > 90%).

CONCLUSIONS

OH is very common, affecting one in five community-dwelling older people and almost one in four older people in long-term care. There is great variability in methods used to identify OH.

Value of ambulatory blood pressure measurement in diagnosing hypotension in hypertensive diabetic patients with medication-controlled BP

Background

Hypotension is a common clinical finding in diabetic patients on anti-hypertensive medications. In the absence of clearly defined and documented hypotensive episodes, clinicians are faced with the challenge of modifying antihypertensive medication in potentially symptomatic diabetic patients.

Objective

To determine the value of ambulatory blood pressure monitor (ABPM) in diagnosing hypotensive episodes in hypertensive diabetic patients with medication-controlled blood pressure.

Patients and methods

The records of all hypertensive diabetic patients with medication-controlled were obtained between 2017 and 2018. Patients' demographic data, comorbid conditions, hypotensive symptoms and echocardiography results were obtained and compared to office-based blood pressure and ABPM.

Results

Of 926 patients screened in the department of medicine outpatient clinics, 231 patients had diabetes and hypertension and were taking antihypertension medications, so only 86 patients were recruited. Using 24 h ABPM, hypotensive events were documented in 65 (75.6%) patients without correlated hypotensive symptoms in the patient sheet. Patients who had hypotensive episodes recorded by ABPM tended to have these between 5 and 10 a.m. and were significantly older - 60.71 versus 58.76 (P = .022) - and more likely to have lower ejection fractions by echocardiography 46.31 versus 62.85 (EF) (P < .001).

Conclusion

In treated hypertensive diabetic patients with antihypertensive medication, ABPM may be beneficial in capturing bouts of asymptomatic (silent) hypotension readings that occur in the out-of-hospital setting. Diabetic patients with controlled hypertension based on office reading showed a significant number of asymptomatic hypotensive readings detected with ambulatory BP monitoring that can have a role in following up such patients.

Prevalence and related factors of office and home hypotension in older treated hypertensive patients

BACKGROUND

Older hypertensive adults under treatment are especially susceptible to hypotensive episodes, which entail an elevated risk. However, data on this subject are very scarce.

AIM

The purpose of this study was to determine the prevalence and predictors of office and home hypotension in older (≥ 65 years) treated hypertensive adults.

METHODS

Blood pressure (BP) was measured at the office and at home, using a validated oscillometric device. Office and home hypotension were defined as systolic BP (SBP) < 110 and/or diastolic BP (DBP) < 70 mmHg, and SBP < 105 and/or DBP < 65 mmHg, respectively. Masked hypotension was considered when office BP ≥ 110/70 and home BP < 105 and/or < 65 mmHg. We evaluated factors associated with hypotension both at the office and at home through multivariable models.

RESULTS

The prevalence of hypotension among the 302 patients included in the study was 29.8% at the office and 23.9% at home, whereas the prevalence of masked hypotension was 10.4%. Older age, lower body mass index and use of calcium channel blockers were associated with office hypotension, while older age, diabetes and ischemic heart disease were predictors for home hypotension.

CONCLUSION

Hypotension is frequent in older hypertensive adults under treatment. The presence of diabetes, ischemic heart disease and older age should alert for screening of hypotension at home to avoid overtreatment.

Regulation of Cell Behavior by Hydrostatic Pressure

Hydrostatic pressure (HP) regulates diverse cell behaviors including differentiation, migration, apoptosis, and proliferation. Abnormal HP is associated with pathologies including glaucoma and hypertensive fibrotic remodeling. In this review, recent advances in quantifying and predicting how cells respond to HP across several tissue systems are presented, including tissues of the brain, eye, vasculature and bladder, as well as articular cartilage. Finally, some promising directions on the study of cell behaviors regulated by HP are proposed.

Nonpharmacologic Management of Orthostatic Hypotension in Older People: A Systematic Review. The SENATOR ONTOP Series

OBJECTIVES

Nonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.

DESIGN

Systematic review of systematic reviews.

SETTING AND PARTICIPANTS

MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.

RESULTS

Eleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) -12.56, -7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI -18.20, -6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.

CONCLUSIONS/IMPLICATIONS

There is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.

Effects of sodium intake on postural lightheadedness: Results from the DASH-sodium trial

Lightheadedness after standing contributes to adverse clinical events, including falls. Recommendations for higher sodium intake to treat postural lightheadedness have not been evaluated in a trial setting. The Dietary Approaches to Stop Hypertension (DASH)-Sodium trial (1998-1999) tested the effects of the DASH diet and sodium reduction on blood pressure (BP). Participants were randomly assigned to DASH or a typical Western diet (control). During either diet, participants ate three sodium levels (50, 100, 150 meq/d at 2100 kcal) in random order for 30-days, separated by 5-day breaks. Participants reported the presence and severity of postural lightheadedness at baseline and after each feeding period. There were 412 participants (mean age 48 years; 57% women; 57% black). Mean baseline SBP/DBP was 135/86 mm Hg; 9.5% reported baseline lightheadedness. Among those consuming the DASH diet, high vs low sodium increased lightheadedness (OR 1.71; 95% CI: 1.01, 2.90; P = 0.047) and severity of lightheadedness (P = 0.02), but did not affect lightheadedness in those consuming the control diet (OR 0.77; 95% CI: 0.46, 1.29; P = 0.32). Among those consuming high vs low sodium in the context of the DASH diet, adults <60 vs ≥60 years old experienced more lightheadedness (P-interaction = 0.04), along with obese vs non-obese adults (P-interaction = 0.01). In the context of the DASH diet, higher sodium intake was associated with more frequent and severe lightheadedness. These findings challenge traditional recommendations to increase sodium intake to prevent lightheadedness.

Health and Functional Determinants of Orthostatic Hypotension in Geriatric Ward Patients: A Retrospective Cross Sectional Cohort Study

OBJECTIVE

Orthostatic hypotension (OH) is a common problem in older people. Although it is indicated that OH can be a marker of frailty there are no studies that evaluate this relationship in hospitalized patients. The aim of the study was to assess the prevalence of OH in geriatric ward patients and its association with health and functional ability characteristics and patients' frailty status.

DESIGN AND SETTING

A retrospective cross-sectional cohort study was conducted among patients aged 60 or over hospitalized in the geriatric ward.

PARTICIPANTS

Patients' medical records were analyzed and those with Active Standing Test (AST) results were included in the study.

MEASUREMENTS

Orthostatic hypotension was defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up in AST. The database included sociodemographic characteristics, nutritional, functional and cognitive state, comorbidity and medical treatment. Frailty syndrome was diagnosed with Clinical Frailty Scale. Correlations with OH were counted and multivariable logistic regression models were built.

RESULTS

416 patients were hospitalized in the study period and 353 (84.9%) were included, 78 (22.1%) men and 298 (84.4%) 75+ year-old. AST was not available in patients significantly more dependent in ADL and more frail. OH was diagnosed in 57 (16.2%) patients, significantly more frequently in men (systolic- 45,5%, systolic-diastolic- 40,0%). The significant independent predictors of OH were lower diastolic blood pressure at admittance, nutritional risk in MNA-SF, Parkinson disease, α1-blockers, neuroleptics and memantine, and not the frailty syndrome diagnosed with Clinical Frailty Scale.

CONCLUSIONS

OH affects a significant percentage of patients in the geriatric ward, although this problem may be underestimated due to limitations in the performance of AST in very frail and functionally dependent patients.

Association of Beta-Blockers with Survival on Patients Presenting with ACS Treated with PCI: A Propensity Score Analysis from the BleeMACS Registry

PURPOSE

The aim was to evaluate prognostic value of beta-blocker (BB) administration in acute coronary syndromes (ACS) patients in the percutaneous coronary intervention (PCI) era.

METHODS AND RESULTS

The BleeMACS project is a multicenter, observational, retrospective registry enrolling patients with ACS worldwide in 15 hospitals. Patients discharged with BB therapy were compared to those discharged without a BB before and after propensity score with matching. The primary endpoint was all-cause mortality at 1 year. Secondary endpoints included in-hospital reinfarction, in-hospital heart failure, 1-year myocardial infarction, 1-year bleeding and 1-year composite of death and recurrent myocardial infarction. After matching, 2935 patients for each group were enrolled. The primary endpoint of 1-year death was significantly lower in the group on BB therapy (4.5 vs 7%, p < 0.05), while only a trend was noted for recurrent acute myocardial infarction (4.5 vs 4.9%, p = 0.54). These results were consistent for patients older than 80 years of age, for ST-elevation myocardial infarction (STEMI) patients, and for those discharged with complete versus incomplete revascularization, but not for non-STEMI/unstable angina patients.

CONCLUSIONS

BB therapy was related to 1-year lower risk of all-cause mortality, independently from completeness of revascularization, admission diagnosis, age and ejection fraction. Randomized controlled trials for patients treated with PCI for ACS should be performed.

Orthostatic Hypotension and Associated Factors among Home Care Clients Aged 75 Years or Older - A Population-Based Study

OBJECTIVES

The aim of this study was to examine orthostatic hypotension (OH) and associated factors among home care clients aged 75 years or older.

DESIGN

Non-randomised controlled study.

SETTING AND PARTICIPANTS

The study sample included 244 home care clients aged 75 years or older living in Eastern and Central Finland.

MEASUREMENTS

Nurses, nutritionists and pharmacists collected clinical data including orthostatic blood pressure, depressive symptoms (15-item Geriatric Depression Scale GDS-15), nutritional status (Mini Nutritional Assessment MNA), drug use, self-rated health, daily activities (Barthel ADL Index and Lawton and Brody IADL scale) and self-rated ability to walk 400 metres. Comorbidities were based on medical records.

RESULTS

The prevalence of OH was 35.7% (n = 87). No association between OH and the number of drugs used or causative drug use and OH was found. In univariate analysis, coronary heart disease, systolic and diastolic blood pressure in a sitting position and lower mean MNA scores were associated with a risk of OH. Multivariate analysis showed that lower mean MNA scores (OR 1.140, 95% CI: 1.014-1.283) appeared to be independently connected to a risk of OH.

CONCLUSION

One-third of the home clients had OH and it was associated with lower MNA scores.

Orthostatic hypotension: pathophysiology, assessment, treatment and the paradox of supine hypertension

Both hypertension and orthostatic hypotension (OH) are strongly age-associated and are common management problems in older people. However, unlike hypertension, management of OH has unique challenges with few well-established treatments. Not infrequently, they both coexist, further compounding the management. This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management. Special references are made to patients with supine hypertension and postprandial hypotension and older hypertensive patients.

Hyponatremia in the elderly: challenges and solutions

Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome. The aim of this review is to present certain challenges in the evaluation and treatment of hyponatremia in the elderly population and provide practical solutions. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multifactorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. The treatment of hyponatremia depends on the type of hyponatremia. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. In conclusion, both the evaluation and the treatment of hyponatremia pose many challenges in the elderly population.

Postural Hypotension and Cognitive Function in Older Adults

Background: Cognitive decline in the elderly is associated with chronic cerebral hypoperfusion. While many forms of exercise can slow or reverse cognitive decline, compliance in unsupervised exercise programs is poor. Objective: We address whether passive exercise, that is, muscle stimulation, is capable of reversing postural hypotension in an older adult population sufficiently to significantly improve cognitive function as measured by executive function tests. Subjects and Methods: In this study, 50- to 80-year-old women underwent cognitive testing, long-duration cardiac hemodynamic recordings during quiet sitting, and 60 min of soleus muscle stimulation with continued hemodynamic recording. Results: Two thirds of our subjects were hypotensive (diastolic blood pressure [DBP] < 70 mmHg) after 30 min of quiet sitting. Cognitive performance was significantly better in individuals with higher DBPs (0.79 s per 1-mmHg increase in DBP). Soleus muscle stimulation resulted in an average increase in DBP of 6.1 mmHg, which could translate into a 30% or greater improvement in cognitive performance. Conclusions: Incongruent Stroop testing provides high statistical power for distinguishing differential cognitive responses to resting DBP levels. These results set the stage to investigate whether regular use of calf muscle pump stimulation could effectively reverse age-related cognitive impairment.

Orthostatic hypotension: prevalence and associated risk factors among the ambulatory elderly in an Asian population

INTRODUCTION

The prevalence of orthostatic hypotension (OH) among the elderly population in Singapore, as defined by a decline in blood pressure upon a change in position, is not well-established. Studies associate OH with clinically significant outcomes such as falls. This study aims to determine the prevalence of OH among elderly patients attending a public primary care clinic (polyclinic) for chronic disease management, and examine the relationships between postulated risk factors and OH.

METHODS

Patients aged ≥ 65 years attending a typical polyclinic in Geylang were identified and targeted for recruitment at the study site. A questionnaire on symptoms and postulated risk factors was administered, followed by supine and standing blood pressure measurements. Cross-sectional analysis was performed with independent sample t-test for continuous data and chi-square test for categorical data. Prevalence rate ratios with 95% confidence interval were calculated for the latter.

RESULTS

A total of 364 multiethnic patients participated in the study. The prevalence of OH was 11.0%. Older age, comorbidities such as cardiac failure and kidney disease, being physically inactive at work, fatigue, self-reported dizziness in the past year, and the use of loop diuretics were found to be significantly associated with OH.

CONCLUSION

About one in ten elderly patients at a local polyclinic was affected by OH, which was associated with multiple factors. Some of these factors are modifiable and can be addressed to reduce the incidence of OH.

Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study

BACKGROUND

Orthostatic hypotension (OH) is commonly reported among older adults and is associated with an increased risk of mortality. This study aimed to describe the prevalence and investigate the possible associations between OH with sociodemographic variables, chronic medical conditions, health service utilisation, dementia and cognitive status among older adults residing in Singapore.

METHODS

Data was collected from 2266 participants aged 60 years and older who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013. Face-to-face interviews were conducted and data collected includes sociodemographic information, blood pressure measurements, medical history, health services utilisation, and cognitive status.

RESULTS

The prevalence of OH among older adults in Singapore was 7.8%. OH was highest in participants aged 85 years and above (OR: 2.33; 1.26-4.30; p=0.007) compared to those aged 75-84 years (OR: 1.76; 1.08-2.85; p=0.023). Participants with hypertension were more likely to have OH (OR: 3.03; 1.56-5.88, p=0.001) than those without hypertension. Those with dementia were also more likely to have OH than those with normal cognitive status (p=0.007).

CONCLUSIONS

Older age, hypertension, and dementia were independently associated with OH in the older adult population in Singapore. Interventions such as home safety assessment and preventive measures should be implemented to improve older adult's functional capacity and quality of life to prevent injury.

Assessment of effects of differences in trunk posture during Fowler's position on hemodynamics and cardiovascular regulation in older and younger subjects

Background

Downward shifts in blood volume with changing position generally cause tachycardic responses. Age-related decreases in vagal nerve activity could contribute to orthostatic hypotension in older individuals. Fowler’s position is a reclined position with the back between 30° and 60°, used to facilitate breathing, eating, and other routine daily activities in frail and elderly patients.

Objective

This study examined whether stroke volume (SV) was higher and heart rate (HR) lower in Fowler’s position with an upright upper trunk than in Fowler’s position with the whole trunk upright in both older and younger subjects, based on the assumption that lower HR would result from reduced sympathetic activation in older individuals.

Methods

We assessed hemodynamics and HR variability from electrocardiography, noninvasive arterial pressure and impedance cardiography in 11 younger male subjects (age range, 20–22 years) and 11 older male subjects (age range, 64–79 years), using three positions: supine, or Fowler’s positions with either 30° of lower trunk inclination and 60° of upper trunk inclination (UT60) or 60° of whole trunk inclination (WT60). Comparisons were then made between age groups and between positions.

Results

Reductions in SV and tachycardic response were smaller with UT60 than with WT60, in both younger and older subjects. In addition, reduced tachycardic response with upright upper trunk appeared attributable to decreased vagal withdrawal in younger subjects and to reduced sympathetic activation in older subjects.

Conclusion

Our findings indicate that an upright upper trunk during Fowler’s position allowed maintenance of SV and inhibited tachycardic response compared to an upright whole trunk regardless of age, although the autonomic mechanisms underlying tachycardic responses differed between younger and older adults. An upright upper trunk in Fowler’s position might help to reduce orthostatic stress and facilitate routine activities and conversation in frail patients.

[Orthostatic hypotension; that great unknown]

Orthostatic hypotension is an anomaly of growing interest in scientific research. Although certain neurogenic diseases are associated with this phenomenon, it can also be associated with non-neurological causes. Although orthostatic hypotension is defined by consensus as a decrease in the systolic blood pressure of at least 20mmHg, or a decrease in diastolic blood pressure of at least 10mmHg, within 3min of standing, the studies differ on how to diagnose it. Orthostatic hypotension is associated with certain cardiovascular risk factors and with drug treatment, but the results are contradictory. The purpose of this review is to update the knowledge about orthostatic hypotension and its treatment, as well as to propose a method to standardise its diagnosis.

Lower body mass index is associated with orthostatic hypotension in Parkinson's disease

INTRODUCTION

Lower body mass index (BMI) is associated with orthostatic hypotension (OH) in the general population, especially in the elderly; however, no studies have addressed this issue in Parkinson's disease (PD).

METHODS

We investigated the results of the head-up tilt test and BMI of patients with PD, and evaluated whether BMI is related to orthostatic systolic blood pressure (SBP) change during the head-up tilt test. PD patients were divided into male and female groups, and further divided into middle-aged (age<65years) and elderly (age≥65years) subgroups in each sex.

RESULTS

OH was observed in 13 of 64 male and 12 of 75 female patients with PD. BMI was lower in patients with OH than in those without, in both men and women. In the elderly group, a significant correlation between BMI and orthostatic SBP change was found (men, r=0.47, p=0.006; women, r=0.43, p=0.005), and a BMI below mean-0.5 standard deviation increased OH odds (men: BMI<20.5; odds ratio, 6.79; 95% CI, 1.06-43.36; women: BMI<18.5; odds ratio, 5.11; 95% CI, 1.05-24.96).

CONCLUSION

Lower BMI is a predisposing factor of OH in elderly patients with PD.

Orthostatic hypotension and drug therapy in patients at an outpatient comprehensive geriatric assessment unit

OBJECTIVE

To assess the rate of orthostatic hypotension and factors associated with it among elderly patients who underwent a comprehensive, ambulatory geriatric assessment.

METHODS

The study included patients 65 years and older who were assessed in the outpatient comprehensive geriatric assessment unit. Data were collected from the computerized medical record including sociodemographic data, lifestyle, falls, blood pressure, BMI, functional and cognitive status, medications, and comorbidity.

RESULTS

The study population consisted of 571 patients who underwent assessment over a nine-year period. The mean age was 83.7 ± 6.1, 35.9% were men, and 183 (32.1%) were diagnosed with orthostatic hypotension. Multiple drugs, in general, and multiple drugs with the potential to cause orthostatic hypotension in particular increased the risk for orthostatic hypotension after adjustment for age, sex, chronic comorbidity, and supine systolic blood pressure ≥150 mmHg [odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.03-1.14 and OR = 1.22, 95% CI: 1.08-1.37, respectively]. In addition, α-blockers and calcium channel blockers increased the risk for orthostatic hypotension after similar adjustments (OR = 1.82, 95% CI: 1.01-3.16 and OR = 1.66, 95% CI: 1.11-2.48, respectively). Similarly, two additional drug types increased the risk for orthostatic hypotension: selective serotonin reuptake inhibitors (OR = 2.09, 95% CI: 1.33-3.19) and tricyclic antidepressants (OR = 4.36, 95% CI: 1.85-10.06). There were no specific associations between age, cognitive and functional state, morbidity (as measured by the Charlson Comorbidity Index), and specific diseases, and orthostatic hypotension.

CONCLUSION

The results of the present study reinforce evidence of an association between drug therapy and orthostatic hypotension.

Ambulatory blood pressure monitoring in older people with dementia: a systematic review of tolerability

BACKGROUND

ambulatory blood pressure monitoring (ABPM) may be helpful for the management of hypertension, but little is known about its tolerability in people with dementia.

OBJECTIVE

to review the published evidence to determine the tolerability of ABPM in people with dementia.

METHODS

English language search conducted in MEDLINE and EMBASE, using 'Ambulatory blood pressure' AND 'Dementia' (and associated synonyms) from 1996 to March 2015.

INCLUSION CRITERIA

people diagnosed with dementia AND in whom blood pressure was measured using ABPM. The initial search was undertaken using title and abstract reviews, with selected papers being agreed for inclusion by two reviewers. Potentially eligible papers were assessed, and high-quality papers were retained. Two reviewers agreed the abstracted data for analysis. Meta-analysis was used to combine results across studies.

RESULTS

of the 221 screened abstracts, 13 studies (6%) met inclusion criteria, 5 had sufficient data and were of sufficient quality, involving 461 participants, most of whom had mild-moderate dementia. 77.7% (95% CI 62.2-93.2%) were able to tolerate ABPM; agreement with office BP was moderate to weak (two studies only-coefficients 0.3-0.38 for systolic blood pressure and 0.11-0.32 for diastolic blood pressure). One study compared home BP monitoring by a relative or ambulatory BP monitoring with office BP measures and found high agreement (κ 0.81). The little available evidence suggested increased levels of dementia being associated with reduced tolerability.

CONCLUSIONS

ABPM is well tolerated in people with mild-moderate dementia and provides some additional information over and above office BP alone. However, few studies have addressed ABPM in people with more severe dementia.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment

The prevalence of cognitive impairment and orthostatic hypotension (OH) increases with age, but the results of studies that assessed possible associations between them are inconsistent.The aim of this study is to assess possible associations between cognitive impairment and OH in patients ≥65 years of age who underwent a comprehensive geriatric assessment.A retrospective analysis was conducted of the computerized medical records of the study population from 2005 to 2013. Data collected included blood pressure measurements that enabled the calculation of OH, results of the mini-mental state examination (MMSE), results of the Montreal cognitive assessment (MoCA) test, and cognitive diagnoses that were determined over the course of the assessment.The rate of OH in the study population of 571 adults was 32.1%. The mean MMSE score was 22.5 ± 5.2 among participants with OH and 21.6 ± 5.8 among those without OH (P = 0.09). The absence of a significant association between OH and MMSE remained after adjusting the MMSE score for age and education level. The mean MoCA score was 16.4 ± 5.0 among participants with OH and 16.4 ± 4.8 among those without (P = 0.33). The prevalence of OH was 39% among participants without cognitive impairment, 28.9% among those with mild cognitive impairment (MCI), and 30.6% among those with dementia (P = 0.13).There was no association between OH and cognitive impairment in adults who underwent a comprehensive geriatric assessment.

Factors associated with orthostatic hypotension in hospitalized elderly patients

OBJECTIVE

To assess the factors associated with orthostatic hypotension (OH) in hospitalized elderly patients.

DESIGN

Prospective observational single center study.

SETTING

A French academic center.

PARTICIPANTS

One hundred and thirty-one patients without OH symptoms who underwent OH testing.

MEASUREMENTS

The OH test was performed when the patient was able to get out of the bed and was no longer receiving parenteral fluids. The blood pressure was measured after a 10-min rest while the patients were sitting and then standing at 1 and 3 min. Demographic data, co-morbidities, current medications and biological parameters were recorded.

RESULTS

The mean patient age was 84.3 ± 7 years. The mean CIRS-G score was 10.6 ± 3.8. The OH test was performed 6.3 ± 3.9 days after admission and was positive in 39 (29.8 %) patients (95 % confidence interval (CI) 22, 38) and positive at 1 min in 87.2 % of the cases. Multivariate analysis showed that OH prevalence correlated with diabetes (odds ratio (OR) = 4.23; 95 % CI 1.10, 16.24; P = 0.03), serum 25-hydroxyvitamin D <20 ng/ml (OR = 3.38; 95 % CI 1.36, 8.42; P = 0.008), use of tranquilizers (anxiolytic and hypnotic) (OR = 2.96; 95 % CI 1.18, 7.4; P = 0.02), CIRS-G score (OR = 1.15; 95 % CI 1.01, 1.31; P = 0.03) and lack of diuretics (OR = 0.20; 95 % CI 0.06, 0.63; P = 0.005).

CONCLUSION

In older adults, OH is often misdiagnosed because it is asymptomatic. As practitioners may be reluctant to perform the OH test because of time constraints, targeting a subgroup of patients with a higher risk of OH should be worthwhile to prevent further OH complications.

Prevalence of orthostatic hypotension in non-institutionalised elderly aged 80 and over. A diagnostic study using an oscillometric device

BACKGROUND

Orthostatic hypotension (OH) is a common disorder, and possibly underdiagnosed. In the elderly, OH has been considered a common cause of falls, fractures, and fear of falling. Its prevalence increases with age, probably related to the number of drug treatments, decreased fluid intake, and the progressive dysfunction of the autonomic nervous system.

OBJECTIVES

To evaluate the prevalence of OH in a non-institutionalised population ≥80 years, according to different criteria based on sequential measurements taken at minute 0, 1, 3 and 5 of standing.

METHODS DESIGN

A diagnostic accuracy study using an oscillometric device.

SETTING AND PARTICIPANTS

Convenience sampling of 176 people ≥80 years attended in an urban Primary Health Care Centre.

MEASUREMENTS

Supine and standing blood pressure (BP) measurements, at minutes 0, 1, 3 and 5 using the OMRON 705-CP blood pressure device. OH definition: decrease ≥20mmHg in systolic BP (SBP) and/or ≥10mmHg in diastolic BP (DBP).

RESULTS

Mean age (Standard Deviation) was 85.2 (3.7) years, and 60.2% were women. Prevalence of OH: 30.7% at minute 0; 19.3% at minute 1; 18.2% at minute 3; and 20.5% at minute 5. Age, sedentary life, smoking, diabetes and SBP values were significantly associated with a greater BP decrease at minute 0.

CONCLUSION

A third of the sample had OH, with a maximum prevalence at minute 0. From a clinical point of view, it is suggested that the definition of OH is prioritized according to the BP at minute 0.

Estimated glomerular filtration rate, urine albumin excretion, and survival among patients consulting in public Chilean public primary care clinics

Chronic renal disease (CRD) in its pre-dialysis stage is an important risk factor for mortality among adults. The aim of this study was to assess the effects of CRD on mortality among consultants in Chilean public primary care clinics. We obtained information about serum creatinine, urinary albumin excretion (UAE), blood pressure, and body mass index of 5224 consultants [3379 females aged 67 (59-75) years and 1845 males aged 68 (59-75) years] in three clinics of Metropolitan Santiago. Kaplan-Meier curves and Cox proportional hazard regression models were used to determine risk factors for mortality, determined 41 months after obtaining the blood samples. During the follow-up period, 262 patients died (33% due to circulatory causes and 29% due to tumors). Kaplan-Meier curves showed that there was a significant association between survival, estimated glomerular filtration rate, and UAE. Cox models showed that serum creatinine, UAE, a lower body mass index, and a history of diabetes were significant mortality predictors. A sensitivity analysis performed eliminating extreme ages (less than 50 and more than 80 years), included high diastolic pressure as a predictor of survival. We conclude that among patients with CRD in its pre-dialysis stage, UAE is an important predictor of survival, along with serum creatinine. A low body mass index was associated with a higher mortality.

Single Agent Antihypertensive Therapy and Orthostatic Blood Pressure Behaviour in Older Adults Using Beat-to-Beat Measurements: The Irish Longitudinal Study on Ageing

Background

Impaired blood pressure (BP) stabilisation after standing, defined using beat-to-beat measurements, has been shown to predict important health outcomes. We aimed to define the relationship between individual classes of antihypertensive agent and BP stabilisation among hypertensive older adults.

Methods

Cross-sectional analysis from The Irish Longitudinal Study on Ageing, a cohort study of Irish adults aged 50 years and over. Beat-to-beat BP was recorded in participants undergoing an active stand test. We defined grade 1 hypertension according to European Society of Cardiology criteria (systolic BP [SBP] 140-159mmHg ± diastolic BP [DBP] 90-99mmHg). Outcomes were: (i) initial orthostatic hypotension (IOH) (SBP drop ≥40mmHg ± DBP drop ≥20mmHg within 15 seconds [s] of standing accompanied by symptoms); (ii) sustained OH (SBP drop ≥20mmHg ± DBP drop ≥10mmHg from 60 to 110s inclusive); (iii) impaired BP stabilisation (SBP drop ≥20mmHg ± DBP drop ≥10mmHg at any 10s interval during the test). Outcomes were assessed using multivariable-adjusted logistic regression.

Results

A total of 536 hypertensive participants were receiving monotherapy with a renin-angiotensin-aldosterone-system inhibitor (n = 317, 59.1%), beta-blocker (n = 89, 16.6%), calcium channel blocker (n = 89, 16.6%) or diuretic (n = 41, 7.6%). A further 783 untreated participants met criteria for grade 1 hypertension. Beta-blockers were associated with increased odds of initial OH (OR 2.05, 95% CI 1.31–3.21) and sustained OH (OR 3.36, 95% CI 1.87–6.03) versus untreated grade 1 hypertension. Multivariable adjustment did not attenuate the results. Impaired BP stabilisation was evident at 20s (OR 2.59, 95% CI 1.58–4.25) and persisted at 110s (OR 2.90, 95% CI 1.64–5.11). No association was found between the other agents and any study outcome.

Conclusion

Beta-blocker monotherapy was associated with a >2-fold increased odds of initial OH and a >3-fold increased odds of sustained OH and impaired BP stabilisation, compared to untreated grade 1 hypertension. These findings support existing literature questioning the role of beta-blockers as first line agents for essential hypertension.

Neurocardiovascular instability may modulate end-organ damage: A review of this hypothesis investigating the eye and manifestations of NCVI

Neurocardiovascular instability (NCVI) represents age-related changes in blood pressure and heart rate behaviour. It has been associated with increased leukoaraiosis in the brain and also conditions which are likely to be are related to cerebral end-organ damage, such as stroke and falls. The eye is a 'window' into the brain and cardiovascular (CV) system, changes in retinal microvasculature being independently predictive of cardiovascular events. The eye is highly vascular, having two circulatory systems and as such the ideal target end-organ to investigate NCVI and early end-organ damage. The retinal and choroidal circulations of the eye would be vulnerable to NCVI if ocular vasoregulation becomes impaired with age, particularly given the high metabolic activity of the retina. The choroid is predominantly extrinsically regulated by the autonomic nervous system. In patients with NCVI, autonomic dysfunction is more common and thus impairment of the tightly regulated ocular microcirculation may indeed be compromised. We review the evidence for the hypothesis that NCVI may modulate end-organ cardiovascular pathology and that the eye is the ideal target organ to monitor this.

Prevalence of orthostatic hypotension in the unselected ambulatory population of persons aged 65 years old and above

BACKGROUND

The diagnostic recommendation for orthostatic hypotension (OH) is to measure blood pressure during the first 3 min after getting up from a lying position. There are no clear definitions as to the amount of time that the patient should lie down before this, and the number of measurements to be taken in lying and standing positions. The aim of this study was to identify the optimal time to measure blood pressure when lying and standing.

METHODS

This was a prospective study of 99 patients aged 65 years and above in an urban primary care clinic. Blood pressure was measured at 1 min intervals over 10 min in the lying position and 7 min standing.

RESULTS

OH was found in 37 patients (37.4%). Of these, 56.8% were identified in the 1st minute, 67.6% after 2 min and 83.8% after 3 min of standing. In all cases, participants with OH were asymptomatic. In the lying position, blood pressure stabilized after 7 min, but when the 7th minute was used as a reference for OH many cases were lost.

CONCLUSION

To optimize the identification of OH, blood pressure should be measured at 1 min intervals over the first 3 min after standing up. The amount of time that patients should lie down before blood pressure is measured standing up still has to be determined.

Impact of missing data mechanism on the estimate of change: a case study on cognitive function and polypharmacy among older persons

Longitudinal studies typically suffer from incompleteness of data. Attrition is a major problem in studies of older persons since participants may die during the study or are too frail to participate in follow-up examinations. Attrition is typically related to an individual’s health; therefore, ignoring it may lead to too optimistic inferences, for example, about cognitive decline or changes in polypharmacy. The objective of this study is to compare the estimates of level and slope of change in 1) cognitive function and 2) number of drugs in use between the assumptions of ignorable and non-ignorable missingness. This study demonstrates the usefulness of latent variable modeling framework. The results suggest that when the missing data mechanism is not known, it is preferable to conduct analyses both under ignorable and non-ignorable missing data assumptions.

Does lowering blood pressure with antihypertensive therapy preserve independence in activities of daily living? A systematic review

BACKGROUND

Hypertension is a major risk factor for functional impairment. Dependence is an important related outcome for older adults, but outcomes in hypertension trials appear to focus primarily on major vascular events. This systematic review had 2 objectives: (i) to determine the proportion of randomized controlled trials (RCTs) evaluating antihypertensive therapies that reported a measure of a person's ability to carry out activities of daily living (ADL) and (ii) to evaluate the effect of blood pressure (BP)-lowering therapies on ability to carry out ADL compared with control therapy.

METHODS

We searched electronic databases, reference lists of relevant meta-analyses, and hypertension guidelines for clinical trials of adults with hypertension/prehypertension that were randomized to antihypertensive therapy or control for ≥1 year.

RESULTS

Of 2,924 citations screened, there were 93 eligible RCTs. One (1%) reported ADL as a primary outcome measure. Nine (10%) reported ADL as a secondary outcome. Of these, 6 used validated ADL scales, whereas 4 measured ADL within quality-of-life scales. Six trials with duration of ≥1 year (n = 12,663) were amenable to meta-analysis, despite use of different ADL scales. The odds of having difficulty with ADL was reduced by BP-lowering therapy compared with control therapy (odds ratio = 0.84; 95% confidence interval = 0.77-0.92; I (2) = 0%).

CONCLUSIONS

We identified few trials of antihypertensive therapy that reported ADL as an outcome measure, with heterogeneity in scales used. Antihypertensive therapy was associated with a lower risk of ADL impairment compared with control therapy. RCTs evaluating the effect of antihypertensive drugs on ADL in older adults with mild hypertension are required.

Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial

BACKGROUND

There are few rigorous studies to confirm or refute the commonly cited concern that control of blood pressure to lower thresholds may result in an increased risk of falls and fractures.

OBJECTIVE

To compare falls and fractures in participants with type 2 diabetes in the intensive (targeting a systolic blood pressure of < 120 mmHg) and standard (targeting a systolic blood pressure of < 140 mmHg) blood pressure control arms of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized trial (N = 4,733).

PARTICIPANTS

A subset of 3,099 participants self-reported annually on the occurrence of falls and non-spine fractures. Fractures were centrally adjudicated.

MAIN MEASURES

The incidence of falls in the two treatment groups was compared using a random-effects negative binomial model, and fracture risk was compared using Cox proportional hazards models.

KEY RESULTS

At enrollment in both groups, the mean age was 62 years, 44% were women, 25% were Black, and mean blood pressure was 138/75 mmHg. During follow-up, all classes of medications, particularly thiazide diuretics, were more commonly prescribed in the intensive group. After 1 year of follow-up, the mean systolic blood pressure was 133 ± 15 mmHg in the standard group and 119 ± 14 mmHg in the intensive group. The adjusted rate of falls did not differ in the intensive and standard groups (62.2/100 person-years vs. 74.1/100 person-years, RR = 0.84, 95% CI 0.54-1.29, p = 0.43). The risk of non-spine fractures was nonsignificantly lower in the intensive than in the standard blood pressure group (HR 0.79, 95% CI 0.62-1.01, p = 0.06).

CONCLUSIONS

We conclude that intensive antihypertensive treatment that lowered mean systolic blood pressure to below 120 mmHg was not associated with an increased risk of falls or non-spine fractures in patients age 40 to 79 years with type 2 diabetes.

Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project

The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.

Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusion

Orthostatic hypotension (OH) has deleterious effects on patients' cardiovascular prognoses. The combination of increased age and diabetes adds to the risk of OH. The aim of the study was to describe the elderly diabetic population relative to the degree of hypertension, the occurrence of complications, medications and cognitive function.

METHODS

In the Gerodiab study (a 5-year French multicentre, prospective, observational study), a total of 987 type 2 diabetic autonomous patients, aged 77±5 years, were recruited between June 2009 and July 2010. Clinical blood pressure measurements were taken supine and then after 1, 3 and 5minutes in a standing position. OH was defined as a decrease in systolic blood pressure (SBP) of at least 20mmHg and/or a decrease in diastolic blood pressure (DBP) of at least 10mmHg at any of the measurements while standing.

RESULTS

At inclusion 301 (30.5%) patients had OH; SBP and DBP at rest were higher in patients with OH than in those without (146±21/78±11mmHg vs. 138±17/72±10mmHg; P<0.001). Individuals with OH exhibited higher pulse pressure (PP) than individuals without (68±18 vs. 65±15mmHg; P<0.05). A significant increase in waist-to-hip ratio was recorded in those with OH versus patients without (P<0.01). Despite more severe hypertension (SBP>160mmHg at inclusion; P<0.01), no significant difference was recorded in the mean number of antihypertensive drugs (1.7±1.1), or in the class of antihypertensive drugs, including beta-blockers (P=0.19) and diuretics (P=0.84). Patients with OH were more likely to have a history of peripheral arterial disease and amputations (31% vs. 24%, P<0.05, and 3.3% vs. 1.5%, P=0.056). There was no significant association between OH and history of peripheral neuropathy (P=0.37), stroke, heart failure or ischemic heart disease. In multivariate analysis, OH remained associated with severe hypertension (P<0.01), increased waist-to-hip ratio (P<0.05) and amputations (P<0.05).

CONCLUSION

About one-third of elderly, autonomous diabetic patients had OH. They had more severe hypertension, with higher SBP, DBP and PP at rest. However, the number of anti-hypertensive drugs did not differ compared to patients without OH. This could reflect the medical teams' fears about intensifying treatment.

Excessive pulse pressure response to standing in community population with orthostatic systolic hypertension

The postural change of pulse pressure (PP) in the persons with orthostatic hypertension (OHT) is unclear. This study included 2849 (65.0 ± 9.3 years) community participants. Blood pressures (BPs) in supine and standing positions were measured. The differences between upright and supine BP and PP were recorded as ΔBP and ΔPP. The criteria for OHT was ΔBP ≥10 mm Hg, for orthostatic hypotension (OH) was ≤-10 mm Hg and for orthostatic normotension (ONT) was -9 to 9 mm Hg. Fasting blood lipids and glucose were measured. The supine SBP of the sOHT group were similar to that of sONT group (140.9 ± 20.2 mm Hg vs 138.2 ± 19.7 mm Hg), but significantly lower than that of sOH group (151.9 ± 19.2 mm Hg; P < .05). Their PPs were 65.3 ± 15.9, 62.8 ± 14.7, and 71.1 ± 15.1 mm Hg, respectively, and with the similar group difference like SBP. When the position changed from supine to standing, the sOHT group showed PP rise, while sOH and sONT groups showed PP reduction (3.8 ± 7.1 mm Hg vs -17.0 ± 8.5 mm Hg and -5.8 ± 6.6 mm Hg; both P < .05). Thus, the standing PP in the sOHT group was significantly higher than in the sONT (69.1 ± 18.0 mm Hg vs 57.0 ± 15.8 mm Hg; P < .05) and in the sOH (54.2 ± 15.2 mm Hg; P < .05) groups. The postural PP profile varies with the postural responses of SBP. The sOHT group has obviously increased PP and significantly higher standing PP compared with the sONT group.

Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study

BACKGROUND

Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown.

AIM

To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes.

DESIGN AND SETTING

A cross-sectional study in primary care in the Netherlands.

METHOD

A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument.

RESULTS

The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively.

CONCLUSION

OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.

The prevalence and pathological correlates of orthostatic hypotension and its subtypes when measured using beat-to-beat technology in a sample of older adults living in the community

BACKGROUND

beat-to-beat technology is increasingly used for investigating orthostatic intolerance (OI) but the prevalence of orthostatic hypotension (OH) diagnosed with this technology is unclear.

OBJECTIVES

(i) to use beat-to-beat technology to define the prevalence of OH, (ii) to investigate the pathological correlates of OH, (iii) to report the diversity of postural BP responses.

METHODS

cross-sectional study of adults ≥ 65 years. BP responses to a 3-min head-up tilt were analysed.

RESULTS

of 326 participants, 203(62.3%) were females. The median (IQR) age was 73 (70-78). One hundred and ninety-one (58.6%) met standard (20 mmHg systolic/10 mmHg diastolic) criteria for OH. The prevalence was higher in females (60.1% F versus 56.1% M); 47% were arteriolar subtype, 33% were venular, 9% were mixed and 11.0% could not be classified. Morphological analysis identified 102 subjects with 'small drop, overshoot', 131 with 'medium drop, slow recovery' and 31 with 'large drop, nonrecovery'. Those with OH had a lower BMI (P = 0.02), a higher resting heart rate (P = 0.005), were more likely to take a psychotropic (P = 0.02), have vertigo (P = 0.004) and report OI (P = 0.02). The 95th centile for the duration of systolic BP (SYSBP) decay >20 mmHg was 175 s and the slope of systolic BP decay was 4.75 mmHg/s. The 5th centile for percentage recovery of SYSBP was 81.4%.

CONCLUSION

(i) beat-to-beat methods identify a higher prevalence of OH than sphygmomanometry, (ii) the pathological correlates of OH diagnosed in this manner are similar to those described for sphygmomanometry, (iii) there is a diverse pattern of orthostatic BP decay that could be used in future research to predict adverse outcomes in OH.