Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis

An interdisciplinary approach for reducing falls related to orthostatic hypotension on a Veteran Administration long term care unit: A quality improvement project

BACKGROUND

Falls in the long-term care setting occur often, have a multifactorial etiology, and can result in injury and even death. This quality improvement project focused on older adult Veterans and aimed to decrease falls post-intervention from orthostatic hypotension (OH).

METHODS

Two rounds of the Plan-Do-Study-Act (PDSA) model of quality improvement were completed. Round one included OH evaluation and round two added postprandial OH (PPH) evaluation. Each round included interdisciplinary team meetings to establish interventions to treat positive OH/PPH.

RESULTS

Of the twenty-five Veterans screened, twelve were OH or PPH positive with seven being negative post-intervention. Comparing fall rates three months pre/post intervention, three reduced, four increased, four had no change, and one was unobtainable.

CONCLUSION

Evaluation of fall risk is key for reducing future falls. This project found that one critical consideration is timing of evaluation, and that inclusion of a postprandial evaluation could increase the identification of OH.

Hypertensive heart disease in older patients: considerations for clinical practice

Appropriate management of older people with hypertension is essential to reduce the burden of hypertensive heart disease and further cardiovascular sequelae but there may be challenges given the presence of concurrent senescent changes, comorbidities and impairment in functionality. It is recommended that frailty level and functional status are assessed periodically to understand patient needs and to guide treatment decisions. Office blood pressure should be measured with an appropriate cuff as per standard guidelines. There should be a high index of suspicion for orthostatic hypotension and white coat/masked hypertension, both common in older individuals. Cardiac imaging often identifies age-related changes that may not result from hypertension alone, including smaller ventricular volumes, a sigmoid septum and non-ischaemic fibrosis. Diastolic dysfunction is common and other pathologies, including cardiac amyloidosis, may need to be considered in the presence of red flags. Screening for atrial fibrillation during blood pressure evaluation is advised. Decisions for blood pressure management should follow current recommendations and take into consideration the patient's age and tolerance. There is limited evidence regarding heart failure management in older patients, however, disease-modifying therapy as per guidelines should be pursued. Sufficient outcome data are lacking for this patient group and a multidisciplinary approach is often needed to design optimal therapy.

Effects of Daily Lifestyle Habits on Non-Neurogenic Orthostatic Hypotension in Older Adults in South Korea: A Cross-Sectional Study

Background: Orthostatic hypotension (OH) is a chronic, debilitating condition common in older adults. This study examined the effects of daily lifestyle habits on non-neurogenic OH in older adults in South Korea. We further compared the effects of daily lifestyle habits on OH to those of the autonomic nervous system (ANS) function. Methods: In a cross-sectional study, 217 community-dwelling older adults aged ≥65 years were recruited using the convenience sampling method. Data were collected using two questionnaires to assess OH and daily lifestyle habits: OH was measured by Orthostatic Grading Scale (OGS) and lifestyle habits included nutrition, sleep, physical activity, and psychological status (stress and depression levels). Plasma catecholamines (epinephrine and norepinephrine) were measured to indicate the ANS function. The data were analyzed using t-tests, Pearson's correlation coefficients, and multiple linear regression analysis. Results: Significant factors related to OGA score included nutritional status (B = -0.20, p ≤ 0.040), poorer sleep quality (B = 0.15, p = 0.005), physical activity (B = -0.01, p = 0.032), stress (B = 0.04, p = 0.001), and depression (B = 0.23, p = 0.001). These together explained 40.5% of the variance in OH. However, no significant association was found between catecholamines and OGS score. Conclusions: These results suggest that lifestyle habits are important factors, while ANS function may be less associated with non-neurogenic OH. Thus, preventive and non-pharmacological interventions for decreasing OH symptoms should focus on maintaining healthy lifestyle habits in older adults.

Exploring the feasibility of using a bedside device to help prevent nighttime falls

BACKGROUND

Older people living in the community are at risk of preventable nighttime falls. Technology can support falls interventions but there is a lack of research into this area. A new bedside device called Bide senses movement and changes in light levels and plays a prerecorded message encouraging the user to follow falls prevention advice when trying to mobilise at night.

AIM

To test the feasibility of using the Bide device in a community health service.

METHOD

Healthcare workers were trained in the use of the Bide device and asked to identify potential participants. The research team subsequently recruited participants, provided them with a device and explained how to use it. After four weeks, participants took part in face-to-face semi-structured interviews regarding the acceptability of the device. Participants' fear of falling was calculated before and after the intervention using the Falls Efficacy Scale-International.

FINDINGS

The Bide device appeared to increase patients' confidence to mobilise at night and no adverse events were reported from its use. The device was generally found to be acceptable and easy to use, although one participant found it irritating. Healthcare workers flagged up very few potential participants to the research team, which may have been due to workload pressures and a disconnect between healthcare workers and technology.

CONCLUSION

It appears feasible to study the use of the Bide device for nighttime falls prevention in the community. To enhance recruitment, a member of the research team may be embedded in the clinical team with the aim of proactively identifying potential participants.

Orthostatic hypotension and cerebral small vessel disease: A systematic review

Orthostatic hypotension(OH) is highly prevalent in ageing populations and may contribute to cognitive decline through cerebral small vessel disease(CSVD). Research on the association between OH and CSVD is fragmented and inconsistent. We systematically reviewed the literature for studies assessing the association between OH and CSVD, published until December 1st 2023 in MEDLINE, PubMed or Web of Science. We included studies with populations aged ≥60, that assessed OH in relation to CSVD including white matter hyperintensities(WMH), lacunes and cerebral microbleeds. Modified JBI checklist was used to assess risk of bias. A narrative synthesis of the results was presented. Of 3180 identified studies, eighteen were included. Fifteen studies reported on WMH, four on lacunes, seven on microbleeds. Six of fifteen studies on WMH found that OH was related to an increased burden of WMH, neither longitudinal studies found associations with WMH progression. Findings were inconsistent across studies concerning lacunes and microbleeds. Across outcomes, adequate adjustment for systolic blood pressure tended to coincide with smaller effect estimates. Current evidence on the OH-CSVD association originates mostly from cross-sectional studies, providing inconsistent and inconclusive results. Longitudinal studies using standardized and fine-grained assessment of OH and CSVD and adequate adjustment for supine blood pressure are warranted.

Prevalence of orthostatic hypotension and associated factors among older people with hypertension in Northern Ethiopia

BACKGROUND

The prevalence of hypertension increases with age, and older people with this condition are at increased risk of developing orthostatic hypotension (OH) due to age-related changes in blood pressure regulation mechanisms as well as prescribed medications. OH increases the risk of falls, often with subsequent fractures as well as other morbidity and even mortality. The prevalence and characteristics of OH in older people with hypertension in Low-Income Countries have not been well characterized. This study aims to determine the prevalence of OH and associated factors among older people with hypertension in northern Ethiopia.

METHOD

A hospital-based cross-sectional study was conducted using a convenience sample of patients aged 60 years and older with hypertension receiving pharmacotherapy and followed up at the University of Gondar Hospital, Ethiopia. Blood pressure (BP) was measured in the supine position, and after 3 min of standing; the level of BP drop (> 20/10) was used to define measured OH. Data regarding symptoms of OH were also collected using the Orthostatic Hypotension Questionnaire (OHQ). The data were entered into Microsoft Excel version 2016 and exported to SPSS version 20 for statistical analysis. Logistic regression analysis was conducted to assess the factors associated with OH.

RESULTS

A total of 240 participants were included, with a mean age of 68.8 ± 7.1 years. The prevalence of OH was 23.8% (CI: 21.5%, 26.1%). Of the medications used, calcium channel blocker (CCBs) treatment was strongly associated with OH (AOR = 2.03[95%CI = 1.08-3.8]). Two-thirds (61.4%) of participants with measured OH experienced relevant symptoms of OH.

CONCLUSION

There was a high prevalence of OH among older patients with hypertension attending a tertiary care hospital in Gondar, with one in four affected. The use of CCBs was identified as an independent risk factor for OH. Most patients with OH experienced relevant symptoms, so monitoring this condition in this group may help prevent adverse consequences.

Managing hypertension in older people: current concepts

Hypertension management in older people is challenging due to pathophysiological changes brought about by ageing, associated comorbidities, frailty and polypharmacy and often has a poor evidence base. This article gives an overview of these factors and related available evidence with particular attention to clinical issues and consensus guidance.

A scoping review of functional near-infrared spectroscopy biomarkers in late-life depression: Depressive symptoms, cognitive functioning, and social functioning

Late-life depression is one of the most damaging mental illnesses, disrupting the normal lives of older people by causing chronic illness and cognitive impairment. Patients with late-life depression, accompanied by changes in appetite, insomnia, fatigue and guilt, are more likely to experience irritability, anxiety and somatic symptoms. It increases the risk of suicide and dementia and is a major challenge for the public health systems. The current clinical assessment, identification and effectiveness assessment of late-life depression are primarily based on history taking, mental status examination and scale scoring, which lack subjectivity and precision. Functional near-infrared spectroscopy is a rapidly developing optical imaging technology that objectively reflects the oxygenation of hemoglobin in different cerebral regions during different tasks and assesses the functional status of the cerebral cortex. This article presents a comprehensive review of the assessment of functional near-infrared spectroscopy technology in assessing depressive symptoms, social functioning, and cognitive functioning in patients with late-life depression. The use of functional near-infrared spectroscopy provides greater insight into the neurobiological mechanisms underlying depression and helps to assess these three aspects of functionality in depressed patients. In addition, the study discusses the limitations of previous research and explores potential advances in the field.

Neuromuscular manifestations of wild type transthyretin amyloidosis: a review and single center's experience

Transthyretin amyloidosis (ATTR) is a condition defined by accumulation of insoluble transthyretin amyloid deposits in multiple organs, especially in the peripheral nerve and heart muscle. ATTR may result from transthyretin mutations (variant ATTR or ATTRv) or may occur with normal transthyretin genotype (wild type ATTR or ATTRwt). ATTRwt was previously known as "senile amyloidosis" and causes cardiomyopathy which may lead to heart failure with a preserved ejection fraction, affecting predominantly elderly men. The exact prevalence of ATTRwt in the general population remains unclear, but its occurrence may be underestimated in women. It was observed that a proportion of ATTRwt cardiomyopathy patients may develop slowly progressing neuropathy that is milder and indolent in comparison with typical progressive neuropathy associated with ATTRv. Furthermore, the causality of neuropathy is often uncertain in patients with ATTRwt. Neuropathy symptoms, including distal sensory loss, unsteadiness and (neuropathic) pain are common in elderly patients with multiple potential causes, and as ATTRwt patients are typically older, relatively high prevalence of peripheral neuropathy is expected with frequent comorbidities. Relatively high prevalence of ATTRwt in elderly population contrasts few documented cases of neuropathy caused by ATTRwt, and there is uncertainty whether ATTRwt neuropathy is an infrequent occurrence or a significant manifestation of multisystemic ATTRwt. We review neurologic and musculoskeletal manifestations of ATTRwt and present clinical features of a single center cohort of ATTRwt patients with suspected peripheral neuropathy.

Syncope in older adults: challenges, approach and treatment

Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.

Prevalence of postprandial hypotension in older adults: a systematic review and meta-analysis

BACKGROUND

Older adults with postprandial hypotension (PPH) increase susceptibility to falls, syncope, stroke, acute cardiovascular diseases and even death. However, the prevalence of this condition varies significantly across studies. We aimed to determine the prevalence of PPH in older adults.

METHODS

Web of Science, PubMed, Cochrane Library, Embase and CINAHL were searched from their inception until February 2023. Search terms included 'postprandial period', 'hypotension' and 'postprandial hypotension'. Eligible studies were assessed using the Joanna Briggs Institute tool. Meta-analyses were performed among similar selected studies.

RESULTS

Thirteen eligible studies were included, and data from 3,021 participants were pooled. The meta-analysis revealed a PPH prevalence of 40.5% [95% confidence interval (CI): 0.290-0.519] in older adults, and this was prevalent in the community (32.8%, 95% CI: 0.078-0.647, n = 1,594), long-term healthcare facility (39.4%, 95% CI: 0.254-0.610, n = 1,062) and geriatrics department of hospitals (49.3%, 95% CI: 0.357-0.630, n = 365). The pooled results showed significant heterogeneity (I2 > 90%), partially related to the different ages, sex, pre-prandial systolic blood pressure levels of participants, or the different criteria and methodology used to diagnose PPH.

CONCLUSIONS

PPH is a prevalent condition in older adults. Further research is needed to confirm this result, and priority should be given to establishing international consensus on PPH diagnostic criteria and designing its diagnostic procedure.

Role of ambulatory blood pressure monitoring in elderly hypertensive patients

Background

Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this.

Aim

In this review, we will gather the most important information about this subject.

Results

As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management.

Conclusion

As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00205-6.

Feasibility of Diagnosing Initial Orthostatic Hypotension Using a Continuous Blood Pressure Device in Geriatric Rehabilitation Inpatients: RESORT

Background

Initial orthostatic hypotension (IOH) is highly prevalent in older adults and may interfere with the ability to regain function after acute hospitalization. IOH assessment requires a non-invasive, beat-to-beat continuous blood pressure device, which is not widely used in geriatric rehabilitation. Our aim was to test the feasibility of diagnosing IOH using a continuous blood pressure device in geriatric rehabilitation inpatients.

Methods

Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort admitted to a tertiary hospital were randomly selected to undergo continuous blood pressure monitoring (Finapres) for 5 min in the supine position and 3 min of standing or sitting when unable to stand. Interventions to warm hands and adjusting the cuff pressure sizes were attempted if no signal was obtained or an error message occurred.

Results

Of 37 randomly selected inpatients, 29 {55.2% female; mean age 82.8 (standard deviation [SD]) 6.6 years} agreed to the continuous blood pressure measurement. Successful measurements were achieved in 20 out of 29 inpatients, two after hand warming. Patients with unsuccessful measurements were likely to be older (mean age 87.2 [SD] 4.4 years, p = 0.03), have cerebrovascular disease (p = 0.006), lower body mass index (p = 0.012), and a lower short physical performance battery score (p = 0.039). Eight out of 20 patients had IOH.

Conclusion

The number of unsuccessful continuous blood pressure measurements was high in a population with high IOH prevalence despite multiple interventions to establish a signal. Future research should focus on improving the efficiency of continuous blood pressure devices in hospitalized patients with unsuccessful signals.

Autonomic dysfunction in post-COVID patients with and witfhout neurological symptoms: a prospective multidomain observational study

The autonomic nervous system (ANS) can be affected by COVID-19, and dysautonomia may be a possible complication in post-COVID individuals. Orthostatic hypotension (OH) and postural tachycardia syndrome (POTS) have been suggested to be common after SARS-CoV-2 infection, but other components of ANS function may be also impaired. The Composite Autonomic Symptom Scale 31 (COMPASS-31) questionnaire is a simple and validated tool to assess dysautonomic symptoms. The aim of the present study was to administer the COMPASS-31 questionnaire to a sample of post-COVID patients with and without neurological complaints. Participants were recruited among the post-COVID ambulatory services for follow-up evaluation between 4 weeks and 9 months from COVID-19 symptoms onset. Participants were asked to complete the COMPASS-31 questionnaire referring to the period after COVID-19 disease. Heart rate and blood pressure were manually taken during an active stand test for OH and POTS diagnosis. One-hundred and eighty participants were included in the analysis (70.6% females, 51 ± 13 years), and OH was found in 13.8% of the subjects. Median COMPASS-31 score was 17.6 (6.9-31.4), with the most affected domains being orthostatic intolerance, sudomotor, gastrointestinal and pupillomotor dysfunction. A higher COMPASS-31 score was found in those with neurological symptoms (p < 0.01), due to more severe orthostatic intolerance symptoms (p < 0.01), although gastrointestinal (p < 0.01), urinary (p < 0.01), and pupillomotor (p < 0.01) domains were more represented in the non-neurological symptoms group. This study confirms the importance of monitoring ANS symptoms as a possible complication of COVID-19 disease that may persist in the post-acute period.