Orthostatic blood pressure rise is associated with frailty in older patients

Were Frailty Identification Criteria Created Equal? A Comparative Case Study on Continuous Non-Invasively Collected Neurocardiovascular Signals during an Active Standing Test in the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

In this observational study, we compared continuous physiological signals during an active standing test in adults aged 50 years and over, characterised as frail by three different criteria, using data from The Irish Longitudinal Study on Ageing (TILDA).

METHODS

This study utilised data from TILDA, an ongoing landmark prospective cohort study of community-dwelling adults aged 50 years or older in Ireland. The initial sampling strategy in TILDA was based on random geodirectory sampling. Four independent groups were identified: those characterised as frail only by one of the frailty tools used (the physical Frailty Phenotype (FP), the 32-item Frailty Index (FI), or the Clinical Frailty Scale (CFS) classification tree), and a fourth group where participants were not characterised as frail by any of these tools. Continuous non-invasive physiological signals were collected during an active standing test, including systolic (sBP) and diastolic (dBP) blood pressure, as well as heart rate (HR), using digital artery photoplethysmography. Additionally, the frontal lobe cerebral oxygenation (Oxy), deoxygenation (Deoxy), and tissue saturation index (TSI) were also non-invasively measured using near-infrared spectroscopy (NIRS). The signals were visualised across frailty groups and statistically compared using one-dimensional statistical parametric mapping (SPM).

RESULTS

A total of 1124 participants (mean age of 63.5 years; 50.2% women) were included: 23 were characterised as frail only by the FP, 97 by the FI, 38 by the CFS, and 966 by none of these criteria. The SPM analyses revealed that only the group characterised as frail by the FI had significantly different signals (p < 0.001) compared to the non-frail group. Specifically, they exhibited an attenuated gain in HR between 10 and 15 s post-stand and larger deficits in sBP and dBP between 15 and 20 s post-stand.

CONCLUSIONS

The FI proved to be more adept at capturing distinct physiological responses to standing, likely due to its direct inclusion of cardiovascular morbidities in its definition. Significant differences were observed in the dynamics of cardiovascular signals among the frail populations identified by different frailty criteria, suggesting that caution should be taken when employing frailty identification tools on physiological signals, particularly the neurocardiovascular signals in an active standing test.

2023 update and perspectives

Total 276 manuscripts were published in Hypertension Research in 2022. Here our editorial members picked up the excellent papers, summarized the current topics from the published papers and discussed future perspectives in the sixteen fields. We hope you enjoy our special feature, 2023 update and perspectives in Hypertension Research.

Frail OLDER ADULTS are more likely TO have autonomic dysfunction: A systematic review and META-ANALYSIs

Autonomic dysfunction and frailty are two common and complex geriatric syndromes. Their prevalence increases with age and they have similar negative health outcomes. In PubMed and Web of Science we screened studies identifying a relationship between autonomic function (AF) and frailty in adults aged ≥65 years. Twenty-two studies of which two prospective and 20 cross-sectional were included (n=8375). We performed a meta-analysis for the articles addressing orthostatic hypotension (OH). Frailty was associated with 1.6 higher odds of suffering from consensus OH (COH) {OR=1.607 95%CI [1.15-2.24]; 7 studies; n=3488}. When measured for each type of OH the largest trend was seen between initial OH (IOH) and frailty {OR=3.08; 95%CI [1.50-6.36]; 2 studies; n=497}. Fourteen studies reported other autonomic function alterations in frail older adults with 4-22% reduction in orthostatic heart rate increase, 6% reduction in systolic blood pressure recovery, 9-75% reduction in most common used heart rate variability (HRV) parameters. Frail older adults were more likely to have impaired AF. Diagnosis of frailty should promptly lead to orthostatic testing as OH implicates specific treatment modalities, which differ from frailty management. As IOH is most strongly correlated with frailty, continuous beat to beat blood pressure measurements should be performed when present at least until cut-off values for heart rate variability testing are defined.

Prevalence of orthostatic hypertension and its association with cerebrovascular diagnoses in patients with suspected TIA and minor stroke

Purpose

We aimed to compare the rate of stroke, transient ischemic attack, and cerebrovascular disease diagnoses across groups of patients based on their orthostatic blood pressure response in a transients ischemic attack clinic setting.

Materials and Methods

We retrospectively analysed prospectively collected data from 3201 patients referred to a transient ischemic attack (TIA)/minor stroke outpatients clinic. Trained nurses measured supine and standing blood pressure using an automated blood pressure device and the patients were categorized based on their orthostatic blood pressure change into four groups: no orthostatic blood pressure rise, systolic orthostatic hypertension, diastolic orthostatic hypertension, and combined orthostatic hypertension. Then, four stroke physicians, who were unaware of patients' orthostatic BP response, assessed the patients and made diagnoses based on clinical and imaging data. We compared the rate of stroke, TIA, and cerebrovascular disease (either stroke or TIA) diagnoses across the study groups using Pearson's χ² test. The effect of confounders was adjusted using a multivariate logistic regression analysis.

Results

Cerebrovascular disease was significantly less common in patients with combined systolic and diastolic orthostatic hypertension compared to the "no rise" group [OR = 0.56 (95% CI 0.35–0.89]. The odds were even lower among the subgroups of patients with obesity [OR = 0.31 (0.12–0.80)], without history of smoking [OR 0.34 (0.15–0.80)], and without hypertension [OR = 0.42 (95% CI 0.19–0.92)]. We found no significant relationship between orthostatic blood pressure rise with the diagnosis of stroke. However, the odds of TIA were significantly lower in patients with diastolic [OR 0.82 (0.68–0.98)] and combined types of orthostatic hypertension [OR = 0.54 (0.32–0.93)]; especially in patients younger than 65 years [OR = 0.17 (0.04–0.73)] without a history of hypertension [OR = 0.34 (0.13–0.91)], and patients who did not take antihypertensive therapy [OR = 0.35 (0.14–0.86)].

Conclusion

Our data suggest that orthostatic hypertension may be a protective factor for TIA among younger and normotensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02600-1.

Association between orthostatic blood pressure dysregulation and geriatric syndromes: a cross-sectional study

Background

Orthostatic blood pressure dysregulation, including orthostatic hypotension (OH) and orthostatic hypertension (OHT), is common in the elderly. The association between OH and, to a lesser extent, OHT with geriatric syndromes is controversial and little investigated.

Our objective was to assess the association between orthostatic blood pressure dysregulation and geriatric syndromes in an ambulatory outpatient population.

Methods

This observational study included all outpatients for whom a one-visit comprehensive geriatric assessment was performed during a year. OH was defined as a decrease of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) after 1 or 3 min of standing. OHT was defined as an increase of more than 20 mmHg in SBP after 1 or 3 min of standing. Comorbidities, drugs regimen, a history of previous falls, nutritional, frailty, functional and cognitive status were compared between patients with OHT or OH and controls (NOR).

Results

Five hundred thirty patients (mean age: 82.9 ± 5.1 years) were included. 19.6% had an OH and 22.3% an OHT. OHT patients were more frequently female, had more diabetes and a lower resting SBP than patients with NOR. OH patients had a higher resting SBP than NOR. After adjusting for age, sex, resting SBP and diabetes, OHT was associated with a low walking speed (OR = 1.332[1.009–1.758]; p = 0.043) and severe cognitive impairment at MMSe score (OR = 1.629[1.070–1.956]; p = 0.016) compared to NOR. Conversely, OH was associated with a lower grip strength (p = 0.016) than NOR.

Conclusion

OHT and OH are common in elderly but associated with different geriatric phenotypes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02844-8.

Orthostatic intolerance: a frailty marker for older adults

PURPOSE

Frailty, orthostatic blood pressure changes (OBPC), and orthostatic intolerance syndrome (OIS) are common in geriatric patients. However, the results of the studies evaluating the relationship between these entities are discordant. We aimed to investigate the association between frailty and OIS with or without OBPC.

METHODS

Comprehensive geriatric assessment (CGA), frailty assessment, OBPC evaluations in the active-standing test (1st, 3rd, 5th, and 10th min), OIS investigation both in history before the test (self-reported OIS) and emerged during the active-standing test, and sarcopenia assessment via BIA and handgrip strength (HGS) were performed in 102 geriatric outpatients.

RESULTS

Patients were divided into three categories according to their frailty status (non-frail, prefrail, and frail) by Modified Fried Frailty Index (FFI) and Clinical Frailty Scale (CFS). Prevalence of self-reported OIS and OIS during the test were statistically higher in the frail group assessed by both frailty scales (P value: 0.001 for CFS, P value < 0.0001 for FFI, and P value: 0.001 for CFS, P value: 0.007 for FFI, respectively). Logistic regression analysis showed that OIS significantly increased frailty assessed both by FFI and CFS, when adjusted for age, sex, comorbidities, CGA, and sarcopenia (For FFI, OR: 19.37; 95% CI: 2.38-157.14; P value: 0.006 and for CFS OR: 4.32; 95% CI: 1.184-11.47; P value: 0.003, respectively).

CONCLUSION

To the best of our knowledge, this is the first study defining OIS as symptoms both self-reported and provoked during the test, and showed a strong correlation between OIS and frailty. OIS may be defined as a multifactorial and independent marker for frailty, regardless of OBPC. Further prospective investigations are warranted to support the relationships between OIS and frailty.

Blood Pressure Drop Rate After Standing Up Is Associated With Frailty and Number of Falls in Geriatric Outpatients

Background

The relationship between orthostatic hypotension and clinical outcome in older adults is poorly understood. Blood pressure drop rate (ie, speed of blood pressure drop) may particularly reflect the imposed challenge to the baroreflex and the associated clinical outcome (ie, frailty and number of falls). This study aimed to compare orthostatic blood pressure drop rate and drop magnitude with regard to their association with frailty and number of falls.

Methods and Results

Blood pressure was measured continuously during a standardized active stand task in 168 patients (mean age 81.4±7.0; 55.4% female) who visited a geriatric outpatient clinic for cognitive or mobility problems. The association of orthostatic blood pressure drop rate, blood pressure drop magnitude, and baroreflex sensitivity (ie, increase in heart rate divided by systolic blood pressure drop magnitude) with frailty (Fried criteria and 4 frailty markers) and self‐reported number of falls was assessed using linear regression models, adjusting for age and sex. Systolic blood pressure drop rate had the strongest association with frailty according to the 4 frailty markers (β 0.30; 95% CI, 0.11–0.49; P=0.003) and number of falls (β 1.09; 95% CI, 0.19–1.20; P=0.018); diastolic blood pressure drop magnitude was most strongly associated with frailty according to the Fried criteria (β 0.37; 95% CI, 0.15–0.60; P<0.001). Baroreflex sensitivity was associated with neither frailty nor number of falls.

Conclusions

Orthostatic blood pressure drop rate was associated with frailty and falls and may reflect the challenge to the baroreflex rather than drop magnitude.