The “Nondipper” Elderly: A Clinical Entity or a Bias?

Factors Associated with Volunteer Activities and Sleep Efficiency in Older Adults with Hypertension: A Sequential Model Study

The purpose of this study was to examine, using a sequential model, factors associated with volunteer participation and sleep efficiency in Japanese older adults receiving treatment for hypertensive disease. A questionnaire survey was conducted to collect data on participant demographics, lifestyle, health status, and depression, and sleep activity monitors were used to objectively measure sleep status and sleep efficacy. Of the 167 respondents, the 59 being treated for hypertension were divided into two groups based on their participation in volunteering. Comparison between the groups showed significant differences in nocturnal awakening, sleep efficiency, and nap frequency. Volunteers had less nocturnal awakening, increased sleep efficiency, fewer naps, and decreased depression. Covariance structure analysis of the survey data and sleep measurements for hypertensive older adults in the volunteer group was performed by modeling the relationships between variables with a path diagram. Our model showed strong goodness of fit (χ² test = 15.636, p = 0.111, GFI = 0.925, AGFI = 0.842, CFI = 0.925, RMSEA = 0.099). The findings of this study suggest that older adults with hypertension who participate in volunteer activities have less nocturnal awakening, improved sleep quality, and reduced risk of depression, and provides evidence to promote social participation in volunteering among older adults with hypertension.

The relationship between hypertension and nocturnal waking in community-dwelling elderly individuals

AIM

This study aimed to clarify the relationship between hypertension and nocturnal waking among community-dwelling elderly individuals.

SUBJECTS AND METHODS

The survey was performed by asking questions related to the basic attributes, lifestyle, sleep conditions and the health status of 422 elderly individuals who belonged to elderly clubs. The subjects were divided into a hypertension group and a non-hypertension group. The data were analyzed using Spearman's rank correlation coefficient and a logistic regression analysis.

RESULTS

Two hundred of the 422 elderly individuals responded to the questions (response rate: 47.4%). The rate of obesity in the hypertension group was significantly higher (p=.01) than that in the non-hypertension group. The logistic regression analysis revealed that hypertension was associated with the BMI (OR=1.148, 95%CI: 1.022-1.289) and the number of nocturnal waking episodes (OR=1.449, 95%CI: 1.015-2.067). In the hypertension group, the number of nocturnal waking episodes was significantly correlated with age (rs=0.232), and the performance of volunteer activities was associated with a decreased number of nocturnal waking episodes (rs=-0.356).

CONCLUSIONS

It was shown that nocturnal waking and obesity were strongly associated with hypertension. The performance of volunteer activities was also correlated a decrease in the number of nocturnal waking episodes. Further studies should be performed to investigate the relationship between hypertension, the number of nocturnal waking episodes and sympathetic nerve activity. A greater number of physiological activities should be evaluated and the volunteer activities in which the elderly people participated should be precisely analyzed.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

OBJECTIVES

A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design.

METHODS

In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed.

RESULTS

In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge.

CONCLUSIONS

In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.

Night-time blood pressure patterns and target organ damage: a review

BACKGROUND

Individuals who do not have a 10% to 20% reduction in blood pressure (BP) during the night are known as 'nondippers'. The cause of this nondipping phenomenon is not fully understood; however, there is a growing body of evidence linking a nondipping BP pattern with target organ damage.

OBJECTIVE

To review the literature and present an overview of the target organ damage found to be associated with a nondipping BP pattern.

METHODS

PubMed, CINAHL and Medscape searches of all available English language articles from 1986 to 2005 were performed. Search terms included 'BP nondipping', 'BP dipping' and 'target organ damage'.

RESULTS

There is evidence to suggest that individuals with hypertension who exhibit a nondipping BP profile are at higher risk of cardiac and extracardiac morbidity and mortality. In particular, nondippers with essential hypertension have been found to have more advanced left ventricular hypertrophy, left ventricular mass and left ventricular mass index, carotid artery wall thickness, carotid artery atherosclerotic plaques, silent cerebral infarct, stroke, cognitive impairment and microalbuminuria.

CONCLUSION

A better understanding of the importance of the circadian variations of BP may help to identify those at higher risk of cardiovascular morbidity and mortality, as well as lay the foundation for interventions to prevent/treat alterations in night-time BP patterns.

Nondipping blood pressure patterns among individuals with essential hypertension: a review of the literature

BACKGROUND

Researchers have discovered that blood pressure (BP) varies in a diurnal manner throughout a 24-hour period, being higher during the day and lower at night. Most people have a dipping BP pattern characterized by a nighttime BP that is 10-20% lower than their daytime BP. Individuals who experience a less than 10% reduction in nighttime BP are described as having a nondipping BP pattern. Although controversial, there is a growing body of evidence suggesting that a nondipping BP pattern is associated with a greater risk of target organ damage among individuals with essential hypertension.

AIM

To review the literature on the most common factors associated with nondipping BP patterns among individuals with essential hypertension.

METHODS

CINAHL (1982-March 2006), PubMed (1950-March 2006) and Cochrane Library (1966-March 2006) databases were searched using the keywords: dipper, dipping, nondipper, nondipping, ambulatory blood pressure monitoring, ABPM, hypertension, essential hypertension, high blood pressure, blood pressure, nocturnal blood pressure, nighttime blood pressure, diurnal blood pressure, and blood pressure patterns. Published studies, abstracts, dissertations as well as the reference lists of retrieved articles were reviewed. Studies were included if they involved subjects with only treated or untreated essential hypertension or those with samples of both nomotensive and treated or untreated essential hypertensive individuals. Additionally, studies needed to evaluate 24-hour, daytime and nighttime BP patterns.

RESULTS

There is some evidence to suggest advanced age, African-American ethnicity, female sex, postmenopausal status, sodium sensitivity, sleep apnea, sleep quality, anger, hostility, depression, stress, social support, and socioeconomic status have an association with nondipping BP patterns.

CONCLUSION

Knowledge of the potential factors associated with an altered nighttime BP pattern is of importance because it can help identify persons at risk for nondipping BP patterns and potential target organ damage. Furthermore, knowledge of these factors associated with a nondipping BP profile will lay the foundation for interventions to prevent/treat alterations in nighttime BP patterns.

Hypertension in the Elderly

Hypertension is predictive of a wide variety of subsequent adverse events in elderly patients, at least up to the age of 80 years. Treatment can reduce these adverse outcomes, although the benefits in the very elderly remain somewhat unclear. In the very elderly, there appears to be a reduction in cardiovascular events, but this reduction is perhaps at the expense of an increase in overall mortality. Target BPs in the elderly remain controversial. Among patients who have not had previous stroke or significant cardiovascular or renal disease, the benefits of reducing the SBP below 159 mm Hg are well documented. There is some evidence to suggest, however, that if doing so increases the day-night difference in BP by more than 20% or is associated with a decline in DBP below 65 mm Hg, then the benefits of treatment may be attenuated or lost. In addition, there is some suggestion that reducing SBP consistently below 135 mm Hg may accelerate cognitive decline. There appears to be a role for sodium restriction in those who can comply without otherwise compromising nutrient intake. Likewise, exercise may be beneficial and have benefits beyond simply lowering BP. Weight loss in those who are overweight may also help in lowering the BP. For most patients, low-dose thiazides such as hydrochlorothiazide are likely to be the appropriate first-line therapy (even in patients who have diabetes) unless they exacerbate or precipitate urinary incontinence or gout or complicate concomitant drug therapy (eg, lithium treatment of bipolar disorder). In very elderly patients, the apparent beneficial effects on strokes, major cardiovascular events, and heart failure rates may justify treating despite lack of benefit on overall mortality.