Cerebral perfusion responses to active standing are attenuated in patients with vasovagal syncope

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council (IRC): Government of Ireland Postgraduate Scholarship Programme 2018, Dublin, Ireland Fundació Universitària Agustí Pedro i Pons, Universitat de Barcelona, Barcelona, Spain

Background

Syncope is a transient loss of consciousness due to cerebral hypoperfusion. While traditionally peripheral haemodynamics are monitored during clinical assessment of syncope, relatively little is known about cerebrovascular haemodynamics during orthostasis in patients with syncope.

Purpose

Here we investigated whether young patients with syncope present an altered cerebral perfusion when compared to healthy controls. Given potential hyper-reactivity of the autonomic nervous system previously reported in these patients, we hypothesise that an overly active cerebral autoregulation will be present in patients with syncope.

Methods

Consecutive patients were prospectively recruited from a National Falls and Syncope Unit, and a convenience sample of young healthy community dwelling adults was recruited from a local university (16-30 years). Participants performed a 3 minute active stand test with continuous measurement of beat-to-beat peripheral haemodynamics (blood pressure (BP), heart rate (HR)) and changes in concentration of oxygenated Δ[O2Hb] and deoxygenated Δ[HHb] haemoglobin were derived from a near-infrared spectroscopy (NIRS) monitor. Baseline, steady state and other time domain features were derived for Δ[O2Hb] (nadir, overshoot, overshoot-to-nadir, overshoot-to-nadir recovery rate) and Δ[HHb] (peak, trough, peak-to-trough, peak-to-trough recovery rate) and multiple linear regression was used to compare differences between the two groups correcting for covariates (p < 0.05 significant).

Results

Patients (n = 40) were younger (20(5.5) vs 23(1) years, p = 0.003) than controls (n = 17) and were well matched in gender, weight, height, BMI and resting haemodynamics. Patients had a smaller Δ[O2Hb] overshoot-to-nadir difference (β: -0.749, CI:(-1.593 0.094), p = 0.08), a slower Δ[O2Hb] recovery rate (β: -0.186, CI:(-0.388 0.016), p = 0.071), and smaller Δ[HHb] peak-to-trough difference (β: -0.530, CI:( -0.921 0.138), p = 0.018) and slower Δ[HHb] recovery rate (β: -0.151, CI: (0.244 0.057), p = 0.008).

Conclusion

Patients with syncope had signs of an attenuated cerebral oxygenation response to an AS when compared to controls. We hypothesise that this is due to hyper-reactive cerebral autoregulation mechanism, which might be related to a hyper-sensitive autonomic system. Furthering our understanding of vasovagal syncope physiology can help inform future interventions and treatments. This study shows the clinical value of measuring cerebral perfusion using NIRS, an easy to use and readily applicable tool, in the assessment of syncope. Abstract Figure. Cerebral oxygenation upon standing

Do patients with syncope have a hyper-reactive autonomic nervous system?

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council (IRC): Government of Ireland Postgraduate Scholarship Programme 2018, Dublin, Ireland Fundació Universitària Agustí Pedro i Pons, Universitat de Barcelona, Barcelona, Spain.

Background

The origin of syncope, a transient loss of consciousness due to cerebral hypoperfusion, remains unclear. Recent studies suggest that a hypersensitive autonomic nervous system might be involved in the pathophysiology of vasovagal syncope (VVS).

Purpose

Here we test the hypothesis that patients with VVS have a hyper-reactive autonomic nervous system by investigating the peripheral haemodynamic responses during a standing (AS) test in a group of young VVS patients vs a control group.

Methods

A prospective sample of consecutive patients from a National Falls and Syncope Unit was recruited, and a convenience sample of young healthy community dwelling adults was recruited from a local university (16-30 years). Participants performed a 3 minute AS with continuous measurement of beat-to-beat blood pressure (BP), heart rate (HR), and cerebral oxygenation measured with near infrared spectroscopy. Baseline, steady-state and other time domain features were obtained for systolic BP (SBP) (i.e. nadir, overshoot, overshoot-to-nadir, overshoot-to-nadir recovery rate) and for HR (i.e. peak, trough, peak-to-trough, peak-to-trough recovery rate). Multiple linear regression was used to compare these features between patients and controls while correcting for covariates (p < 0.05 significant).

Results

Forty patients and 17 controls were included, the former group being younger ((20(5.5) vs 23(1) years, p = 0.003). During steady-state standing SBP was higher as compared to controls (β: 6.853, CI: (0.713 12.993), p = 0.029). Patient data trended toward lower steady-state HR (β: -5.262, CI:(-11.201 0.677), p = 0.081), together with a larger peak-to-trough difference (β: 7.212, CI:(1.329 -15.754), p = 0.096).

Conclusion

These results tend to support the hypothesis and previous literature suggesting the presence of autonomic hyper-reactivity in patients with syncope, presenting as an exaggerated peripheral circulatory response to standing. Understanding the pathophysiology of VVS can help us improve its assessment and develop better treatment pathways for these patients. Abstract Figure.

Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

BACKGROUND

Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission.

AIM

To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness.

DESIGN

Pre- and post-cohort study.

METHODS

Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS).

RESULTS

There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030).

CONCLUSION

This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

Perspective: Vitamin D deficiency and COVID-19 severity - plausibly linked by latitude, ethnicity, impacts on cytokines, ACE2 and thrombosis

BACKGROUND

SARS-CoV-2 coronavirus infection ranges from asymptomatic through to fatal COVID-19 characterized by a 'cytokine storm' and lung failure. Vitamin D deficiency has been postulated as a determinant of severity.

OBJECTIVES

To review the evidence relevant to vitamin D and COVID-19.

METHODS

Narrative review.

RESULTS

Regression modelling shows that more northerly countries in the Northern Hemisphere are currently (May 2020) showing relatively high COVID-19 mortality, with an estimated 4.4% increase in mortality for each 1 degree latitude north of 28 degrees North (P = 0.031) after adjustment for age of population. This supports a role for ultraviolet B acting via vitamin D synthesis. Factors associated with worse COVID-19 prognosis include old age, ethnicity, male sex, obesity, diabetes and hypertension and these also associate with deficiency of vitamin D or its response. Vitamin D deficiency is also linked to severity of childhood respiratory illness. Experimentally, vitamin D increases the ratio of angiotensin-converting enzyme 2 (ACE2) to ACE, thus increasing angiotensin II hydrolysis and reducing subsequent inflammatory cytokine response to pathogens and lung injury.

CONCLUSIONS

Substantial evidence supports a link between vitamin D deficiency and COVID-19 severity but it is all indirect. Community-based placebo-controlled trials of vitamin D supplementation may be difficult. Further evidence could come from study of COVID-19 outcomes in large cohorts with information on prescribing data for vitamin D supplementation or assay of serum unbound 25(OH) vitamin D levels. Meanwhile, vitamin D supplementation should be strongly advised for people likely to be deficient.

The cross-sectional association between diabetes and orthostatic hypotension in community-dwelling older people

AIMS

Orthostatic hypotension is a recognized complication of diabetes, but studies examining prevalence in diabetes are limited. The aim of this study was to ascertain the prevalence of orthostatic hypotension and the pattern of orthostatic BP response in a cohort of people with diabetes aged ≥ 50 years, embedded within the Irish Longitudinal Study of Ageing.

METHODS

Orthostatic hypotension was defined as a drop in systolic blood pressure (SBP) ≥ 20 mmHg or drop in diastolic blood pressure (DBP) ≥ 10 mmHg at 30 s after standing. Diabetes was defined by self-report but cross-checked against HbA_1c and medication records. Multilevel mixed effects linear regression models were used to compare orthostatic BP in people with and without diabetes.

RESULTS

Some 3222 people were included, 7% (213 of 3222) of whom had diabetes. Prevalence of orthostatic hypotension in the group with diabetes was 22% (46 of 213) vs. 13% in those without diabetes; χ² = 12.43; P < 0.001. Multilevel models demonstrated prolonged recovery of DBP in people with diabetes, with only 41% (87 of 213) returning to baseline by 60 s. Logistic regression models demonstrated that diabetes was associated with a significantly increased likelihood of orthostatic hypotension (odds ratio 1.84, 95% confidence interval 1.30-2.59; P = 0.001) and this remained robust after controlling for covariates.

CONCLUSION

Over one-fifth of older people with diabetes had orthostatic hypotension. Recovery of DBP is related to dynamic changes in total peripheral resistance and impairment of this baroreflex-mediated response may explain the higher prevalence in diabetes. Given the prognostic implications when co-existing with diabetes, orthostatic hypotension may represent a potentially modifiable risk factor for adverse outcomes in late-life diabetes.

Vitamin D and Inflammation: Potential Implications for Severity of Covid-19

Background Recent research has indicated that vitamin D may have immune supporting properties through modulation of both the adaptive and innate immune system through cytokines and regulation of cell signalling pathways. We hypothesize that vitamin D status may influence the severity of responses to Covid-19 and that the prevalence of vitamin D deficiency in Europe will be closely aligned to Covid-19 mortality. Methods We conducted a literature search on PubMed (no language restriction) of vitamin D status (for older adults) in countries/areas of Europe affected by Covid-19 infection. Countries were selected by severity of infection (high and low) and were limited to national surveys or where not available, to geographic areas within the country affected by infection. Covid-19 infection and mortality data was gathered from the World Health Organisation. Results Counter-intuitively, lower latitude and typically 'sunny' countries such as Spain and Italy (particularly Northern Italy), had low mean concentrations of 25(OH)D and high rates of vitamin D deficiency. These countries have also been experiencing the highest infection and death rates in Europe. The northern latitude countries (Norway, Finland, Sweden) which receive less UVB sunlight than Southern Europe, actually had much higher mean 25(OH)D concentrations, low levels of deficiency and for Norway and Finland, lower infection and death rates. The correlation between 25(OH)D concentration and mortality rate reached conventional significance (P=0.046) by Spearman's Rank Correlation. Conclusions Optimising vitamin D status to recommendations by national and international public health agencies will certainly have benefits for bone health and potential benefits for Covid-19. There is a strong plausible biological hypothesis and evolving epidemiological data supporting a role for vitamin D in Covid-19.

Near-infrared spectroscopy in evaluating psychogenic pseudosyncope-a novel diagnostic approach

BACKGROUND

Psychogenic pseudosyncope (PPS), a conversion disorder and syncope mimic, accounts for a large proportion of 'unexplained syncope'. PPS is diagnosed by reproduction of patients' symptoms during head-up tilt (HUT). Electroencephalogram (EEG), a time consuming and resource intensive technology, is used during HUT to demonstrate absence of cerebral hypoperfusion during transient loss of consciousness (TLOC). Near-infrared spectroscopy (NIRS) is a simple, non-invasive technology for continuous monitoring of cerebral perfusion. We present a series of patients for whom PPS diagnosis was supported by NIRS during HUT.

METHODS

Eight consecutive patients with suspected PPS referred to a syncope unit underwent evaluation. During HUT, continuous beat-to-beat blood pressure (BP), heart rate (HR) and NIRS-derived tissue saturation index (TSI) were measured. BP, HR and TSI at baseline, time of first symptom, presyncope and apparent TLOC were measured. Patients were given feedback and followed for symptom recurrence.

RESULTS

Eight predominantly female patients (6/8, 75%) aged 31 years (16-54) were studied with (5/8, 63%) having comorbid psychiatric diagnoses, and (5/8, 63%) presenting with frequent episodes of prolonged TLOC with eyes closed (6/8, 75%). All patients experienced reproduction of typical events during HUT. Systolic BP (mmHg) increased from baseline (129.7 (interquartile range [IQR] 124.9-133.4)) at TLOC (153.0 (IQR 146.7-159.0)) (P-value = 0.012). HR (bpm) increased from baseline 78 (IQR 68.6-90.0) to 115.7 (IQR 93.5-127.9) (P-value = 0.012). TSI (%) remained stable throughout, 71.4 (IQR 67.5-72.9) at baseline vs. 71.0 (IQR 68.2-73.0) at TLOC (P-value = 0.484).

CONCLUSIONS

NIRS provides a non-invasive surrogate of cerebral perfusion during HUT. We propose HUT incorporating NIRS monitoring in the diagnostic algorithm for patients with suspected PPS.

75 Is Cerebral Autoregulation Altered in Ageing? A Review

Introduction

Cerebral autoregulation (CA) ensures constant cerebral blood flow (CBF) in the face of blood pressure (BP) disturbances. While CA impairment is often implicated in the aetiology of age-related disorders e.g. falls, syncope, and brain ageing, there is conflicting evidence on the effect of normal or healthy ageing on cerebral autoregulation. Here we present results of a review investigating the effect of ageing on CA.

Methods

A search was performed in Pubmed using the search terms “cerebral autoregulation” AND (“ageing” OR “age” OR “older” OR “elderly”). Studies were included if they were human studies in English assessing CA in healthy volunteers (free from disease) in which the effect of ageing on CAR was studied. Exclusion criteria included non-human studies, diseased cohorts and studies not measuring CA.

Results

26 studies (n=1326 total participants, age range 12-88) meeting the inclusion/exclusion criteria were identified. Significant heterogeneity was noted in applied methodologies with 88% of studies using static and 53% using dynamic protocols to measure CA. Transcranial Doppler (88%) and Near Infrared Spectroscopy (NIRS) (11%) were the most commonly used. Transfer function analysis (TFA) (38%), the Autoregulatory Index (ARI) (15%), and wavelet analysis (11%) were used to derive CA metric. The majority of studies suggested that CA is preserved (n=15) with ageing. However, a smaller number of studies (n=7) noted that CA is impaired or altered with ageing.

Conclusions

There is a paucity of literature examining the relationship between CA and chronological ageing, with 60 per cent of studies reviewed suggesting that CA is preserved. Current hypotheses suggest that preservation of CA with ageing serves as a ‘reserve’ to compensate for impairment of other systems. Future work should investigate the role of impaired CA as potential biomarker of biological ageing.

Automatic Disability Categorisation based on ADLs among Older Adults in a Nationally Representative Population using Data Mining Methods

The world's ageing population is rapidly increasing but people's healthspan is not being sustained. Activities of daily living and Montreal Cognitive Assessment scores from the first wave of a large nationally representative longitudinal study in ageing (TILDA) were analysed using multiple correspondence analysis, k-means clustering, network analysis and association rules mining, to find latent patterns in the data and categorise disability among older adults. It was observed that 6.2% of the population had a greater degree of frailty, specifically cognitive impairment. Additionally, the overall population showed difficulty in performing physically demanding activities. Thus, self-reported ADLs have a diagnostic importance as they indicate the level of cognitive and physical functional decline in the older population.

The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study

BACKGROUND

Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults.

AIM

This study assesses the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50.

DESIGN

Cross-sectional analysis of data from wave 1 of The Irish Longitudinal Study on Ageing.

METHODS

Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorizing based on BZD use and sleep quality variables.

RESULTS

Of 8175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for confounders [Odds Ratio (OR) 1.40; 1.08, 1.82; P-value 0.012]. There was no significant association between BZDs and unexplained falls, controlling for confounders [OR 1.41; 95% Confidence Interval (CI) 0.95, 2.10; P-value 0.09]. Participants who use BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; P-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; P-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; P-value 0.015), have an increased odds of unexplained falls.

CONCLUSION

BZD use is associated with falls, with larger effect size in those reporting poor sleep quality in community dwelling older adults. Appropriate prescription of medications such as BZDs is an important public health issue.

Characterization of alcohol consumption patterns among older adults in Ireland

Background

Identifying the factors associated with hazardous drinking patterns and problem drinking is imperative to develop appropriate intervention strategies for alcohol harm reduction among the older population. The aim of this study was 1) To explore the patterns of alcohol consumption among older adults in the Republic of Ireland, and 2) To establish possible predictors of hazardous and problem drinking in this population.

Methods

A cross-sectional analysis was carried out on samples of individuals aged &gt;50 years at Wave 3 of The Irish Longitudinal Study on Ageing (N = 4948). Hazardous alcohol consumption was defined as drinking above Irish guidelines [women &gt;11 Standard Irish Drinks (SD)/week; men &gt;17 SD/week], and/or having at least one heavy drinking episode per week (&gt;6 SD/day). Problem drinking was defined as a score of &gt; 2 on the CAGE instrument. Regression analyses investigated outcome differences according to socio-demographic and health characteristics. Sampling weights were applied to account for differential non-response.

Results

The prevalence of drinking patterns was 13% for lifetime alcohol abstainers, 8% for former drinkers, 26% for occasional drinkers and 53% for weekly drinkers. Among weekly drinkers 25% exceeded the guideline threshold, 23% had at least one heavy drinking episode per week and 16% had an alcohol problem according to the CAGE. In fully adjusted models, hazardous drinking and problem drinking were associated with younger older adults, male sex, current or past smoking, higher levels of stress and/or social isolation.

Conclusions

Our findings serve as a starting point to monitor trends of alcohol consumption among older adults in the Republic of Ireland. Our results highlight areas of opportunity for targeted screening and public interventions that seek to reduce alcohol harm among this population.

Key messages

In the Irish context, older adults who are younger, male, current or past smokers, with higher levels of stress and/or social isolation are more likely to engage in hazardous alcohol consumption. Our characterization of drinking patterns highlights areas of opportunity for targeted screening and public interventions that seek to reduce alcohol harm among older adults in Ireland.

P5678Near-infrared spectroscopy (NIRS) in the evaluation of psychogenic pseudosyncope - Moving towards a simplified diagnostic pathway

Background

Psychogenic pseudosyncope (PPS) is a conversion disorder that often mimics syncope, is commonly referred to cardiology clinics and accounts for a large proportion of patients admitted with “unexplained syncope”. Unlike syncope, PPS is characterized by normal blood pressure (BP) and heart rate (HR) values at TLOC inferring the absence of cerebral hypoperfusion. The current gold standard for the diagnosis of PPS is the reproduction of patients' symptoms during a head-up tilt test (HUTT) with concurrent electroencephalogram (EEG) monitoring showing normal haemodynamic and brainwave measurements. However, EEG is time consuming, resource intensive and many syncope units lack ready access, thereby solely relying on absence of peripheral haemodynamic changes to diagnose PPS.

Purpose

Near-infrared spectroscopy (NIRS) is a non-invasive technology used for continuous monitoring of cerebral oxygenation. Measuring adequacy of tissue oxygenation is an appropriate surrogate for cerebral perfusion. In this study, we present a case series of patients for whom the diagnosis of PPS was confirmed by NIRS during TLOC. We propose use of NIRS in routine clinical assessment of suspected PPS.

Methods

We describe nine consecutive patients with suspected PPS referred to a dedicated syncope unit for investigation of recurrent unexplained syncope. All patients underwent evaluation in accordance with European Society of Cardiology guidelines including HUTT. Continuous beat-to-beat BP and HR measurements were recorded using finger plethysmography. In addition, continuous NIRS-derived tissue saturation index (TSI) - a measure of percentage oxygenation - was recorded using an optical sensor applied to the left lateral forehead to assess cerebral perfusion. Absolute values of BP, HR and TSI at baseline, time of first symptom onset, presyncope and apparent TLOC were recorded. The evaluation was diagnostic for PPS when apparent TLOC occurred in the absence of typical haemodynamic or cerebral perfusion changes.

Results

The median age was 35 years (range 14–54). Clinical features were consistent with those previously described in PPS literature - female preponderance, comorbid psychiatric diagnosis, frequent attack history, with prolonged TLOC and eyes closed during events. During HUTT, all patients experienced an apparent TLOC which they recognised as reproductive of typical events. BP and HR measurements increased significantly at time of TLOC. There was no significant change in TSI at any of the time points throughout HUTT. (Figure 1 shows averaged absolute values of systolic and diastolic BP, HR and TSI with median values represented by thickened lines.)

Figure 1. Measurements during HUTT

Conclusion

NIRS is readily available, easily accessible and provides an appropriate surrogate measure of cerebral perfusion during HUTT. We propose that HUTT incorporating concurrent NIRS monitoring will enhance diagnostic yield and patient management providing important biofeedback.

A comprehensive assessment of risk factors for falls in middle-aged adults: co-ordinated analyses of cohort studies in four countries

We identified demographic, health and lifestyle factors associated with falls in adults aged 50-64 years from Australia, The Netherlands, Great Britain and Ireland. Nearly all factors were associated with falls, but there were differences between countries and between men and women. Existing falls prevention programs may also benefit middle-aged adults.

INTRODUCTION

Between ages 40-44 and 60-64 years, the annual prevalence of falls triples suggesting that middle age may be a critical life stage for preventive interventions. We aimed to identify demographic, health and lifestyle factors associated with falls in adults aged 50-64 years.

METHODS

Harmonised data were used from four population-based cohort studies based in Australia (Australian Longitudinal Study on Women's Health, n = 10,641, 51-58 years in 2004), Ireland (The Irish Longitudinal Study on Ageing, n = 4663, 40-64 years in 2010), the Netherlands (Longitudinal Ageing Study Amsterdam, n = 862, 55-64 years in 2012-13) and Great Britain (MRC National Survey of Health and Development, n = 2987, 53 years in 1999). Cross-sectional and prospective associations of 42 potential risk factors with self-reported falls in the past year were examined separately by cohort and gender using logistic regression. In the absence of differences between cohorts, estimates were pooled using meta-analysis.

RESULTS

In cross-sectional models, nearly all risk factors were associated with fall risk in at least one cohort. Poor mobility (pooled OR = 1.71, CI = 1.34-2.07) and urinary incontinence (OR range = 1.53-2.09) were consistently associated with falls in all cohorts. Findings from prospective models were consistent. Statistically significant interactions with cohort and sex were found for some of the risk factors.

CONCLUSION

Risk factors known to be associated with falls in older adults were also associated with falls in middle age. Compared with findings from previous studies of older adults, there is a suggestion that specific risk factors, for example musculoskeletal conditions, may be more important in middle age. These findings suggest that available preventive interventions for falls in older adults may also benefit middle-aged adults, but tailoring by age, sex and country is required.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Change in perceived stress and 2-year change in cognitive function among older adults: The Irish Longitudinal Study on Ageing

Prolonged or severe stress can adversely affect older adults' cognitive function, but population-based studies investigating this relationship over time are rare. Previous studies have largely focused on stress either evaluated at a single time point or linked to specific life events. This study aimed to investigate whether a change in perceived stress over 2 years predicts a change in cognitive performance over the same time period in a population-based sample of older adults. Data from the first 2 waves of The Irish Longitudinal Study on Ageing were analyzed. Five thousand and seventy adults aged 50 and older completed the 4-item Perceived Stress Scale and measures of verbal fluency, immediate and delayed word recall 2 years apart. A first differences regression model revealed that the change in stress over 2 years was inversely associated with a change in immediate word recall performance, even after adjustment for change in possible confounders (B = -0.030, 95% CI [-.056, -.004], p < .05). No association was observed for delayed recall or verbal fluency performance. Change in perceived stress is inversely correlated with change in immediate recall, even over a short period. Stress modifying interventions could potentially reduce the risk of cognitive decline associated with ageing.

Noninvasive beat-to-beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages

Over the past 30 years, noninvasive beat-to-beat blood pressure (BP) monitoring has provided great insight into cardiovascular autonomic regulation during standing. Although traditional sphygmomanometric measurement of BP may be sufficient for detection of sustained orthostatic hypotension, it fails to capture the complexity of the underlying dynamic BP and heart rate responses. With the emerging use of noninvasive beat-to-beat BP monitoring for the assessment of orthostatic BP control in clinical and population studies, various definitions for abnormal orthostatic BP patterns have been used. Here, age-related changes in cardiovascular control in healthy subjects will be reviewed to define the spectrum of the most important abnormal orthostatic BP patterns within the first 180 s of standing. Abnormal orthostatic BP responses can be defined as initial orthostatic hypotension (a transient systolic BP fall of >40 mmHg within 15 s of standing), delayed BP recovery (an inability of systolic BP to recover to a value of >20 mmHg below baseline at 30 s after standing) and sustained orthostatic hypotension (a sustained decline in systolic BP of ≥20 mmHg occurring 60-180 s after standing). In the evaluation of patients with light-headedness, pre(syncope), (unexplained) falls or suspected autonomic dysfunction, it is essential to distinguish between normal cardiovascular autonomic regulation and these abnormal orthostatic BP responses. The prevalence, clinical relevance and underlying pathophysiological mechanisms of these patterns differ significantly across the lifespan. Initial orthostatic hypotension is important for identifying causes of syncope in younger adults, whereas delayed BP recovery and sustained orthostatic hypotension are essential for evaluating the risk of falls in older adults.

Is orthostatic hypotension more common in individuals with atrial fibrillation?-Findings from The Irish Longitudinal Study on Ageing (TILDA)

Introduction

atrial fibrillation (AF) and orthostatic hypotension (OH) share common risk factors such as age, hypertension and cardiovascular (CV) disease. The autonomic nervous system (ANS) also plays a role in the pathogenesis of both AF and OH. The aim of this study is to assess whether individuals with AF are more likely to have OH than those without AF.

Methods

data from wave 1 of The Irish Longitudinal Study on Ageing were used. Beat-to-beat blood pressure was measured during active stand lasting 110 s. OH, defined as a drop in systolic blood pressure (SBP) ≥20 mmHg or a drop in diastolic blood pressure ≥10 mmHg at 30, 60 and 90 s was assessed. Initial OH (IOH) was assessed as a drop in SBP ≥40 mmHg or a drop in diastolic BP≥20 mmHg.

Results

in total 4,408 participants aged ≥50 had active stand and electrocardiogram data suitable for analysis. AF was identified in 101 of these. Logistic regression found participants with AF were more likely to have OH at 30 (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.24-3.06) and 60 (OR 2.13, 95% CI 1.18-3.87) seconds, and IOH (OR 1.81, 95% CI 1.21-2.70). The association between IOH and OH at 30 s remained significant following adjustment for confounders (age, sex, baseline HR, education, BP, smoking, frailty, beta blocker (BB) use, anti-hypertensive use (excluding BBs) and number of CV conditions).

Conclusion

OH is more common in individuals with AF, this may reflect the role of the ANS in both AF and OH.

The discrepancy between social isolation and loneliness as a clinically meaningful metric: findings from the Irish and English longitudinal studies of ageing (TILDA and ELSA)

OBJECTIVE

Scant evidence is available on the discordance between loneliness and social isolation among older adults. We aimed to investigate this discordance and any health implications that it may have.

METHOD

Using nationally representative datasets from ageing cohorts in Ireland (TILDA) and England (ELSA), we created a metric of discordance between loneliness and social isolation, to which we refer as Social Asymmetry. This metric was the categorised difference between standardised scores on a scale of loneliness and a scale of social isolation, giving categories of: Concordantly Lonely and Isolated, Discordant: Robust to Loneliness, or Discordant: Susceptible to Loneliness. We used regression and multilevel modelling to identify potential relationships between Social Asymmetry and cognitive outcomes.

RESULTS

Social Asymmetry predicted cognitive outcomes cross-sectionally and at a two-year follow-up, such that Discordant: Robust to Loneliness individuals were superior performers, but we failed to find evidence for Social Asymmetry as a predictor of cognitive trajectory over time.

CONCLUSIONS

We present a new metric and preliminary evidence of a relationship with clinical outcomes. Further research validating this metric in different populations, and evaluating its relationship with other outcomes, is warranted. Copyright © 2016 John Wiley & Sons, Ltd.

Failure to control hypercholesterolaemia in the Irish adult population: cross-sectional analysis of the baseline wave of The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Hypercholesterolaemia is an important modifiable risk factor for cardiovascular disease (CVD) which requires monitoring and management at a population level.

AIMS

This study aims to describe the distribution of serum cholesterol in a community living population of older adults in Ireland and to examine the awareness, treatment and control of hypercholesterolaemia according to CVD risk status.

METHOD

This is a cross-sectional study in a nationally representative sample of adults aged 50-79 years (n = 5287). Hypercholesterolaemia was defined as low-density lipoprotein cholesterol (LDL-C) in excess of the recommended CVD risk category target and/or on lipid-lowering medication.

RESULTS

This study reports a mean total cholesterol (TC) of 5.1 mmol/L (95% CI 5.0-5.1 mmol/L) and a mean LDL-C of 2.9 mmol/L (95% CI 2.8-2.9 mmol/L) in those aged 50-79 years. In a subgroup aged 50-64 years, 73% (95% CI 71.5-74.5%) were hypercholesterolaemic. LDL-C was controlled to the guideline target in 57% of those with CVD and 49% of those with diabetes. Lack of awareness of hypercholesterolaemia was high across the remainder of the population.

CONCLUSION

Despite a substantial reduction in population mean TC from a high of 6.0 mmol/L in the 1980s to 5.1 mmol/L, this study reports a failure to control hypercholesterolaemia to recommended risk-stratified targets in the Irish adult population. Recommendations for policy include continued monitoring of those at highest risk and CVD risk assessment in those perceived to be at low risk in order to inform shared decision making in relation to lifestyle modification and medication management.

Non-Dietary Correlates and Determinants of Plasma Lutein and Zeaxanthin Concentrations in the Irish Population

OBJECTIVE

To investigate non-dietary correlates and determinants of plasma lutein (L) and zeaxanthin (Z) concentrations in The Irish Longitudinal Study on Ageing (TILDA) sample.

DESIGN

Cross-sectional study.

SETTING

Community dwelling adults in the Republic of Ireland (ROI).

PARTICIPANTS

3,681 participants aged 50 years and older.

MEASUREMENTS

TILDA is a nationally representative prospective cohort study of community dwelling adults aged 50 years and over in the ROI. Demographic and health variables were collected during a face-to-face interview carried out in the home (n=8175), and a substantial proportion of these (n=5035; 62%) also attended a study visit in a health assessment centre. Blood samples collected at baseline (wave 1, the subject of the current study), were analysed for plasma concentrations of L and Z by reversed-phase high performance liquid chromatography, and macular pigment (MP) optical density was also measured (using customized heterochromatic flicker photometry).

RESULTS

After excluding participants with eye disease, data from 3,681 participants were available for analysis. For this group of participants, plasma L and Z were inversely and significantly associated with body mass index (BMI), and were positively and significantly associated with MP, total cholesterol, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) (p<0.001, for all). Plasma L and Z were significantly lower in males, current smokers, participants reporting less physical exercise, and participants reporting lower levels of education (p<0.05, for all). Plasma L was significantly higher in participants reporting a family history of age-related macular degeneration (AMD) (p=0.001), and in the group of ≥75 years old (p<0.05). For each of these variables, the significant associations remained after controlling for other potential confounding variables.

CONCLUSION

The findings of this large study indicate that plasma concentrations of L and Z were lower in association with indicators of a poor lifestyle (high BMI, tobacco use, and less physical exercise) and in association with lower education, indicating that modifying lifestyle in a positive way is likely to be reflected in higher concentrations of plasma carotenoids, with consequential and putative health benefits.