Prognosis of diastolic and systolic orthostatic hypotension in older persons

Pyridostigmine in the management of orthostatic hypotension: a systematic review and meta-analysis

BACKGROUND

Current pharmacological approaches for the treatment of orthostatic hypotension (OH) may detrimentally affect supine blood pressure (BP). This side effect is often unacceptable and limits the utility of medical management. Pyridostigmine has been proposed as a potential treatment alternative which may improve OH without worsening supine hypertension. This systematic review and meta-analysis aimed to evaluate the currently available data regarding the use of pyridostigmine in the treatment of all-cause OH.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EMBASE, Cochrane and SCOPUS were searched for publications until 4 June 2024. A random-effects model was used for meta-analysis.

RESULTS

The search returned 715 results, of which 6 randomised controlled trials met the inclusion criteria. Several studies reported a statistically significant improvement in orthostatic BP following pyridostigmine administration. Two studies found that pyridostigmine had no effect on standing BP among patients with severe autonomic failure. One study suggested that combination therapy with atomoxetine may elicit a synergistic effect. In most studies, pyridostigmine had no significant effect on supine BP. Adverse effects were minimal across the included studies. The pooled results from the meta-analysis showed that while pyridostigmine alone resulted in lower systolic and diastolic orthostatic drop, neither result was statistically significant. However, when pyridostigmine is combined with midodrine, this demonstrated a significant improvement in systolic orthostatic drop.

CONCLUSIONS

Pyridostigmine may be useful in the management of OH, particularly in patients with supine hypertension. The standing BP response to pyridostigmine may be greater in patients who have a relatively preserved baroreflex function and sympathetic reserve.

PROSPERO REGISTRATION NUMBER

CRD42024555402.

Frail Older Adults with High Anticholinergic Burden are at Risk of Orthostatic Hypotension

OBJECTIVES

Frailty has been shown to be linked with orthostatic hypotension (OH) in older adults, but the role of anticholinergic drugs in this relationship never has been explored. The purpose of this was to examine the relationship between anticholinergic burden (ACB) and OH in frail older adults living in the community and to examine whether this association differs according to polypharmacy.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

Frail community-dwelling individuals aged ≥65 years admitted to the geriatric outpatient clinic (n = 399).

METHODS

Frailty status was defined by having ≥3 clinical features of the Fried Frailty Index. OH was a drop of ≥20 mm Hg in systolic blood pressure or a drop of ≥10 mm Hg in diastolic blood pressure 1 or 3 min after rising from a sitting position. ACB for each participant was categorized as none (ACB = 0), low (ACB = 1), or high (ACB ≥2). Multivariate logistic regression models were implemented to examine the association of ACB with OH.

RESULTS

The mean age of the sample was 79.8 years and 59.9% were women; 59 (13.3%) participants had OH. Exposure to anticholinergics was present in 41.4% of the participants, polypharmacy in 48.1%, and potentially inappropriate drug use in 44.1%. Multivariate analysis yielded a statistically significant risk of high ACB-related OH in the fully adjusted model [OR: 4.14 (1.33-12.86), P = .014]. None of the interaction terms of ACB with polypharmacy were significant in any model.

CONCLUSIONS AND IMPLICATIONS

In frail older people, because exposure to a high anticholinergic load may be associated with OH, special attention should be paid to anticholinergics in medical treatment to prevent a reduction in blood pressure upon standing.

Chronic kidney disease and orthostatic hypotension in hospitalised older adults

PURPOSE

Orthostatic hypotension (OH) may predispose older adults to health complications leading to functional impairment. Despite the central role of the kidney in blood pressure control, the contribution of renal function in orthostatic hypotension is poorly investigated. To verify the association between Chronic Kidney Disease (CKD) and OH a population of hospitalised elderly patients with comorbidities was studied.

MATERIALS AND METHODS

174 patients were consecutively admitted to Acute Geriatric Wards. On admission, patients underwent postural systolic (SBP) and diastolic (DBP) blood pressure evaluation by automatic oscillometric device after 10 min rest in lying position, and in standing position at time 0, 1, 3 and 5 min. CKD was assumed for estimated glomerular filtration rate (e-GFR) less than 60 mL/min/1.73 m2.

RESULTS

The mean age of the population enrolled was 74.4 ± 7.0. OH was found in 46.0% and CKD in 56.3% of patients, respectively. A lower e-GFR was observed in patients with (56.1 ± 16.7 mL/min/1.73 m2) than in those without OH (61.1 ± 15.9 mL/min/1.73 m2) (p < 0.05). A greater fall in SBP at 0-min (12.8 ± 6.3 vs. 7.7 ± 3.2 mmHg) and at 1-min (8.4 ± 4.5 vs. 5.7 ± 2.8 mmHg) was found in CKD patients in respect to patients without CKD during active standing test (p < 0.05). Similarly, a DBP reduction at 0-min and at 1-min was observed in CKD patients in respect to patients without CKD (p < 0.05). A multivariate logistic regression analysis showed that CKD was associated to OH (OR 2.426; 95%CI 1.192-4.937; p = 0.014).

CONCLUSIONS

CKD is associated to OH in hospitalised older adults.

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.

Effects of continuous supplementation of Acanthopanax senticosus Harms on the cardiac autonomic function of community-dwelling elderly individuals during resting and standing tests: a randomized controlled trial

Background

Cardiac autonomic function (CAF) decreases with aging, and Acanthopanax senticosus Harms (ASH) consumption reportedly induces anti-stress effects. This study aimed to assess the effect of continuous supplementation of ASH on CAF during resting and standing tests in the elderly population.

Methods

This double-blind, randomized controlled trial was conducted in the morning in a laboratory setting and was carried out between June 2017 and July 2017 at Kambaikan, Doshisha University (Karasuma-higashi-iru, Imadegawa-dori, Kamigyo-ku, Kyoto 602-8580, Japan). In total, 28 community-dwelling elderly individuals (mean ± standard deviation = 72.5 ± 4.5 years) were included. Each subject was instructed to consume ASH or placebo supplements twice daily for 4 weeks. An autonomic reflex orthostatic tolerance recorder was used to measure CAF in pre- and post-intervention phases. Parameters were measured in a seated position and included coefficient of variation of R-R intervals (CVRR), low frequency (LF), high frequency (HF), LF/HF ratio, blood pressure, and heart rate (HR). Changes in each parameter were evaluated before and after standing. All parameters were defined as the difference between the mean value obtained in a standing position for 2 min and that obtained in a 2-min seated position.

Results

A two-way analysis of variance revealed a significant group-time interaction effect on CVRR, HF, and ΔLF/HF ratio. Following the intervention, CVRR, HF, LF/HF ratio, systolic blood pressure (SBP), HR, ΔLF/HF ratio, ΔSBP, and ΔHR improved significantly in the ASH group only.

Conclusions

Four-week supplementation of ASH improved CAF in community-dwelling elderly individuals during resting and standing tests.

Clinical Trial Registration

https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000031218, UMIN Clinical Trials Registry (UMIN000027251).

Screening for orthostatic hypotension in the geriatric population in a real-world primary care setting reduces prescribed antihypertensive medications

BACKGROUND

To determine if outpatient screening for orthostatic hypotension (OH) in the geriatric population results in fewer prescribed antihypertensive medications and if a relationship exists between OH and specific pharmacologic classes of antihypertensive medications.

MATERIALS AND METHODS

Patients ≥ 65 years were screened for OH, defined as a decrease in systolic blood pressure (SBP) ≥ 20 mm Hg or a decrease in diastolic blood pressure (DBP) ≥ 10 mm Hg after standing for 3 minutes. Sitting blood pressure (BP) was measured after patients had been seated quietly in an exam room. Patients then stood for approximately 3 minutes at which time standing BP was recorded.

RESULTS

OH prevalence was 18%. Standing DBP was significantly different between the two groups (70 mmHg ± 18, 80 mmHg ± 13, P  = 0.007). Compared to patients without OH, patients with OH were more likely to have been previously prescribed beta-blockers (56% vs. 32%, P  = 0.056) and potassium-sparing diuretics (11% vs. 1%, P  = 0.026). Physicians discontinued an antihypertensive medication more often in patients who screened positive for OH than in to those who did not (17% vs. 4%, P  = 0.037). Calcium channel blockers were the most frequently discontinued class of medication.

CONCLUSION

Asymptomatic OH is prevalent in geriatric patients. Screening for OH may lead to de-escalation of antihypertensive regimen and a reduction in polypharmacy. Positive screening for OH was associated with de-prescribing of antihypertensive medications. Prior use of beta-blockers and potassium-sparing diuretics was most largely associated with OH.

Relationship between orthostatic blood pressure changes and intensive blood pressure management in patients with hypertension

INTRODUCTION

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that closely controlling blood pressure (BP) could decrease cardiovascular outcome risk without increasing the orthostatic hypotension rate. We aimed to evaluate the association between baseline orthostatic BP change and major adverse cardiovascular event (MACE) occurrence.

METHODS

We conducted a post hoc analysis using SPRINT data including 9329 patients with hypertension. The SPRINT trial was a two-arm, multicentre, randomised clinical trial designed to test whether an intensive treatment aimed at reducing systolic BP (SBP) to <120 mm Hg would reduce cardiovascular disease risk. Orthostatic BP change was defined as baseline standing systolic BP (SBP)-baseline mean seated SBP, or diastolic BP (DBP)-baseline mean seated DBP.

RESULTS

We found a U-shaped relationship between orthostatic BP changes and MACE occurrence. All lowest risk points were around 0 mm Hg. On the left side of the inflection point, MACE risk decreased with orthostatic BP change decrease (HR=0.99, 95% CI (0.98 to 1.00), p=0.04, SBP change) (HR=0.97, 95% CI (0.95 to 0.99), p<0.01, DBP change); on the right side, MACE risk increased with orthostatic BP change increase (HR=1.02, 95% CI (1.01 to 1.06), p<0.01, SBP change) (HR=1.01, 95% CI (1.00 to 1.03), p=0.16, DBP change). There was no significant interaction effect between orthostatic SBP (p for interaction=0.37) or DBP changes (p for interaction=0.33) and intensive BP management.

CONCLUSIONS

Orthostatic DBP increase and SBP decrease were associated with an increased MACE risk. The benefits of intensive BP management were also consistent across different orthostatic BP change ranges.

Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021

Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.

Time in range, as an emerging metric of glycemic control, is associated with orthostatic blood pressure changes in type 2 diabetes

AIMS

To exlpore whether time in range(TIR) was associated with orthostatic blood pressure(BP) changes in type 2 diabetes(T2DM).

METHODS

A total of 342 T2DM patients were recruited. TIR was defined as the time percentage spent within the target range(3.9-10.0 mmol/L). Orthostatic hypotension(OH) and orthostatic hypertension(OHT) were defined as a decrease or an increase of at least 20 mmHg in SBP and/or 10 mmHg in DBP after standing for 3 min.

RESULTS

Compared with orthostatic normotension group, patients with OH or OHT showed lower levels of TIR (P < 0.001). The prevalences of OH and OHT both decreased with ascending TIR tertiles (OH, P < 0.001; OHT, P = 0.019), and both absolute SBP and DBP changes were negatively correlated with TIR (r = -0.171, -0.190, P < 0.05). After stratifying by BMI, only the prevalence of OH in the lower layer and the prevalence of OHT in the higher layer remained significant difference among tertiles of TIR. Multivariate logistics regression revealed that lower TIR and lower BMI were risk factors for OH, whereas lower TIR but higher BMI were risk factors for OHT.

CONCLUSIONS

We find a differential correlation dependent of BMI milieus between TIR and orthostatic BP status.

The Pathogenesis and Treatment of Cardiovascular Autonomic Dysfunction in Parkinson's Disease: What We Know and Where to Go

Cardiovascular autonomic dysfunctions (CAD) are prevalent in Parkinson’s disease (PD). It contributes to the development of cognitive dysfunction, falls and even mortality. Significant progress has been achieved in the last decade. However, the underlying mechanisms and effective treatments for CAD have not been established yet. This review aims to help clinicians to better understand the pathogenesis and therapeutic strategies. The literatures about CAD in patients with PD were reviewed. References for this review were identified by searches of PubMed between 1972 and March 2021, with the search term “cardiovascular autonomic dysfunctions, postural hypotension, orthostatic hypotension (OH), supine hypertension (SH), postprandial hypotension, and nondipping”. The pathogenesis, including the neurogenic and non-neurogenic mechanisms, and the current pharmaceutical and non-pharmaceutical treatment for CAD, were analyzed. CAD mainly includes four aspects, which are OH, SH, postprandial hypotension and nondipping, among them, OH is the main component. Both non-neurogenic and neurogenic mechanisms are involved in CAD. Failure of the baroreflex circulate, which includes the lesions at the afferent, efferent or central components, is an important pathogenesis of CAD. Both non-pharmacological and pharmacological treatment alleviate CAD-related symptoms by acting on the baroreflex reflex circulate. However, pharmacological strategy has the limitation of failing to enhance baroreflex sensitivity and life quality. Novel OH treatment drugs, such as pyridostigmine and atomoxetine, can effectively improve OH-related symptoms via enhancing residual sympathetic tone, without adverse reactions of supine hypertension. Baroreflex impairment is a crucial pathological mechanism associated with CAD in PD. Currently, non-pharmacological strategy was the preferred option for its advantage of enhancing baroreflex sensitivity. Pharmacological treatment is a second-line option. Therefore, to find drugs that can enhance baroreflex sensitivity, especially via acting on its central components, is urgently needed in the scientific research and clinical practice.

Preparation and evaluation of fast-dissolving films of etilefrine hydrochloride for practical buccal dosing

Etilefrine hydrochloride (ET) is an important drug in the treatment of hypotension, and parenteral injections and oral tablets are the conventional dosage forms. However, parenteral injections may cause abnormally high plasma levels as well as pain and necrosis, and oral tablets undergo first-pass metabolism. Although fast-dissolving buccal tablets were previously reported, the initial absorption rate was a little slow and the plasma levels were varied extensively. Recently, many films have been developed as novel dosage forms. Therefore, in the present study, film dosage forms containing ET were produced using water-soluble polymers and glycerin (GLY) as excipients to obtain a practical buccal dosage form. Films composed of ET, GLY, and sodium alginate (AL) exhibited good physical characteristics and rapid release in vitro (more than 70% at 2 min). The compacted AL film containing 2 mg ET (1 × 1 cm) exhibited rapid absorption (>19 ng/mL at 0.5 h), maintained an effective plasma level (>7 ng/mL) for a long time period (0.5-4 h), and had an adequate plasma concentration-time profile with a smaller standard error (<15.3 ng/mL). These results suggest that the present compacted buccal film is a superior dosage form of ET for practical use.

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.

Associations of the systolic and diastolic components of orthostatic hypotension with markers of cardiovascular risk in older men: A cross-sectional analysis from The British Regional Heart Study

The mechanisms underlying the association between orthostatic hypotension (OH) and cardiovascular disease are unclear. We investigated whether OH is associated with circulating cardiovascular risk markers. This was a cross-sectional analysis of 3857 older, community-dwelling men. "Consensus OH" was defined as a sitting-to-standing decrease in systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg that occurred within three minutes of standing. Multiple generalized linear regression and logistic models were used to examine the association between cardiovascular risk markers and OH. Consensus OH was present in 20.2%, consisting of isolated systolic OH in 12.6%, isolated diastolic OH in 4.6%, and combined systolic and diastolic OH in 3.0%. Concentration of von Willebrand factor, a marker of endothelial dysfunction, was positively associated with isolated systolic OH (OR 1.35, 95% CI 1.05-1.73) and combined systolic and diastolic OH (OR 2.27, 95% CI 1.35-3.83); high circulating phosphate concentration, which may reflect vascular calcification, was associated with isolated diastolic OH (OR 1.53, 95% CI 1.04-2.25) and combined systolic and diastolic OH (OR 2.12, 95% CI 1.31-3.44), high-sensitivity troponin T, a marker of myocardial injury, was positively associated with isolated diastolic OH (OR 1.69, 95% CI 1.07-2.65) and N-terminal pro-brain natriuretic peptide, a marker of cardiac stress, was positively associated with combined systolic and diastolic OH (OR 2.14, 95% CI 1.14-4.03). In conclusion, OH is associated with some cardiovascular risk markers implicated in endothelial dysfunction, vascular calcification, myocardial injury, and cardiac stress. Clinicians should consider assessing cardiovascular risk in patients with OH.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients

OBJECTIVES

. To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients.

METHODS

. This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used.

RESULTS

. The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r² = 0.04; dBP: p = 0.59; r² = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r² = 0.02; dBP: p = 0.82; r² = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes.

CONCLUSION

. No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

Morbidity and mortality in orthostatic hypotension

This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.

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.

Time point of blood pressure drop in patients with orthostatic hypotension in the emergency department

OBJECTIVE

The purpose of this study was to identify the time of blood pressure (BP) drop in the orthostatic hypotension test, and to propose a realistic and appropriate duration in the orthostatic hypotension test.

METHODS

A total of 879 consecutive patients (61-year-old and 44% women) with positive on the orthostatic hypotension test in the emergency department were retrospectively reviewed. Orthostatic hypotension was defined as drop in standing SBP of at least 20 mmHg or standing DBP of at least 10 mmHg from their supine values after standing for 5 min. BP measurements was made at 1, 3, and 5 min after standing.

RESULTS

Six hundred and eighty-four (77.8%), 152 (17.3%) and 43 (4.9%) patients had BP drop meeting orthostatic hypotension criteria at 1, 3, and 5 min, respectively. In multivariable analysis, older age (≥60 years) and higher blood urea nitrogen (BUN) (≥15.5 mg/dl) were independently associated with early BP drop at 1 min, and younger age (<40 years) was independently associated with later BP drop at 5 min even after controlling for potential confounders.

CONCLUSION

To measure orthostatic BP for orthostatic hypotension diagnosis at emergency department, older patients (≥60 years) with high BUN (≥15.5 mg/dl) should be monitored carefully as BP can drop quickly within 1 min. On the contrary, in younger people (<40 years), BP drop occurred slowly after 3 min, suggesting that clinicians measure BP for a longer time.

Back to Basics: Key Physical Examinations and Theories in Patients with Heart Failure

Heart failure (HF) is a leading cause of hospitalization. Suitable pharmacologic management is critical. Distinct physical findings such as congestion and peripheral hypoperfusion need to be considered in selecting pharmacologic therapy. By applying the pretest probability and likelihood ratios of unique physical findings of HF to a Markov model, a definite posttest probability can be obtained. This article focuses on the findings of S3, jugular venous pressure, proportional pulse pressure, bendopnea, trepopnea, and various heart murmurs. Incorporating statistical precision in physical assessments, diagnoses of HF can be further refined, providing a sophisticated approach to evaluate patients hemodynamics status noninvasively.

Orthostatic hypotension among elderly patients in Italian internal medicine wards: an observational study

Orthostatic hypotension (OH) is a multifactorial disorder, often asymptomatic. The prevalence of OH increases with age, ranging from 5 to 11% among middle-aged patients to 55% in the frail elderly depending on age and associated comorbidities. OH is often unrecognized or misdiagnosed and little is known about its prevalence in hospitalized elderly patients. Our aims were: (1) to determine the prevalence of OH in a cohort of elderly patients hospitalized in two internal medicine wards in Italy; (2) and to describe their characteristics and symptoms. During the 5 months from March 1, 2017 to July 31, 2017, the first 85 consecutive patients (65 years or older) admitted in two internal medicine wards were enrolled. Patients were included in the study if they were able to get out of bed alone or with minor assistance, and able to stand up for at least 3 min. The study population comprised 85 patients with a mean age of 79.6 ( ± 7.2) years. OH was found in 64 (75.3%), occasional OH in 41 (48.2%), persistent OH in 23 (27.1%), and 21 (24.7%) patients had no OH. All patients had diastolic OH and 37 (57.8%) also systolic. Patients with persistent OH were oldest, with a higher percentage of renal failure. Twenty-six patients (40.6%) with OH reported symptoms. Dizziness was the most common symptom, especially after breakfast. No association was found between type of medications and risk of OH. Mortality risk was not statistically different between patients with or without OH 3 (p = 0.10) and 6 months after discharge (p = 0.18), but a trend was observed. We found that OH is very common in the patients admitted in the internal medicine wards, particularly diastolic OH. Close attention should be paid to OH and its symptoms, especially dizziness, in the oldest-old patients, and in patients with renal failure.

Orthostatic hypotension is associated with new-onset atrial fibrillation: Systemic review and meta-analysis

Introduction

Orthostatic hypotension (OH) is common among elderly patients. Its presence may herald severe underlying comorbidities and be associated with a higher risk of mortality. Interestingly, recent studies suggest that OH is associated with new-onset atrial fibrillation (AF). However, a systematic review and meta-analysis of the literature has not been performed. We assessed the association between AF and OH through a systematic review of the literature and a meta-analysis.

Methods

We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2018. Published prospective or retrospective cohort studies that compared new-onset AF between male patients with and without OH were included. Data from each study were combined using the random-effects, generic inverse-variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals.

Results

Four studies from October 2010 to March 2018 were included in the meta-analysis involving 76,963 subjects (of which 3318 were diagnosed with OH). The presence of OH was associated with new-onset AF (pooled risk ratio 1.48; 95% confidence interval [1.21, 1.81], p?< 0.001; I2 = 69.4%). In hypertensive patients, analysis revealed an association between OH and the occurrence of new-onset AF (OR 1.46; 95% CI [1.27, 1.68], p < 0.001 with I2 = 0).

Conclusions

OH was associated with new-onset AF up to 1.5-fold compared with those subjects without OH. The interplay between OH and AF is likely bidirectional.

Aortic stiffness and central systolic pressure are associated with ambulatory orthostatic BP fall in chronic kidney disease

OBJECTIVE

Orthostatic hypotension (OH) has a significant association with cardiovascular disease. OH becomes more common in older age, as does arterial stiffness, shown to be independently associated with impaired baroreflex sensitivity and OH. Measurement of arterial compliance and central blood pressures are increasingly important, with evidence that central BP more closely correlates to end-organ damage and mortality than peripheral measurements. Patients with chronic kidney disease (CKD) are high risk for cardiovascular events, which can be predicted through measures of arterial compliance. We hypothesised that OH is associated with arterial stiffness and central blood pressure in CKD patients.

DESIGN/SETTING

We tested this hypothesis within the arterial compliance and oxidant stress as predictors of loss of renal function, morbidity and mortality in chronic kidney disease (ACADEMIC) study, a single-centre prospective observational study of the progression of arterial stiffness and renal function.

PARTICIPANTS

One hundred and forty-six patients with CKD 3 or 4.

MEASUREMENTS

Twenty-four-hour ambulatory BP monitoring with postural sensing (DIASYS Integra 2, Novacor France); central systolic and diastolic BP (cSBP and cDBP) and aortic Augmentation Index using Sphygmocor^® (Atcor, Australia); Carotid-femoral pulse wave velocity (cfPWV) using Complior^® (ALAM Medical, France).

RESULTS

Twenty-three patients had a postural SBP fall (prevalence 15.8%), with mean drop 7 mmHg. Patients with OH had higher cfPWV (15.2 m/s vs 12.7 m/s in patients without OH, p < 0.001) and central SBP (147.5 vs 135.7, p = 0.012). Regression analysis gave an odds ratio (OR) of orthostatic SBP fall for cfPWV of 1.46 (95% CI 1.16-1.84, p = 0.001) and 1.03 for cSBP (95% CI 1.004-1.06, p = 0.024) after adjustment for cardiovascular risk factors.

CONCLUSION

Aortic stiffness and central SBP are independently associated with orthostatic SBP fall in CKD patients. This suggests that enhanced arterial stiffness may be an underlying mechanism in baroreflex dysfunction, and may partly explain the vascular risk in CKD patients.

(r)Alpha Lipoic Acid Is a Safe, Effective Pharmacologic Therapy of Chronic Orthostatic Hypotension Associated with Low Sympathetic Tone

Chronic orthostatic hypotension (OH), affecting 10 to 30% of the elderly, is associated with falls, and increased morbidity and mortality. Current pharmacologic therapy can cause or worsen hypertension and fluid retention. (r)α lipoic acid (ALA), a powerful natural antioxidant, avoids those complications and may assist management of chronic neurogenic orthostatic hypotension (NOH). The purpose of this study is to demonstrate improvement in the symptoms of orthostatic dysfunction with r-ALA, including improved sympathetic (S) and blood pressure (BP) responses to head-up postural change (standing). A cohort of 109 patients with low S tone upon standing was detected using the ANX -3.0, Autonomic Monitor, ANSAR Medical Technologies, Inc., Philadelphia, PA. From the cohort, 29 patients demonstrated NOH (change in (∆) standing BP ≥ -20/-10 mm Hg); 60 patients demonstrated orthostatic intolerance (OI, ∆ standing systolic BP between -6 and -19 mm Hg). These 89 were given ALA orally: either 590 to 788 mg (r)ALA or 867 to 1,500 mg of the less expensive 50 to 50% mixture (r)ALA and inactive (s)ALA. Changes in their S and parasympathetic (P) tone, and BPs, were compared with 20 control patients during mean follow-up of 2.28 years. Nineteen of 29 (66%) NOH patients responded with a ∆ standing BP from -28/-6 mm Hg to 0/+2 mm Hg. Forty of 60 (67%) of patients with OI responded with a ∆ standing BP of -9/+1 mm Hg to +6/+2 mm Hg. Although all patients treated with ALA increased S tone, the ∆ BP depended upon the pretreatment of S tone. Those with the lowest S tone responded the least well. The only treatment side effects were nausea, intolerable in only 5%. Nausea improved with routine gastrointestinal medications. Glucose levels improved in the 28% of patients who were diabetic. Also, resting hypertension improved. Control patients had no ∆ BP and no increase in S tone. (r)ALA improves S-, and BP, responses to head-up postural change, and thereby NOH/OI, in a majority of patients without causing harmful side effects.

Orthostatic hypotension in older persons is not associated with cognitive functioning, features of cerebral damage or cerebral blood flow

OBJECTIVE

Particularly in old age, orthostatic hypotension has been related to worse cognitive functioning, possibly caused by reduced cerebral blood flow (CBF). This study investigates whether orthostatic hypotension in older people is associated with cognitive dysfunction and, if so, whether this association is mediated by cerebral vascular damage and/or decreased CBF.

METHODS

Four hundred and twenty participants of the Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Study Leiden (mean age 81 years, all using antihypertensive medication and with mild cognitive deficits), and MRI data from 214 participants of the nested DANTE MRI sub-study. Orthostatic hypotension was defined as either a SBP decrease at least 20 mmHg and/or a DBP decrease of at least 10 mmHg within 3 min of standing up. Cognitive functioning was assessed using a battery of six cognitive tests covering global cognition, memory function, executive function and psychomotor speed. Cerebral vascular damage and CBF were assessed using MRI.

RESULTS

The prevalence of orthostatic hypotension was 47% (n = 199). Compared with the group without orthostatic hypotension, participants with orthostatic hypotension showed no differences in any of the cognitive functions, features of cerebral small vessel disease, microstructural integrity or CBF.

CONCLUSION

In this population of older persons, the presence of orthostatic hypotension was not associated with decreased cognition. In addition, no differences were found in the supposedly underlying cerebral vascular mechanisms.

Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) is common in older adults with reported prevalence rates of 5-40%. A direct link between OH and cognitive performance has been proposed due to impaired vascular autoregulation.

AIM

To systematically assess the literature of the association between OH and cognitive performance in older adults.

METHODS

Literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from inception to May 2017. Studies were included if OH and cognition were assessed in subjects of mean or median age ≥65 years. Risk of bias was assessed with the Newcastle Ottawa Scale.

RESULTS

Of 3266 studies screened, 32 studies (22 cross-sectional; 10 longitudinal) reporting data of 28,980 individuals were included. OH prevalence ranged from 3.3% to 58%. Of the 32 studies, 18 reported an association between OH and worse cognitive performance and 14 reported no association. Mini Mental State Examination (MMSE) was the most commonly used cognitive assessment tool. Studies using more than one cognitive assessment tool were more likely to find an association between OH and worse cognition. OH was significantly associated with a lower MMSE mean score (mean difference - 0.51 (95% CI: -0.85, -0.17, p = 0.003)) and an increased risk of cognitive impairment (OR 1.19 (95% CI, 1.00-1.42, p = 0.048)).

CONCLUSIONS

OH is common in older populations and is associated with worse cognition expressed as lower MMSE scores. Use of MMSE alone as a cognitive assessment tool may underestimate the association. It is yet unclear whether the association between OH and worse cognitive performance is causative.

Orthostatic hypotension: A review

Orthostatic hypotension, 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, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.

Impact of variations in blood pressure with orthostatism on mortality: the HOMO study

OBJECTIVE

The aim of this study was to determine the impact of orthostatic hypotension (OH) and orthostatic hypertension (OHT) on all-cause mortality.

PATIENTS AND METHODS

A total of, 1176 adults from the community over 18 years of age were included in this ambispective study. The mean follow-up was 9.4 years. OH and OHT were defined as a decrease or an increase, respectively, in systolic blood pressure (BP) of at least 20 mmHg and/or diastolic BP of at least 10 mmHg from sitting to standing position at 1 and/or 3 min after standing. The impact of systolic or diastolic OH and systolic or diastolic OHT at 1 and 3 min after standing was also analyzed separately.

RESULTS

In total, 135 individuals died during the follow-up. Neither OH [hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.72-2.10] nor OHT (HR 0.90; 95% CI: 0.59-1.38) was associated with all-cause mortality in the adjusted models. In contrast, systolic OHT at 3 min (HR 2.31; 95% CI: 1.14-4.68) was independently associated with global mortality.

CONCLUSION

Systolic OHT at 3 min is associated with all-cause mortality. The determination of this parameter could add valuable prognostic information during the routine examination of patients.

Malnutrition and Malnutrition Risk Can Be Associated with Systolic Orthostatic Hypotension in Older Adults

BACKGROUND

Malnutrition and orthostatic hypotension(OH) are the two important geriatric syndromes, which have similar negative outcomes such as falls. The aim of the study is to detect whether there is any relation between malnutrition and OH.

METHODS

862 geriatric patients, who had undergone comprehensive geriatric assessment (CGA),were included in the retrospective study. OH was identified as 20 and/or 10 mmHg dropped for systolic and/or diastolic blood pressures with the active standing test when patients got up from supine to standing position. Nutritional status was checked according to Mini Nutritional Assesment-Short Form(MNA-SF).

RESULTS

The mean age of the patients was 74±8.05, and %66.3 of them were female. The prevalence of malnutrition, malnutrition-risk and OH were detected as 7.7%, 26.9 % and 21.2%, respectively. When OH, systolic OH, diastolic OH and control group were compared with CGA parameters and the effects of age and gender were removed, the frequency of falls and Timed-Up and Go Test were higher, activity daily living indexes and TINETTI-Balance scores were lower in systolic OH than without it (p<0.05).Systolic OH was more frequent in malnutrition-risk and malnutrition group than control group (p<0.002 and p<0.05, respectively). Diastolic OH was not associated with nutritional status (p>0.05).OH was only higher in malnutrition-risk group than robust (p<0.05).

CONCLUSION

Our findings suggest that not only malnutrition but also malnutrition-risk may be associated with systolic OH, which leads to many negative outcomes in older adults. Because malnutrition/ malnutrition risk is preventable and reversible, nutritional status should be checked during the evaluation of OH patients.

Systolic orthostatic hypotension is related to lowered cognitive function: Findings from the Maine-Syracuse Longitudinal Study

The aim of the present study was to examine the relationship between orthostatic changes in blood pressure (BP) and cognition, with consideration given to cardiovascular risk factors and lifestyle variables. The cross-sectional analysis included 961 community-dwelling participants of the Maine-Syracuse Longitudinal Study, for whom BP clinic measures (five sitting, five recumbent, and five standing) were obtained. Eighteen percent of participants had orthostatic hypotension (fall in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg upon standing) and 6% had orthostatic hypertension (rise in systolic BP ≥20 mm Hg). Orthostatic hypotension and hypertension defined using traditional criteria were unrelated to cognition with covariate adjustment. However, an examination of systolic and diastolic BP change independently revealed that participants with systolic orthostatic hypotension had poorer global cognition, verbal memory, and scanning and tracking scores than those with normal systolic BP change. The authors conclude that systolic orthostatic hypotension is significantly associated with reduced cognitive function.

The effects of body weight status on orthostatic intolerance and predisposition to noncardiac syncope

Orthostatic intolerance (OI) is frequently the mechanism underlying the occurrence of noncardiac syncope (NCS) and is associated with substantial risk for injury. Body weight status appears to be a modifier of orthostatic responses and possibly influences the propensity to NCS. The majority of cross-sectional studies have found that the lower the body mass index (BMI) the greater the predisposition to OI is, accompanied with both down-regulation of sympathetic nervous system activity and up-regulation of parasympathetic nervous system activity. These changes appear to occur across the whole spectrum of BMI values from underweight to obesity, while they may be associated more strongly with central body fat than total body fat. Weight loss following bariatric surgery has been consistently found to increase OI, attributed first to the effects of weight loss per se, second to the specific type of surgical procedure and third to the potential postoperative autonomic neuropathy due to vitamin deficiency. The increased OI following bariatric surgery renders this intervention not easily tolerable for the affected individuals, mandating increased fluid and salt intake, pharmacological measures or surgical adjustments to attenuate OI. All future studies investigating orthostatic responses and NCS should implement a matching of the population arms for BMI and ideally for body fat.

Which is preferable for orthostatic hypotension diagnosis in older adults: active standing test or head-up tilt table test?

BACKGROUND

Correct evaluation of orthostatic hypotension (OH) is crucial in geriatric practice, since OH is associated with mortality and morbidity. The study aimed to determine the most appropriate method for measuring blood pressure in transition from supine to upright position in order to diagnose OH in older adults.

METHODS

Active standing test (AST) and head-up tilt table (HUT) test as well as comprehensive geriatric assessment (CGA), including mini-mental state examination or the cognitive state test, mini-nutritional assessment, basic and instrumental activities of daily living, and Tinetti performance-oriented mobility assessment indexes, were performed in 290 geriatric patients.

RESULTS

The prevalence of OH during HUT and AST was 19% and 37%, respectively. In patients with OH during HUT, the frequency of dementia and recurrent falls were higher (P<0.05); on the other hand, the levels of serum vitamin D and albumin and estimated glomerular filtration rate were lower (P<0.05). However, all these parameters for OH during AST were not significant (P>0.05). Comparison of the groups according to CGA measurements revealed significant differences in terms of cognition, nutritional status, activities of daily life, and balance function in patients with OH only during HUT (P<0.05), but not during AST (P>0.05). The sensitivity, specificity, positive predictive value, and negative predictive values of AST were 49.0%, 65.5%, 25.0%, and 84.6% respectively, according to HUT.

CONCLUSION

The results suggest that orthostatic blood pressure changes determined by HUT might be of higher clinical significance than that by AST in older adults. It might be important that the evaluation of OH by HUT should be included in daily geriatric practice.

[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.

Impact of Hypertension on Cognitive Function: A Scientific Statement From the American Heart Association

BACKGROUND

Age-related dementia, most commonly caused by Alzheimer disease or cerebrovascular factors (vascular dementia), is a major public health threat. Chronic arterial hypertension is a well-established risk factor for both types of dementia, but the link between hypertension and its treatment and cognition remains poorly understood. In this scientific statement, a multidisciplinary team of experts examines the impact of hypertension on cognition to assess the state of the knowledge, to identify gaps, and to provide future directions.

METHODS

Authors with relevant expertise were selected to contribute to this statement in accordance with the American Heart Association conflict-of-interest management policy. Panel members were assigned topics relevant to their areas of expertise, reviewed the literature, and summarized the available data.

RESULTS

Hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. There is strong evidence of a deleterious influence of midlife hypertension on late-life cognitive function, but the cognitive impact of late-life hypertension is less clear. Observational studies demonstrated a cumulative effect of hypertension on cerebrovascular damage, but evidence from clinical trials that antihypertensive treatment improves cognition is not conclusive.

CONCLUSIONS

After carefully reviewing the literature, the group concluded that there were insufficient data to make evidence-based recommendations. However, judicious treatment of hypertension, taking into account goals of care and individual characteristics (eg, age and comorbidities), seems justified to safeguard vascular health and, as a consequence, brain health.

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.

Evaluation of Syncope in Older Adults

The older adult patient with syncope is one of the most challenging evaluations for the emergency physician. It requires clinical skill, patience, and knowledge of specific older adult issues. It demands care in the identification of necessary resources, such as medication review, and potential linkage with several multidisciplinary follow-up services. Excellent syncope care likely requires reaching out to ensure institutional resources are aligned with emergency department patient needs, thus asking emergency physicians to stretch their administrative talents. This is likely best done as preset protocols prior to individual patient encounters. Emergency physicians evaluate elders with syncope every day and should rise to the challenge to do it well.

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.

Diastolic orthostatic hypertension and cardiovascular prognosis in type 2 diabetes: a prospective cohort study

BACKGROUND

In patients with type 2 diabetes, the prognostic impact of an orthostatic rise in blood pressure is not known. Therefore, the aim of this study was to determine the prognostic implications of the diastolic orthostatic blood pressure response in a cohort of patients with type 2 diabetes. We also evaluated associations between different orthostatic blood pressure responses and markers of subclinical cardiovascular organ damage.

METHODS

Office blood pressures were measured in the sitting and in the standing position in 749 patients with type 2 diabetes who participated in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care). Diastolic orthostatic hypertension was defined as a rise of diastolic blood pressure ≥10 mmHg and diastolic orthostatic hypotension was defined as a drop of diastolic blood pressure ≥10 mmHg. Recruitment took place between the years 2005-2008, and patients were followed until any of the primary outcome events (cardiovascular death or hospitalization for either myocardial infarction or stroke) occurred or until December 31st, 2014. Measurements of aortic pulse wave velocity and of carotid intima-media thickness were performed at base-line.

RESULTS

Diastolic orthostatic hypertension was found in 140 patients (18.7 %) and was associated with significantly lower risk of cardiovascular events (crude hazard ratio compared with patients with normal systolic and diastolic orthostatic blood pressure response: 0.450, 95 % C.I. 0.206-0.987, P = 0.046). Diastolic orthostatic hypotension was found in 31 patients (4.1 %) and was associated with higher values for aortic pulse wave velocity and carotid intima-media thickness, compared with patients with normal systolic and diastolic orthostatic blood pressure response.

CONCLUSIONS

Diastolic orthostatic hypertension is common in patients with type 2 diabetes, and may be a novel marker for decreased cardiovascular risk in these patients.

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.

Effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment: the DANTE Study Leiden

BACKGROUND

the relationship between antihypertensive medication and orthostatic hypotension in older persons remains ambiguous, due to conflicting observational evidence and lack of data of clinical trials.

OBJECTIVE

to assess the effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment.

METHODS

a total of 162 participants with orthostatic hypotension were selected from the Discontinuation of Antihypertensive Treatment in Elderly people (DANTE) Study. This randomised clinical trial included community-dwelling participants aged ≥75 years, with mild cognitive impairment, using antihypertensive medication and without serious cardiovascular disease. Participants were randomised to discontinuation or continuation of antihypertensive treatment (ratio 1:1). Orthostatic hypotension was defined as a drop of at least 20 mmHg in systolic blood pressure and/or 10 mmHg in diastolic blood pressure on standing from a seated position. Outcome was the absence of orthostatic hypotension at 4-month follow-up. Relative risks (RR) were calculated by intention-to-treat and per-protocol analyses.

RESULTS

at follow-up, according to intention-to-treat analyses, of the 86 persons assigned to discontinuation of antihypertensive medication, 43 (50%) were free from orthostatic hypotension, compared with 29 (38%) of the 76 persons assigned to continuation of medication [RR 1.31 (95% confidence interval (CI) 0.92-1.87); P = 0.13]. Per-protocol analysis showed that recovery from orthostatic hypotension was significantly higher in persons who completely discontinued all antihypertensive medication (61%) compared with the continuation group (38%) [RR 1.60 (95% CI 1.10-2.31); P = 0.01].

CONCLUSION

in older persons with mild cognitive impairment and orthostatic hypotension receiving antihypertensive medication, discontinuation of antihypertensive medication may increase the probability of recovery from orthostatic hypotension.

Orthostatic hypotension: definition, diagnosis and management

Orthostatic hypotension commonly affects elderly patients and those suffering from diabetes mellitus and Parkinson's disease. It is a cause of significant morbidity in the affected patients. The goal of this review is to outline the pathophysiology, evaluation, and management of the patients suffering from orthostatic hypotension.

Orthostatic Hypotension Predicts a Poor Prognosis in Elderly People with Dementia

Objective The purpose of the present study was to assess the prevalence of orthostatic hypotension (OH) and elucidate its associations with the demographic characteristics and the prognosis in elderly subjects with dementia who visited a hospital for elderly daycare. Methods A total of 64 outpatients (44 females) with a mean age of 84±6 years who visited a hospital for daycare were enrolled in the study. The prevalence of OH and demographic characteristics were examined. Then, the subjects were followed up for 1 year. The blood pressure was measured in the supine position and immediately, 1, 3 and 5 minutes after standing. Poor outcome measures included death, hospitalization for any reason, and admission to a nursing home or geriatric facility. Results OH was present in 17 patients (26.6%). The presence of OH was associated with a higher supine systolic blood pressure. The increase in heart rate in the standing position was also reduced in subjects with OH compared with those without. The presence of OH was associated with faster time in the timed up-and-go test compared with those without OH. During the follow-up period, 22 patients (34.4%) had a poor prognosis, of which 8 (36.4%) had OH, which tended to be higher than those with a favorable prognosis. The event-free survival rate appeared to be lower in subjects with OH than in those without. Conclusion OH is relatively common in frail elderly patients with dementia, and it also appears to be associated with a poor prognosis.

Clinical implications of delayed orthostatic hypotension: A 10-year follow-up study

OBJECTIVE

To define the long-term outcome of delayed orthostatic hypotension (OH).

HYPOTHESIS

Delayed OH is an early and milder form of OH that progresses over time.

METHODS

We reviewed the medical records of 230 previously reported patients who completed autonomic testing at our center from January 1, 2002, through December 31, 2003. All available information on clinical diagnosis, mortality, medication use, and autonomic testing were extracted and included in the reported outcomes. Standard criteria were used to define OH and delayed OH.

RESULTS

Forty-eight individuals with delayed OH, 42 individuals with OH, and 75 controls had complete follow-up data. Fifty-four percent of individuals with delayed OH progressed to OH. Thirty-one percent of individuals with delayed OH developed an α-synucleinopathy. The 10-year mortality rate in individuals with delayed OH was 29%, in individuals with baseline OH was 64%, and in controls was 9%. The 10-year mortality of individuals who progressed to OH was 50%. Progression to OH was associated with developing an α-synucleinopathy, baseline diabetes, and abnormal baseline autonomic test results.

CONCLUSION

Delayed OH frequently progresses to OH with a high associated mortality.