Postural blood pressure electrocardiographic changes are associated with falls in older people

Age-Related Orthostatic Hypotension: A Comprehensive Analysis of Prevalence, Mechanisms, and Management in the Geriatric Population

Geriatric patients frequently encounter orthostatic hypotension (OH), a multifaceted condition characterized by a significant drop in blood pressure upon assuming an upright position. As the elderly population is particularly susceptible to OH, our review endeavors to comprehensively explore the complex nature of this condition and various factors contributing to its development. We investigate the impact of comorbidities, polypharmacy, age-related physiological changes, and autonomic dysfunction in the pathogenesis of OH. Geriatric patients with OH are faced with an elevated risk of falls, syncope, a decline in their overall quality of life, and hence increased mortality. These implications require careful consideration, necessitating a thorough examination of therapeutic strategies. We evaluate various pharmaceutical and nonpharmacological therapies, delving into the effectiveness and safety of each approach in managing OH within geriatric populations. We explore the role of pharmacotherapy in alleviating symptoms and mitigating OH-related complications, as well as the potential benefits of volume expansion techniques to augment blood volume and stabilize blood pressure. We place particular emphasis on the significance of lifestyle changes and nonpharmacological interventions in enhancing OH management among the elderly. These interventions encompass dietary modifications, regular physical activity, and postural training, all tailored to the unique needs of the individual patient. To optimize outcomes and ensure patient safety, we underscore the importance of individualized treatment plans that take into account the geriatric patient's overall health status, existing comorbidities, and potential interactions with other medications. This review aims to improve clinical practice and patient outcomes by advocating for early detection, properly tailored management, and targeted interventions to address OH in the elderly population. By raising awareness of OH's prevalence and complexities among healthcare professionals, we hope to foster a comprehensive understanding of OH and contribute to the overall wellness and quality of life of this vulnerable demographic.

Central command suppresses pressor-evoked bradycardia at the onset of voluntary standing up in conscious cats

NEW FINDINGS

What is the central question of this study? Standing up can cause hypotension and tachycardia. Accumulated evidence poses the simple question, does the cardiac baroreflex operate at the onset of standing up? If the cardiac baroreflex is suppressed, what mechanism is responsible for baroreflex inhibition? What is the main finding and its importance? In cats, we found blunting of cardiac baroreflex sensitivity in the pressor range at the onset of voluntary hindlimb standing, but not of passive hindlimb standing. This finding suggests that central command suppresses pressor-evoked bradycardia at the onset of standing up, probably in advance, to prevent or buffer orthostatic hypotension.

ABSTRACT

It remains unclear whether cardiac baroreflex function is preserved or suppressed at the onset of standing up. To answer the question and, if cardiac baroreflex is suppressed, to investigate the mechanism responsible for the suppression, we compared the sensitivity of the arterial cardiac baroreflex at the onset of voluntary and passive hindlimb standing in conscious cats. Cardiac baroreflex sensitivity was estimated from the maximal slope of the baroreflex curve between the responses of systolic arterial blood pressure and heart rate to a brief occlusion of the abdominal aorta. The systolic arterial blood pressure response to standing up without aortic occlusion was greater in the voluntary case than in the passive case. Cardiac baroreflex sensitivity was clearly decreased at the onset of voluntary standing up compared with rest (P = 0.005) and the onset of passive standing up (P = 0.007). The cardiac baroreflex sensitivity at the onset of passive standing up was similar to that at rest (P = 0.909). The findings suggest that central command would transmit a modulatory signal to the cardiac baroreflex system during the voluntary initiation of standing up. Furthermore, the present data tempt speculation on a close relationship between central inhibition of the cardiac baroreflex and the centrally induced tachycardiac response to standing up.

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

Background

Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older adults.

Objective

To provide a prevalence estimate of initial OH in adults aged 65 years or older.

Methods

Literature search of MEDLINE (from 1946), Embase (from 1947) and Cochrane Central Register of Controlled Trials was performed until 6 December 2019, using the terms ‘initial orthostatic hypotension’, ‘postural hypotension’ and ‘older adults’. Articles were included if published in English and participants were 65 years or older. Random effects models were used for pooled analysis.

Results

Of 5,136 articles screened, 13 articles (10 cross-sectional; 3 longitudinal) reporting data of 5,465 individuals (54.5% female) from the general (n = 4,157), geriatric outpatient (n = 1,136), institutionalised (n = 55) and mixed (n = 117) population were included. Blood pressure was measured continuously and intermittently in 11 and 2 studies, respectively. Pooled prevalence of continuously measured initial OH was 29.0% (95% CI: 22.1–36.9%, I² = 94.6%); 27.8% in the general population (95% CI: 17.9–40.5%, I² = 96.1%), 35.2% in geriatric outpatients (95% CI: 24.2–48.1%, I² = 95.3%), 10.0% in institutionalised individuals (95% CI: 2.4–33.1%, I² = 0%) and 21.4% in the mixed population (95% CI: 7.0–49.6, I² = 0%). Pooled prevalence of intermittently measured initial OH was 5.6% (95% CI: 1.5–18.9%, I² = 81.1%); 1.0% in the general population (95% CI: 0.0–23.9%, I² = 0%) and 7.7% in geriatric outpatients (95% CI: 1.8–27.0%, I² = 86.7%).

Conclusion

The prevalence of initial OH is high in older adults, especially in geriatric outpatients. Proper assessment of initial OH requires continuous blood pressure measurements.

Initial orthostatic hypotension and orthostatic intolerance symptom prevalence in older adults: A systematic review

Background

Initial orthostatic hypotension is a clinically relevant syndrome in older adults which has been associated with symptoms of orthostatic intolerance. The aim of this systematic review was to determine the prevalence of orthostatic intolerance symptoms in older adults with initial orthostatic hypotension.

Methods

MEDLINE (from 1946), EMBASE (from 1974) and Cochrane were searched to December 6th^, 2019 using the terms "initial orthostatic hypotension", "postural hypotension" and "older adults". Study selection involved the following criteria: published in English; mean or median age ≥ 65 years and diagnosis of initial orthostatic hypotension encompassed a decrease in systolic blood pressure by ≥ 40  mmHg and/or diastolic blood pressure by ≥ 20  mmHg within a maximum of 1 min following a postural change.

Results

Of 8311 articles, 12 articles reporting initial orthostatic hypotension prevalence in 3446 participants with a mean age of 75 (6 SD) years (56.5% female) were included. Five initial orthostatic hypotension definition variations were utilised and symptoms were reported in six articles (968 participants, mean age 73.4 (6.1 SD) years, 56% female). The prevalence of symptoms in older adults with initial orthostatic hypotension ranged from 24 to 100% and was dependent on variations in timing or the inclusion of symptoms in the initial orthostatic hypotension definition.

Conclusions

Where orthostatic intolerance symptoms were reported, a large proportion of older adults with a diagnosis of initial orthostatic hypotension were symptomatic. However, the literature on initial orthostatic hypotension and orthostatic intolerance symptoms is scarce and a variety of definitions of initial orthostatic hypotension are utilised.

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

Background

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

Methods and Results

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

Conclusions

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

Multimodal Monitoring of Cardiovascular Responses to Postural Changes

Background

In the poorly understood relationship between orthostatic hypotension and falls, next to blood pressure (BP), baroreflex sensitivity (BRS) and cerebral autoregulation (CAR) may be key measures. The posture- and movement dependency of orthostatic hypotension requires continuous and unobtrusive monitoring. This may be possible using simultaneous photoplethysmography (PPG), electrocardiography (ECG), and near-infrared spectroscopy (NIRS) signal recordings, from which pulse wave velocity (PWV; potentially useful for BP estimation), BRS and CAR can be derived. The PPG, NIRS and PWV signal correlation with BP and BRS/CAR reliability and validity need to be addressed.

Methods

In 34 healthy adults (mean age 25 years, inter quartile range 22–45; 10 female), wrist and finger PPG, ECG, bifrontal NIRS (oxygenated and deoxygenated hemoglobin) and continuous BP were recorded during sit to stand and supine to stand movements. Sixteen participants performed slow and rapid supine to stand movements; eighteen other participants performed a 1-min squat movement. Pulse wave velocity (PWV) was defined as the inverse of the ECG R-peak to PPG pulse delay; PPG, NIRS and PWV signal correlation with BP as their Pearson correlations with mean arterial pressure (MAP) within 30 s after the postural changes; BRS as inter beat interval drop divided by systolic BP (SBP) drop during the postural changes; CAR as oxygenated hemoglobin drop divided by MAP drop. BRS and CAR were separately computed using measured and estimated (linear regression) BP. BRS/CAR reliability was defined by the intra class correlation between repeats of the same postural change; validity as the Pearson correlation between BRS/CAR values based on measured and estimated BP.

Results

The highest correlation with MAP was found for finger PPG and oxygenated hemoglobin, ranging from 0.75–0.79 (sit to stand), 0.66–0.88 (supine to stand), and 0.82–0.94 (1-min squat). BRS and CAR reliability was highest during the different supine to stand movements, ranging from 0.17 – 0.49 (BRS) and 0.42-0.75 (CAR); validity was highest during rapid supine to stand movements, 0.54 and 0.79 respectively.

Conclusion

PPG-ECG-NIRS recordings showed high correlation with BP and enabled computation of reliable and valid BRS and CAR estimates, suggesting their potential for continuous unobtrusive monitoring of orthostatic hypotension key measures.

Impact of Standing Speed on the Peripheral and Central Hemodynamic Response to Orthostasis: Evidence From the Irish Longitudinal Study on Ageing

Assessment of the cerebrovascular and cardiovascular response to standing has prognostic value for a range of outcomes in the older adult population. Studies generally attempt to control for standing speed differences by asking participants to stand in a specified time but little is known about the range of transition times observed. This study aimed to characterize how standing speed associates with cardiovascular and cerebrovascular measures following transition from supine to standing. Continuous cerebral oxygenation, heart rate, systolic and diastolic blood pressure were monitored for 3 minutes after transitioning from supine to standing. An algorithm was used to calculate the time taken to transition from existing Finometer data (from the height correction unit). Linear mixed-effects models were used to assess the influence of transition time on each of the signals while adjusting for covariates. Transition time ranged from 2 to 27 s with 17% of participants taking >10 s to stand. Faster transition was associated with a more extreme decrease 10 s after standing but improved recovery at 20 s for cerebral oxygenation and blood pressure. Standing faster was associated with an elevated heart rate on initiation of stand and a quicker recovery 10 to 20 s after standing. The speed of transitioning from supine to standing position is associated with cardiovascular and cerebrovascular response in the early period after standing (<40 s). Care should be taken in the interpretation of findings which may be confounded by standing speed and statistical adjustment for standing time should be applied where appropriate.

Rapid Systolic Blood Pressure Changes After Standing Up Associate With Impaired Physical Performance in Geriatric Outpatients

Background

Orthostatic hypotension is a prevalent condition in older adults and is associated with impaired physical performance and falls. The ability of older adults to compensate for rapid changes in systolic blood pressure (SBP; ie, SBP decline rate and SBP variability) may be important for physical performance. This study investigates the association of rapid SBP changes after standing up with physical performance.

Methods and Results

Consecutive patients who visited the Center of Geriatrics Amsterdam in 2014 and 2015 were included. The following SBP parameters were computed in 2 intervals (0–15 and 15–180 seconds) after standing up: steepness of steepest SBP decline; ratio of standing/supine SBP variability; and magnitude of largest SBP decline. Physical performance was assessed using the following measures: chair stand time, timed up and go time, walking speed, handgrip strength, and tandem stance performance. A total of 109 patients (45% men; age, mean, 81.7 years [standard deviation, 7.0 years]) were included. Steepness of steepest SBP decline (0–15 seconds) was associated with slower chair stand time (P<0.001), timed up and go time (P=0.022), and walking speed (P=0.024). Ratio of standing/supine SBP variability (0–15 seconds) was associated with slower chair stand time (P=0.005). Magnitude of largest SBP decline was not associated with physical performance.

Conclusions

SBP parameters reflecting rapid SBP changes were more strongly associated with physical performance compared with SBP decline magnitude in geriatric outpatients. These results support the hypothesis of an inadequate cerebral autoregulation during rapid SBP changes and advocate the use of continuous blood pressure measurements.

Orthostatic Hypotension and Falls in Older Adults: A Systematic Review and Meta-analysis

OBJECTIVES

Orthostatic hypotension is a potential risk factor for falls in older adults, but existing evidence on this relationship is inconclusive. This study addresses the association between orthostatic hypotension and falls.

DESIGN

Systematic review and meta-analysis of the cross-sectional and longitudinal studies assessing the association between orthostatic hypotension and falls, as preregistered in the PROSPERO database (CRD42017060134).

SETTING AND PARTICIPANTS

A literature search was performed on February 20, 2017, in MEDLINE (from 1946), PubMed (from 1966), and EMBASE (from 1947) using the terms orthostatic hypotension, postural hypotension, and falls. References of included studies were screened for other eligible studies. Study selection was performed independently by 2 reviewers using the following inclusion criteria: published in English; mean/median age of the population ≥65 years; blood pressure measurement before and after postural change; and assessment of the association of orthostatic hypotension with falls. The following studies were excluded: conference abstracts, case reports, reviews, and editorials. Data extraction was performed independently by 2 reviewers.

MEASURES

Unadjusted odds ratios of the association between orthostatic hypotension and falls were used for pooling using a random effects model. Studies were rated as high, moderate, or low quality using the Newcastle-Ottawa Scale.

RESULTS

Out of 5646 studies, 63 studies (51,800 individuals) were included in the systematic review and 50 studies (49,164 individuals) in the meta-analysis. Out of 63 studies, 39 were cross-sectional and 24 were longitudinal. Orthostatic hypotension was positively associated with falls (odds ratio 1.73, 95% confidence interval 1.50-1.99). The result was independent of study population, study design, study quality, orthostatic hypotension definition, and blood pressure measurement method.

CONCLUSIONS AND IMPLICATIONS

Orthostatic hypotension is significantly positively associated with falls in older adults, underpinning the clinical relevance to test for an orthostatic blood pressure drop and highlighting the need to investigate orthostatic hypotension treatment to potentially reduce falls.

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

BACKGROUND

Orthostatic hypotension (OH) may negatively affect physical functioning and aggravate morbidities, but existing evidence is contradictory.

METHODS

MEDLINE (from 1946), PubMed (from 1966) and EMBASE databases (from 1947) were systematically searched for studies on the association of OH and physical functioning in older adults, categorized as: balance, gait characteristics, walking speed, Timed Up and Go time, handgrip strength (HGS), physical frailty, exercise tolerance, physical activity, activities of daily living (ADL), and performance on the Hoehn and Yahr scale (HY) and Unified Parkinson's Disease Rating Scale (UPDRS). Study quality was assessed using the Newcastle Ottawa Scale.

RESULTS

Forty-two studies were included in the systematic review (29,421 individuals) and 29 studies in the meta-analyses (23,879 individuals). Sixteen out of 42 studies reported a significant association of OH with worse physical functioning. Meta-analysis showed a significant association of OH with impaired balance, ADL performance and HY/UPDRS III performance, but not with gait characteristics, mobility, walking speed, TUG, HGS, physical frailty, exercise tolerance, physical activity and UPDRS II performance.

CONCLUSIONS

OH was associated with impaired balance, ADL performance and HY/UPDRS III performance, but not with other physical functioning categories. The results suggest that OH interventions could potentially improve some aspects of physical functioning.

Stroke and Falls-Clash of the Two Titans in Geriatrics

Both stroke and falls are common conditions affecting the older adult. Despite stroke being considered a well-established major risk factor for falls, there remains no evidence for effective prevention strategies for falls specifically for stroke survivors. Previous observational studies evaluating falls risk factors in stroke have mainly been uncontrolled and found similar risk factors for stroke populations compared to general older populations. Specific risk factors, however, are likely to play a greater role in stroke survivors including unilateral weakness, hemisensory or visual neglect, impaired coordination, visual field defects, perceptual difficulties and cognitive issues. In addition, individuals with stroke are also more likely to have other associated risk factors for falls including diabetes, falls risk increasing drugs, atrial fibrillation, and other cardiovascular risk factors. While anticoagulation is associated with increased risk of intracranial bleeding after a fall, the risk of suffering a further stroke due to atrial fibrillation outweigh the risk of bleeding from a recurrent fall. Similarly, while blood pressure lowering medications may be linked to orthostatic hypotension which in turn increases the risk of falls, the benefit of good blood pressure control in terms of secondary stroke prevention outweighs the risk of falls. Until better evidence is available, the suggested management approach should then be based on local resources, and published evidence for fall prevention. Multicomponent exercise and individually tailored multifactorial interventions should still be considered as published evidence evaluating the above have included stroke patients in their study population.