Does vitamin D deficiency increase orthostatic hypotension risk in the elderly patients?

Postural change, gait, and physical function in older adults

In a more clinical setting, abrupt posture change may be used to determine the presence of orthostatic hypotension, a hemodynamic response with relationships to physical function. Certain gait features and physical function performance are also associated with risk of falling in older adults. However, the extent to which posture change is associated with subsequent gait and physical function has received little attention in the literature. This study aims to determine the effects of posture change on spatiotemporal parameters of gait and Timed Up-and-Go (TUG) performance.

METHODS

Forty-two volunteers (age 73.21 ± 6.22 years) participated in the study. A custom Tekscan Strideway (Tekscan, Boston, MA.) gait system was used to measure gait velocity (VEL), cadence (CAD), stride length (SL), and percent of time spent in active propulsion (AP). Dependent t-tests were used to compare TUG time, VEL, CAD, SL and AP after at least 10 mins of seated rest and supine rest.

RESULTS

Time to complete the TUG was significantly slower after supine rest compared to seated (11.47 ± 0.51 and 10.01 ± 0.33 s, respectively, p<0.001); VEL was significantly slower after supine rest compared to seated (0.888 ± 0.042 and 1.049 ± 0.033 m/s, respectively, p=0.003); CAD was significantly slower after supine rest compared to seated (111.21 ± 2.87 and 120.97 ± 2.56spm, respectively, p=0.001); and AP was significantly lower after supine rest compared to seated (56.87 ± 4.76 and 70.79 ± 4.05 %, respectively, p<0.001). No significant differences were detected in stride length between conditions.

CONCLUSIONS

Among this sample of older adults, standing from a supine posture is associated with spatiotemporal gait parameters consistent with a risk for falling and aging. Additionally, TUG performance worsens significantly after supine rest. Future studies could explore the sensitivity and specificity of falls risk screening after supine rest.

Orthostatic hypotension and cognitive impairment: Systematic review and meta-analysis of longitudinal studies

The association between cognitive disorders and orthostatic hypotension (OH) has been empirically explored, but the results have been divergent, casting doubt on the presence and direction of the association. The objective of this meta-analysis was to systematically review and quantitatively synthesize the association of OH and cognitive function, specifically mean score on the Mini-Mental State Examination (MMSE), cognitive impairment and incident dementia. A Medline search was conducted in May 2022 with no date limit, using the MeSH terms "orthostatic hypotension" OR "orthostatic intolerance" OR "hypotension" combined with the Mesh terms "cognitive dysfunction" OR "Alzheimer disease" OR "dementia" OR "cognition disorder" OR "neurocognitive disorder" OR "cognition" OR "neuropsychological test". Of the 746 selected studies, 15 longitudinal studies met the selection criteria, of which i) 5 studies were eligible for meta-analysis of mean MMSE score comparison, ii) 5 studies for the association of OH and cognitive impairment, and iii) 6 studies for the association between OH and incident dementia. The pooled effect size in fixed-effects meta-analysis was: i) -0.25 (-0.42; -0.07) for the mean MMSE score, which indicates that the MMSE score was lower for those with OH; ii) OR (95 % CI) = 1.278 (1.162; 1.405), P < 0.0001, indicating a 28 % greater risk of cognitive impairment for those with OH at baseline; and iii) HR (95 % CI) = 1.267 (1.156; 1.388), P < 0.0001, indicating a 27 % greater risk of incident dementia for those with OH at baseline. Patients with OH had a lower MMSE score and higher risk of cognitive impairment and incident dementia in this meta-analysis of longitudinal studies. This study confirmed the presence of an association between OH and cognitive disorders in older adults.

Genetic Variability of the Vitamin D Receptor Affects Susceptibility to Parkinson’s Disease and Dopaminergic Treatment Adverse Events

Vitamin D is a lipid-soluble molecule and an important transcriptional regulator in many tissues and organs, including the brain. Its role has been demonstrated also in Parkinson’s disease (PD) pathogenesis. Vitamin D receptor (VDR) is responsible for the initiation of vitamin D signaling cascade. The aim of this study was to assess the associations of VDR genetic variability with PD risk and different PD-related phenotypes. We genotyped 231 well characterized PD patients and 161 healthy blood donors for six VDR single nucleotide polymorphisms, namely rs739837, rs4516035, rs11568820, rs731236, rs2228570, and rs1544410. We observed that VDR rs2228570 is associated with PD risk (p < 0.001). Additionally, we observed associations of specific VDR genotypes with adverse events of dopaminergic treatment. VDR rs1544410 (GG vs. GA + AA: p = 0.005; GG vs. GA: p = 0.009) was associated with the occurrence of visual hallucinations and VDR rs739837 (TT vs. GG: p = 0.036), rs731236 (TT vs. TC + CC: p = 0.011; TT vs. TC: p = 0.028; TT vs. CC: p = 0.035), and rs1544410 (GG vs. GA: p = 0.014) with the occurrence of orthostatic hypotension. We believe that the reported study may support personalized approach to PD treatment, especially in terms of monitoring vitamin D level and vitamin D supplementation in patients with high risk VDR genotypes.

Effects of Vitamin D Supplementation on Orthostatic Hypotension: Results From the STURDY Trial

BACKGROUND

Vitamin D3 supplementation is considered a potential intervention to prevent orthostatic hypotension (OH) based on observational evidence that vitamin D levels are inversely associated with OH. With data from The Study to Understand Fall Reduction and Vitamin D in You (STURDY), a double-blind, randomized, response-adaptive trial, we determined if higher doses of vitamin D3 reduced risk of OH.

METHODS

STURDY tested the effects of higher (1,000+ IU/day, i.e., 1,000, 2,000, and 4,000 IU/day combined) vs. lower-dose vitamin D3 (200 IU/day, comparison) on fall risk in adults ages 70 years and older with low serum 25-hydroxyvitamin D (25(OH)D, 10-29 ng/ml). OH was determined at baseline, 3, 12, and 24 months by taking the difference between seated and standing blood pressure (BP). OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mm Hg after 1 minute of standing. Participants were also asked about OH symptoms during the assessment and the preceding month.

RESULTS

Among 688 participants (mean age 77 [SD, 5] years; 44% women; 18% Black), the mean baseline systolic/diastolic BP was 130 (19)/67 (11) mm Hg, serum 25(OH)D was 22.1 (5.1) ng/ml, and 2.8% had OH. There were 2,136 OH assessments over the maximum 2-year follow-up period. Compared with 200 IU/day, 1,000+ IU/day was not associated with seated, standing, or orthostatic BP, and it did not lower risk of OH or orthostatic symptoms.

CONCLUSIONS

These findings do not support use of higher doses of vitamin D3 supplementation as an intervention to prevent OH.

CLINICAL TRIALS REGISTRATION

Trial Number NCT02166333.

Orthostatic hypotension and vitamin D deficiency in older adults: systematic review and meta-analysis

BACKGROUND

Over the latest years different studies have investigated the possible relationship between D deficiency and occurrence of orthostatic hypotension (OH), often reaching controversial results. We perform an update meta-analysis providing an update overview on the association between hypovitaminosis D and orthostatic hypotension (OH) in older adults.

METHODS

Data extraction was independently performed by two authors and based upon predefined criteria. The meta-analysis was performed using a random-effects model. Statistical heterogeneity between groups was measured using the Higgins I2 statistic.

RESULTS

Eight investigations enrolling 16.326 patients (mean age 75.5 years) met the inclusion criteria and were considered for the analysis. Patients with vitamin D deficiency were more likely to have OH compared to those without (OR: 1.36, 95% CI 1.14-1.63, p = 0.0001, I2 = 43.6%). A further sub-analysis, based on three studies, estimating the risk of OH in patients with hypovitaminosis D receiving antihypertensive treatment, did not reach the statistical significance (OR: 1.40, 95% CI 0.61-3.18, p = 0.418, I2 = 53.3%). Meta-regression performed using age (p = 0.12), BMI (p = 0.73) and gender (p = 0.62) as moderators did not reveal any statistical significance in influencing OH. Conversely, physical activity, Vitamin D supplementation and use of radioimmunoassay for the measurement of vitamin D serum levels showed a significant inverse relationship towards the risk of OH (Coeff.-0.09, p = 0.002, Coeff. - 0.12, p < 0.001 and Coeff. - 0.08, p = 0.03, respectively) among patients with hypovitaminosis D. A direct correlation between the administration of antihypertensive treatment and the risk of OH in older patients with low vitamin D level was observed (Coeff. 0.05, p < 0.001).

CONCLUSIONS

Hypovitaminosis D is significantly associated with OH in older adults and directly influence by the administration of antihypertensive drugs. Conversely, physical activity, vitamin D supplementation and use of radioimmunoassay as analytic method inversely correlated with the risk of OH in older patients.

Vitamin D: Not Just Bone Metabolism but a Key Player in Cardiovascular Diseases

Vitamin D is the first item of drug expenditure for the treatment of osteoporosis. Its deficiency is a condition that affects not only older individuals but also young people. Recently, the scientific community has focused its attention on the possible role of vitamin D in the development of several chronic diseases such as cardiovascular and metabolic diseases. This review aims to highlight the possible role of vitamin D in cardiovascular and metabolic diseases. In particular, here we examine (1) the role of vitamin D in diabetes mellitus, metabolic syndrome, and obesity, and its influence on insulin secretion; (2) its role in atherosclerosis, in which chronic vitamin D deficiency, lower than 20 ng/mL (50 nmol/L), has emerged among the new risk factors; (3) the role of vitamin D in essential hypertension, in which low plasma levels of vitamin D have been associated with both an increase in the prevalence of hypertension and diastolic hypertension; (4) the role of vitamin D in peripheral arteriopathies and aneurysmal pathology, reporting that patients with peripheral artery diseases had lower vitamin D values than non-suffering PAD controls; (5) the genetic and epigenetic role of vitamin D, highlighting its transcriptional regulation capacity; and (6) the role of vitamin D in cardiac remodeling and disease. Despite the many observational studies and meta-analyses supporting the critical role of vitamin D in cardiovascular physiopathology, clinical trials designed to evaluate the specific role of vitamin D in cardiovascular disease are scarce. The characterization of the importance of vitamin D as a marker of pathology should represent a future research challenge.

Risk factors for high fall risk in elderly patients with chronic kidney disease

PURPOSE

Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking.

METHODS

Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m²) were identified using logistic regression models.

RESULTS

Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group.

CONCLUSIONS

Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.

Orthostatic hypotension and age-related sarcopenia

Objectives

This study aims to determine the association of sarcopenia with orthostatic hypotension (OH) which is a significant precursor to falls and related injuries in elderly patients.

Patients and methods

A total of 91 outpatients (18 males, 73 females; mean age 79.3±4.0 years; range, 75 to 91 years) were prospectively enrolled and those who were eligible underwent comprehensive sarcopenia assessment including measurement of muscle mass, strength, physical performance, anthropometric measurements along with frailty tests. Patients classified as sarcopenic or non-sarcopenic based on these measurements underwent supine and standing blood pressure (BP) measurements. The frequency of OH was compared between the two groups.

Results

Of the 91 patients, 29 (31.9%) had sarcopenia. There was no statistical difference in measurements of functional tests which consisted of gait speed, timed up-and-go test and handgrip strength. However, timed sit-to-stand test values were higher in sarcopenic patients (18.2±7.9 vs. 15.0±5.1, p=0.04). Patients with sarcopenia developed OA and intolerance more often compared to the non-sarcopenic patients (n=15 [50.0%] vs. n=14 [23.0%], p<0.01 and n=13 [44.8%] vs. n=9 [15.3%], p<0.01, respectively). The adjusted odds ratio for sarcopenia was 7.80 (95% confidence interval 1.77-34.45), p=0.007.

Conclusion

Age-related sarcopenia increases the risk of OA in the elderly. This may in part explain the increased incidence of falls and also help identification of risky elderly patients for orthostatic BP drops.

Vitamin D deficiency is associated with orthostatic hypotension in older men: a cross-sectional analysis from the British Regional Heart Study

Background

orthostatic hypotension (OH) that occurs within, or at, 1 minute of standing is associated with higher risk of falls, myocardial infarction, syncope and mortality, compared to OH that occurs after 1 minute of standing. Whether vitamin D deficiency increases the risk of OH is controversial.

Methods

this was a cross-sectional analysis of 3,620 older, community-dwelling men. Multinomial, multiple logistic regression models were used to calculate the risk of OH across categories of vitamin D status (deficient [<25 nmol/l], insufficient [≥25–<50 nmol/l] and sufficient [≥50 nmol/l]) and parathyroid hormone quintile.

Results

men with vitamin D deficiency were more likely to have OH that occurred within 1 minute of standing in univariate logistic regression (OR 1.88, 95% CI 1.40–2.53) and multinomial, multiple logistic regression (OR 1.51, 95% CI 1.06–2.15), compared to men with sufficient levels of vitamin D. Vitamin D insufficiency was not associated with the risk of OH. Elevated parathyroid hormone was not associated with risk of OH.

Conclusion

the absence of an association between vitamin D insufficiency and risk of OH and the presence of an association between vitamin D deficiency and risk of OH suggest that there may be a threshold effect; it is only below a particular level of vitamin D that risk of OH is increased. In this cohort, the threshold was <25 nmol/l. Future work should investigate whether treating vitamin D deficiency can improve postural blood pressure or if preventing vitamin D deficiency reduces the incidence of OH.

A Review of the Relationship Between Vitamin D and Parkinson Disease Symptoms

Vitamin D is a fat-soluble secosteroid that exerts its effects by binding to the vitamin D receptor (VDR), through which it directly and indirectly modulates the expression of hundreds to thousands of genes. While originally known for its role in regulating calcium homeostasis and metabolism, vitamin D is now associated with many other health conditions, including Parkinson's disease (PD). A high prevalence of vitamin D deficiency has been noted in PD for at least the past two decades. These findings, along with the discovery that the VDR and 1α-hydroxylase, the enzyme that converts vitamin D to its active form, are highly expressed in the substantia nigra, led to the hypothesis that inadequate levels of circulating vitamin D may lead to dysfunction or cell death within the substantia nigra. Studies investigating the relationship between vitamin D status and PD, however, have been inconsistent. Two prospective studies examined the association between mid-life vitamin D levels and risk of PD and produced conflicting results-one demonstrated an increased risk for PD with lower mid-life vitamin D levels, and the other showed no association between vitamin D and PD risk. One of the most consistent findings in the literature is the inverse association between serum vitamin D level and motor symptom severity in cross-sectional studies. While these data suggest that vitamin D may modify the disease, another likely explanation is confounding due to limited mobility. Fall risk has been associated with vitamin D in PD, but more study is needed to determine if supplementation decreases falls, which has been demonstrated in the general population. The association between vitamin D and non-motor symptoms is less clear. There is some evidence that vitamin D is associated with verbal fluency and verbal memory in PD. Studies in PD have also shown associations between vitamin D status and mood, orthostatic hypotension and olfactory impairment in PD. While more research is needed, given the numerous potential benefits and limited risks, vitamin D level assessment in PD patients and supplementation for those with deficiency and insufficiency seems justified.

Vitamin D Status Is Not Associated With Orthostatic Hypotension in Older Adults

There has been much interest in investigating vitamin D status with orthostatic hypotension. However, studies have been small, inconsistent, and with a lack of standardization. The aim of this study was to investigate the association with vitamin D status in a large, nationally representative older adult population using a traceable standard of measurement and an accurate assessment of beat-to-beat blood pressure (BP). This study used participants aged >50 years from The Irish Longitudinal Study on Ageing. Impaired stabilization of BP on standing was defined as a sustained drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP up to 40 seconds post stand (impaired stabilization of BP on standing). We also analyzed participants who sustained a drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP throughout the 110 seconds stand (OH110). Vitamin D was categorized into sufficient (≥50 nmol/L), insufficient (30-50 nmol/L), and deficient (<30 nmol/L) status. After exclusion criteria 4209 participants were included. Those with deficiency were more likely to be smokers, take antihypertensive medications and had higher levels of cardiovascular disorders compared with those with sufficient status. In a univariate logistic regression those with deficient (odds ratio, 1.18; 95% CI, 0.86-1.61; P=0.303) or insufficient (odds ratio, 1.13; 95% CI, 0.91; P=0.272) status were no more likely to have evidence of impaired stabilization of BP on standing on active stand compared with sufficiency. Similar findings were found for OH110: deficient (odds ratio, 0.85; 95% CI, 0.52-1.40; P=0.528) or insufficient (odds ratio, 0.86; 95% CI, 0.61-1.21; P=0.384) versus sufficiency. In conclusion, vitamin D is not significantly associated with orthostatic hypotension in older adults.

Effect of Vitamin D on Cognitive Functions in Older Adults: 24-Week Follow-Up Study

The purpose of this study is to assess the effect of vitamin D replacement on cognitive function in older adults. A total of 560 patients who underwent comprehensive geriatric assessment including Global cognitive assessment, Basic Activities of Daily Living (BADL), and Instrumental Activities of Daily Living (IADL) twice in 6-month period were retrospectively reviewed. Oral cholecalciferol was replaced to patients with vitamin D deficiency routinely. In baseline cognitive scores, BADL-IADL scores were lower in the severe deficiency group than in the deficiency and adequate groups (P < .05). With regard to the relation between changes in cognitive functions, BADL-IADL scores on the 6-month versus baseline, no difference was determined in patients with and without dementia (P > .05). Vitamin D replacement may not improve cognitive performance in older adults, even if vitamin D is raised to adequate level, suggesting that longer term replacement therapy may be needed to improve cognitive function.

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 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.

Dementia-Related Results of "Costs of Medication in Older Patients: Before and After Comprehensive Geriatric Assessment"

Changes in the pharmacokinetics and pharmacodynamics of drugs in the presence of certain comorbidities and geriatric syndromes and reduced tolerability of potential drug side effects due to physiological changes with aging lead to difficulties in planning treatments in elderly adults, especially patients with dementia. The Comprehensive Geriatric Assessment has an important role in assessing polypharmacy and optimizing potentially inappropriate medications and potentially prescribing omissions in these patients. For this reason, we intend to reexamine our new study titled " Costs of medication in older patients: before and after comprehensive geriatric assessment," because most of these results are also very important for dementia practice.

Costs of medication in older patients: before and after comprehensive geriatric assessment

Background

Polypharmacy and inappropriate drug use cause numerous complications, such as cognitive impairment, frailty, falls, and functional dependence. The present study aimed to determine the effect of the comprehensive geriatric assessment (CGA) on polypharmacy, potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the economic reflections of medication changes.

Methods

One thousand five hundred and seventy-nine older patients, who had undergone CGA, were retrospectively evaluated. The drugs, drug groups, and number of drugs that the patients used were recorded. Appropriate drug therapy was identified by both CGA and STOPP/START criteria. Based on these criteria, PIMs were discontinued and PPOs were started. The monthly cost of these drugs was calculated separately for PIMs and PPOs by using the drugstore records.

Results

After CGA, while the prevalence of non-polypharmacy was increased from 43.3% to 65.6%, the prevalence of polypharmacy and hyperpolypharmacy was decreased from 56.7% to 34.4% and 12.0% to 3.6%, respectively. The three most common PIMs discontinued were proton pump inhibitors, anti-dementia drugs, and antipsychotics, respectively. However, the most common PPOs started were vitamin D and B12 supplements, and anti-depressants. After CGA, monthly saved total per capita cost of PIMs was US$12.8 and monthly increased total per capita cost of PPOs was $5.6.

Conclusion

It was demonstrated that prevalence of polypharmacy, PIM, and PPO could be decreased by CGA including START/STOPP criteria in older adults. Furthermore, this will have beneficial effects on economical parameters due to decreasing drug-related health care costs.

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.

Orthostatic Hypotension and Associated Factors among Home Care Clients Aged 75 Years or Older - A Population-Based Study

OBJECTIVES

The aim of this study was to examine orthostatic hypotension (OH) and associated factors among home care clients aged 75 years or older.

DESIGN

Non-randomised controlled study.

SETTING AND PARTICIPANTS

The study sample included 244 home care clients aged 75 years or older living in Eastern and Central Finland.

MEASUREMENTS

Nurses, nutritionists and pharmacists collected clinical data including orthostatic blood pressure, depressive symptoms (15-item Geriatric Depression Scale GDS-15), nutritional status (Mini Nutritional Assessment MNA), drug use, self-rated health, daily activities (Barthel ADL Index and Lawton and Brody IADL scale) and self-rated ability to walk 400 metres. Comorbidities were based on medical records.

RESULTS

The prevalence of OH was 35.7% (n = 87). No association between OH and the number of drugs used or causative drug use and OH was found. In univariate analysis, coronary heart disease, systolic and diastolic blood pressure in a sitting position and lower mean MNA scores were associated with a risk of OH. Multivariate analysis showed that lower mean MNA scores (OR 1.140, 95% CI: 1.014-1.283) appeared to be independently connected to a risk of OH.

CONCLUSION

One-third of the home clients had OH and it was associated with lower MNA scores.

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.

Effects of Acetylcholinesterase Inhibitors on Balance and Gait Functions and Orthostatic Hypotension in Elderly Patients With Alzheimer Disease

OBJECTIVE

The present study was designed to evaluate the effect of acetylcholinesterase inhibitor (AchEI) therapy on balance, gait, and orthostatic hypotension (OH) in elderly patients with Alzheimer's disease (AD).

METHODS

A total of 102 elderly patients with AD have been recently diagnosed and were treated with AchEI and underwent comprehensive geriatric assessment at baseline and at the end of the sixth month.

RESULTS

Timed Up and Go test and Tinetti Performance-Oriented Mobility Assessment values and the prevalence of OH were not different at the end of the sixth month versus baseline (P > .05). However, it was determined that changes in balance were better in the patients who showed cognitive improvement at the end of the sixth month (P < .05).

CONCLUSION

Curative effects of AchEIs, which are used in the treatment of AD, on cognitive performance are reflected also in balance functions. Moreover, it was observed that these drugs do not increase the prevalence of OH.

Hypovitaminosis D predicts the onset of orthostatic hypotension in older adults

A number of small cross sectional studies have demonstrated that hypovitaminosis D (represented by low 25 hydroxyvitamin D (25OHD) levels) is associated with orthostatic hypotension (OH). We investigated if hypovitaminosis D is associated with the onset of OH in older adults over a follow-up of 4.4 years. 25OHD was categorized using sex-specific quartiles; OH was defined as a drop of ≤20 mm Hg in systolic or ≤10 mm Hg in diastolic blood pressure <3 minutes of standing. Among 1308 elderly without OH at baseline, using an adjusted logistic regression analysis and taking those with higher baseline serum 25OHD as reference, there was a significant increase in the onset of OH in those with lower serum 25OHD levels. The association was significant only in women when we stratified by sex. In conclusion, hypovitaminosis D predicts the onset of OH in older adults, particularly in women.

Hypovitaminosis D and orthostatic hypotension: a systematic review and meta-analysis

OBJECTIVES

Orthostatic hypotension is a common condition among older adults and is associated with a range of deleterious outcomes. Recently, interest has developed in hypovitaminosis D (defined as low 25 hydroxiyvitamin D levels) as a potential risk factor for orthostatic hypotension. We conducted a systematic review and meta-analysis examining the association of orthostatic hypotension between study participants with and without hypovitaminosis D, including the adjustment of potential confounders (age, sex, BMI, renal function, comorbidities, seasonality, use of antihypertensive medications, and supplementation with cholecalciferol).

METHODS

A systematic literature search of major electronic databases from inception until 09/2015 was made for articles providing data on orthostatic hypotension and hypovitaminosis D. A random effects meta-analysis of cross-sectional studies investigating orthostatic hypotension prevalence comparing participants with vs. those without hypovitaminosis D was undertaken, calculating the odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of 317 initial hits, five cross-sectional studies were meta-analysed including 3646 participants (1270 with hypovitaminosis D and 2376 without). The participants with hypovitaminosis D had a higher prevalence of orthostatic hypotension (OR = 1.88; 95% CI: 1.25-2.84; I = 68%) that was not affected by adjusting for a median of five potential confounders (OR = 2.03; 95% CI: 1.13-3.68; I = 73%). People with orthostatic hypotension had significantly reduced serum vitamin D concentrations (standardized mean difference = -0.42; 95% CI: -0.72 to -0.12). One longitudinal study confirmed the association between hypovitaminosis D and orthostatic hypotension.

CONCLUSION

Our meta-analysis highlights that hypovitaminosis D is associated with orthostatic hypotension, independent of potential confounders. Further longitudinal studies and clinical trials are required to confirm these findings.

Factors associated with orthostatic hypotension in hospitalized elderly patients

OBJECTIVE

To assess the factors associated with orthostatic hypotension (OH) in hospitalized elderly patients.

DESIGN

Prospective observational single center study.

SETTING

A French academic center.

PARTICIPANTS

One hundred and thirty-one patients without OH symptoms who underwent OH testing.

MEASUREMENTS

The OH test was performed when the patient was able to get out of the bed and was no longer receiving parenteral fluids. The blood pressure was measured after a 10-min rest while the patients were sitting and then standing at 1 and 3 min. Demographic data, co-morbidities, current medications and biological parameters were recorded.

RESULTS

The mean patient age was 84.3 ± 7 years. The mean CIRS-G score was 10.6 ± 3.8. The OH test was performed 6.3 ± 3.9 days after admission and was positive in 39 (29.8 %) patients (95 % confidence interval (CI) 22, 38) and positive at 1 min in 87.2 % of the cases. Multivariate analysis showed that OH prevalence correlated with diabetes (odds ratio (OR) = 4.23; 95 % CI 1.10, 16.24; P = 0.03), serum 25-hydroxyvitamin D <20 ng/ml (OR = 3.38; 95 % CI 1.36, 8.42; P = 0.008), use of tranquilizers (anxiolytic and hypnotic) (OR = 2.96; 95 % CI 1.18, 7.4; P = 0.02), CIRS-G score (OR = 1.15; 95 % CI 1.01, 1.31; P = 0.03) and lack of diuretics (OR = 0.20; 95 % CI 0.06, 0.63; P = 0.005).

CONCLUSION

In older adults, OH is often misdiagnosed because it is asymptomatic. As practitioners may be reluctant to perform the OH test because of time constraints, targeting a subgroup of patients with a higher risk of OH should be worthwhile to prevent further OH complications.

Uncontrolled hypertension and orthostatic hypotension in relation to standing balance in elderly hypertensive patients

Objective

To investigate the associations among uncontrolled hypertension, orthostatic hypotension (OH), and standing balance impairment in the elderly hypertensive patients referred to comprehensive geriatric assessment (CGA).

Methods

In a cross-sectional study, a total of 176 elderly hypertensive patients who underwent CGA were divided into OH group (n=36) and non-OH group (n=140) according to blood pressure measurement in the supine position, after immediate standing up, and after 1 minute and 3 minutes of standing position. Uncontrolled hypertension was defined as blood pressure of ≥140/90 mmHg if accompanied by diabetes mellitus (DM) or chronic kidney disease (CKD), or ≥150/90 mmHg if no DM and no CKD. Standing balance, including immediate standing balance and prolonged standing balance, was assessed in side-by-side and tandem stance.

Results

Neither uncontrolled hypertension nor OH was associated with prolonged standing balance impairment in elderly hypertensive patients (P>0.05). Blood pressure decrease after postural change was significantly associated with immediate standing balance impairment in side-by-side and tandem stance (P<0.05). Patients with OH were at greater risk of immediate standing balance impairment in both side-by-side and tandem stance than those without OH (odds ratio [OR] 3.44, 95% confidence interval [CI] 1.26–9.33, P<0.05; OR 3.14, 95% CI 1.14–8.64, P<0.01). Furthermore, uncontrolled hypertension was associated with immediate standing balance impairment in side-by-side stance (OR 2.96, 95% CI 1.31–6.68, P<0.05).

Conclusion

Uncontrolled hypertension, OH, and blood pressure decrease after postural change were associated with immediate standing balance impairment, and therefore, a better understanding of the underlying associations might have major clinical value.

Links between Vitamin D Deficiency and Cardiovascular Diseases

The aim of the present paper was to review the most important mechanisms explaining the possible association of vitamin D deficiency and cardiovascular diseases, focusing on recent experimental and clinical data. Low vitamin D levels favor atherosclerosis enabling vascular inflammation, endothelial dysfunction, formation of foam cells, and proliferation of smooth muscle cells. The antihypertensive properties of vitamin D include suppression of the renin-angiotensin-aldosterone system, renoprotective effects, direct effects on endothelial cells and calcium metabolism, inhibition of growth of vascular smooth muscle cells, prevention of secondary hyperparathyroidism, and beneficial effects on cardiovascular risk factors. Vitamin D is also involved in glycemic control, lipid metabolism, insulin secretion, and sensitivity, explaining the association between vitamin D deficiency and metabolic syndrome. Vitamin D deficit was associated in some studies with the number of affected coronary arteries, postinfarction complications, inflammatory cytokines and cardiac remodeling in patients with myocardial infarction, direct electromechanical effects and inflammation in atrial fibrillation, and neuroprotective effects in stroke. In peripheral arterial disease, vitamin D status was related to the decline of the functional performance, severity, atherosclerosis and inflammatory markers, arterial stiffness, vascular calcifications, and arterial aging. Vitamin D supplementation should further consider additional factors, such as phosphates, parathormone, renin, and fibroblast growth factor 23 levels.

Vitamin D insufficiency in the elderly orthopaedic patient: an epidemic phenomenon

PURPOSE

The purpose of this observational study was to evaluate serum levels of 25-OH-D of elderly patients presenting with orthopaedic illness. Furthermore, we enquired about potential confounders and risk factors of hypovitaminosis D in comorbidities and daily medication of the elderly.

METHODS

Vitamin D levels in 1,083 patients aged >70 years and admitted to an orthopaedic surgery department were measured. Univariate and multivariate analyses were used to assess risk factors for insufficient vitamin D levels.

RESULTS

Overall, 86 % of patients had insufficient serum levels of 25-OH-D and >60 % were vitamin D deficient. Serum vitamin D levels were lower during winter and months with fewer sunshine hours. Patients presenting with obesity, hypertension and osteoporosis were more likely to have low vitamin D levels.

CONCLUSIONS

We found a high prevalence of hypovitaminosis D in elderly, nonhospitalized orthopaedic patients. Given the well-known effects of vitamin D on bone metabolism and muscle health, as well as its nonskeletal effects, vitamin D insufficiency may have a negative impact.