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Todd OM, Knight M, Jacobs JA, Derington CG, Sheppard JP, Bress AP. Pharmacologic Treatment of Hypertension in Older Adults. Clin Geriatr Med 2024; 40:629-644. [PMID: 39349036 DOI: 10.1016/j.cger.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
The authors conducted a review of pharmacologic therapy in older adults with hypertension. They reviewed the evidence supporting their use in older adults, understanding the physiologic changes and potential adverse drug effects associated with aging and antihypertensive medication use, exploring guideline recommendations for antihypertensive use in older adults, and evaluating the associated risks and benefits of specific classes of antihypertensive medications.
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Affiliation(s)
- Oliver M Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, LS2 3AA, United Kingdom; Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford BD9 6RJ, United Kingdom.
| | - Matthew Knight
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, LS2 3AA, United Kingdom
| | - Joshua A Jacobs
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84112, USA. https://twitter.com/JoshJPharmD
| | - Catherine G Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Adam P Bress
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
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Saeed D, Carter G, Miller R, Darcy C, Miller K, Madden K, McKee H, Agnew J, Crawford P, Parsons C. Development and Delphi consensus validation of the Medication-Related Fall screening and scoring tool. Int J Clin Pharm 2024; 46:977-986. [PMID: 38753075 PMCID: PMC11286707 DOI: 10.1007/s11096-024-01734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/30/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Falls are a significant public health problem and constitute a major cause of injuries and mortality. Risk factors for falls are multifactorial and include medication use. AIM To develop and investigate the content validity of the Medication-Related fall (MRF) screening and scoring tool. METHOD The MRF tool was developed from clinical practice guidelines addressing medication-related problems, and additional medications identified by specialist pharmacists across a region of the United Kingdom (Northern Ireland). Medication classes were categorised according to their 'potential to cause falls' as: high-risk (three points), moderate-risk (two points) or low-risk (one point). The overall medication-related falls risk for the patient was determined by summing the scores for all medications. The MRF was validated using Delphi consensus methodology, whereby three iterative rounds of surveys were conducted using SurveyMonkey®. Twenty-two experts from 10 countries determined their agreement with the falls risk associated with each medication on a 5-point Likert scale. Only medications with at least 75% of respondents agreeing or strongly agreeing were retained in the next round. RESULTS Consensus was reached for 19 medications/medication classes to be included in the final version of the MRF tool; ten were classified as high-risk, eight as moderate-risk and one as low-risk. CONCLUSION The MRF tool is simple and has the potential to be integrated into medicines optimisation to reduce falls risk and negative fall-related outcomes. The score from the MRF tool can be used as a clinical parameter to assess the need for medication review and clinical interventions.
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Affiliation(s)
- Dima Saeed
- School of Pharmacy, Queen's University Belfast, Belfast, UK
- School of Pharmacy, Middle East University, Amman, Jordan
| | - Gillian Carter
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Ruth Miller
- Western Health and Social Care Trust, Londonderry, UK
| | - Carmel Darcy
- Western Health and Social Care Trust, Londonderry, UK
| | - Karen Miller
- South Eastern Health and Social Care Trust, Belfast, UK
| | - Kevin Madden
- South Eastern Health and Social Care Trust, Belfast, UK
| | - Hilary McKee
- Northern Health and Social Care Trust, Antrim, UK
| | - Jayne Agnew
- Southern Health and Social Care Trust, Craigavon, UK
| | | | - Carole Parsons
- School of Pharmacy, Queen's University Belfast, Belfast, UK.
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Machado-Duque ME, Camacho-Arteaga L, Sabaté M, Machado-Alba JE. Falls in older adults hospitalized in tertiary centers in Colombia. Clinical description and complications. ENFERMERIA CLINICA (ENGLISH EDITION) 2024; 34:302-311. [PMID: 38964715 DOI: 10.1016/j.enfcle.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community. The aim was to determine the characteristics of patients who suffered in-hospital falls and their complications. METHODS This was a cross-sectional study with patients older than 64 years of age, admitted between 2018 and 2020 to four clinics in Colombia who presented a fall during their stay. Clinical data, reasons for the fall, complications and use of drugs with a known risk for causing falls and with an anticholinergic load were reviewed. RESULTS A total of 249 patients were included. The mean age was 77.5 ± 7.4 years, and there was a predominance of males (63.9%). The patients were hospitalized mainly for community-acquired pneumonia (12.4%) and heart failure (10.4%). Falls occurred most frequently in hospitalization wards (77.1%) and emergency departments (20.9%). Falls were related to standing alone (34.4%) and on the way to the bathroom (28.9%), with 40.6% (n = 102) of falls resulting in trauma, especially to the head (27.7%); the incidence of fractures was low (3.2%). Ninety-two percent of patients had polypharmacy (≥5 drugs), 88.0% received psychotropic drugs, and 37.3% received drugs with an anticholinergic load ≥3 points. CONCLUSIONS Hospitalized adults over 65 years of age suffered falls, mainly in hospitalization wards and emergency departments, especially during the process of solitary ambulation. Most had received psychotropic drugs and medications with a high anticholinergic load. These results suggest that it is necessary to improve risk prevention strategies for falls in this population.
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Affiliation(s)
- Manuel E Machado-Duque
- Departamento de Farmacología, Terapéutica y Toxicología, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain; Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma SA, Pereira, Risaralda, Colombia; Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Lina Camacho-Arteaga
- Departamento de Farmacología, Terapéutica y Toxicología, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain; Departamento de Farmacología Clínica, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Grupo de Investigación en Farmacología Clínica, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Mónica Sabaté
- Departamento de Farmacología, Terapéutica y Toxicología, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain; Departamento de Farmacología Clínica, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Grupo de Investigación en Farmacología Clínica, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jorge E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma SA, Pereira, Risaralda, Colombia.
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Jödicke AM, Tan EH, Robinson DE, Delmestri A, Prieto-Alhambra D. Risk of adverse events following the initiation of antihypertensives in older people with complex health needs: a self-controlled case series in the United Kingdom. Age Ageing 2023; 52:afad177. [PMID: 37725973 PMCID: PMC10508980 DOI: 10.1093/ageing/afad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND We assessed the risk of adverse events-severe acute kidney injury (AKI), falls and fractures-associated with use of antihypertensives in older patients with complex health needs (CHN). SETTING UK primary care linked to inpatient and mortality records. METHODS The source population comprised patients aged >65, with ≥1 year of registration and unexposed to antihypertensives in the year before study start. We identified three cohorts of patients with CHN, namely, unplanned hospitalisations, frailty (electronic frailty index deficit count ≥3) and polypharmacy (prescription of ≥10 medicines). Patients in any of these cohorts were included in the CHN cohort. We conducted self-controlled case series for each cohort and outcome (AKI, falls, fractures). Incidence rate ratios (IRRs) were estimated by dividing event rates (i) during overall antihypertensive exposed patient-time over unexposed patient-time; and (ii) in the first 30 days after treatment initiation over unexposed patient-time. RESULTS Among 42,483 patients in the CHN cohort, 7,240, 5,164 and 450 individuals had falls, fractures or AKI, respectively. We observed an increased risk for AKI associated with exposure to antihypertensives across all cohorts (CHN: IRR 2.36 [95% CI: 1.68-3.31]). In the 30 days post-antihypertensive treatment initiation, a 35-50% increased risk for falls was found across all cohorts and increased fracture risk in the frailty cohort (IRR 1.38 [1.03-1.84]). No increased risk for falls/fractures was associated with continuation of antihypertensive treatment or overall use. CONCLUSION Treatment with antihypertensives in older patients was associated with increased risk of AKI and transiently elevated risk of falls in the 30 days after starting antihypertensive therapy.
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Affiliation(s)
- Annika M Jödicke
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, OX37LD, Oxford, UK
| | - Eng Hooi Tan
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, OX37LD, Oxford, UK
| | - Danielle E Robinson
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, OX37LD, Oxford, UK
| | - Antonella Delmestri
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, OX37LD, Oxford, UK
| | - Daniel Prieto-Alhambra
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, OX37LD, Oxford, UK
- Department of Medical Informatics, Erasmus Medical Center University, 40 3015 GD, Rotterdam, Netherlands
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van Poelgeest EP, Handoko ML, Muller M, van der Velde N. Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review. Eur Geriatr Med 2023; 14:659-674. [PMID: 36732414 PMCID: PMC10447274 DOI: 10.1007/s41999-023-00752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Both heart failure and its treatment with diuretics or SGLT2 inhibitors increase fall risk in older adults. Therefore, decisions to continue or deprescribe diuretics or SGLT2 inhibitors in older heart failure patients who have fallen are generally highly complex and challenging for clinicians. However, a comprehensive overview of information required for rationale and safe decision-making is lacking. The aim of this clinical review was to assist clinicians in safe (de)prescribing of these drug classes in older heart failure patients. METHODS We comprehensively searched and summarized published literature and international guidelines on the efficacy, fall-related safety issues, and deprescribing of the commonly prescribed diuretics and SGLT2 inhibitors in older adults. RESULTS Both diuretics and SGLT2 inhibitors potentially cause various fall-related adverse effects. Their fall-related side effect profiles partly overlap (e.g., tendency to cause hypotension), but there are also important differences; based on the currently available evidence of this relatively new drug class, SGLT2 inhibitors seem to have a favorable fall-related adverse effect profile compared to diuretics (e.g., low/absent tendency to cause hyperglycemia or electrolyte abnormalities, low risk of worsening chronic kidney disease). In addition, SGLT2 inhibitors have potential beneficial effects (e.g., disease-modifying effects in heart failure, renoprotective effects), whereas diuretic effects are merely symptomatic. CONCLUSION (De)prescribing diuretics and SGLT2 inhibitors in older heart failure patients who have fallen is often highly challenging, but this clinical review paper assists clinicians in individualized and patient-centered rational clinical decision-making: we provide a summary of available literature on efficacy and (subclass-specific) safety profiles of diuretics and SGLT2 inhibitors, and practical guidance on safe (de)prescribing of these drugs (e.g. a clinical decision tree for deprescribing diuretics in older adults who have fallen).
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Affiliation(s)
- Eveline P van Poelgeest
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Majon Muller
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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Welsh TJ, Mitchell A. Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:675-682. [PMID: 37436689 PMCID: PMC10447259 DOI: 10.1007/s41999-023-00813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications. METHODS Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing. RESULTS Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes. CONCLUSIONS Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.
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Affiliation(s)
- T J Welsh
- University of Bristol, Bristol, UK
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - A Mitchell
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Department of Life Sciences, University of Bath, Bath, UK.
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Liu E, Nahid M, Musse M, Chen L, Hilmer SN, Zullo A, Kwak MJ, Lachs M, Levitan EB, Safford MM, Goyal P. Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure. BMC Cardiovasc Disord 2023; 23:372. [PMID: 37495948 PMCID: PMC10373421 DOI: 10.1186/s12872-023-03401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden. METHODS We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors. RESULTS Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14). CONCLUSIONS FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.
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Affiliation(s)
- Esther Liu
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah N Hilmer
- The University of Sydney and Royal North Shore Hospital, Sydney, NSW, Australia
| | - Andrew Zullo
- Brown University School of Public Health, Providence, USA
| | | | - Mark Lachs
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | | | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA.
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Todd O, Johnson O, Wilkinson C, Hollinghurst J, Dondo TB, Yadegarfar ME, Sheppard JP, McManus RJ, Gale CP, Clegg A. Attainment of NICE blood pressure targets among older people with newly diagnosed hypertension: nationwide linked electronic health records cohort study. Age Ageing 2023; 52:7181252. [PMID: 37247403 DOI: 10.1093/ageing/afad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND it is not known if clinical practice reflects guideline recommendations for the management of hypertension in older people and whether guideline adherence varies according to overall health status. AIMS to describe the proportion of older people attaining National Institute for Health and Care Excellence (NICE) guideline blood pressure targets within 1 year of hypertension diagnosis and determine predictors of target attainment. METHODS a nationwide cohort study of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 years newly diagnosed with hypertension between 1st June 2011 and 1st June 2016. The primary outcome was attainment of NICE guideline blood pressure targets as measured by the latest blood pressure recording up to 1 year after diagnosis. Predictors of target attainment were investigated using logistic regression. RESULTS there were 26,392 patients (55% women, median age 71 [IQR 68-77] years) included, of which 13,939 (52.8%) attained a target blood pressure within a median follow-up of 9 months. Success in attaining target blood pressure was associated with a history of atrial fibrillation (OR 1.26, 95% CI 1.11, 1.43), heart failure (OR 1.25, 95% CI 1.06, 1.49) and myocardial infarction (OR 1.20, 95% CI 1.10, 1.32), all compared to no history of each, respectively. Care home residence, the severity of frailty, and increasing co-morbidity were not associated with target attainment following adjustment for confounder variables. CONCLUSIONS blood pressure remains insufficiently controlled 1 year after diagnosis in nearly half of older people with newly diagnosed hypertension, but target attainment appears unrelated to baseline frailty, multi-morbidity or care home residence.
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Affiliation(s)
- Oliver Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, England LS2 9LH, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford, England BD9 6RJ, UK
| | - Oliver Johnson
- School of Medicine, University of Leeds, Leeds, England, LS2 9LH, UK
| | - Chris Wilkinson
- Hull York Medical School, University of York, York, England YO10 5DD, UK
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, England TS4 3BY, UK
| | - Joe Hollinghurst
- Health Data Research UK (HDR-UK), University of Swansea, Swansea, Wales SA2 8PP, UK
| | - Tatendashe B Dondo
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England LS2 9LH, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, England LS2 9LH, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, England LS2 9LH, UK
| | - Mohammad E Yadegarfar
- School of Life Course & Population Sciences, King's College London, London, England WC2R 2LS, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England OX2 6GG, UK
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England LS2 9LH, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, England LS2 9LH, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, England LS2 9LH, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, England LS2 9LH, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford, England BD9 6RJ, UK
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Kouchaki L, Darvishpoor Kakhki A, Safavi Bayat Z, Khan HTA. Association between fear of falling and self-care behaviours of older people with hypertension. Nurs Open 2023; 10:3954-3961. [PMID: 36824048 PMCID: PMC10170935 DOI: 10.1002/nop2.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/01/2022] [Accepted: 02/04/2023] [Indexed: 02/25/2023] Open
Abstract
AIM This study investigated the association between fear of falling and self-care behaviours of older people with hypertension. DESIGN A cross-sectional study. METHODS This study was conducted in 2019 on 301 older people with hypertension above the age of 60 years in Tehran, Iran. Data were collected using a demographic questionnaire, the Persian Falls Efficacy Scale-International, and a hypertension-related self-care behaviour questionnaire. RESULTS Analyses revealed that gender, educational level and history of falling were significant factors associated with fear of falling; and marital status, educational level and income source were significant factors associated with self-care behaviours (p < 0.05). Partial correlations controlling for education revealed a significant positive correlation showing that high fear of falling is associated with worse health promotion self-care behaviours and significant inverse correlations with psycho-emotional, social and daily self-care behaviours (p < 0.05), meaning that high fear of falling is associated with better self-care for these dimensions. PATIENT OR PUBLIC CONTRIBUTION This study involved patients in order to evaluate the validity and reliability of the questionnaires. The study was conducted on older people with hypertension referred to hypertension clinics in hospitals.
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Affiliation(s)
- Leila Kouchaki
- Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Darvishpoor Kakhki
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Safavi Bayat
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hafiz T A Khan
- College of Nursing, Midwifery and Healthcare, University of West London, London, UK
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Hussain SM, Ernst ME, Barker AL, Margolis KL, Reid CM, Neumann JT, Tonkin AM, Phuong TLT, Beilin LJ, Pham T, Chowdhury EK, Cicuttini FM, Gilmartin-Thomas JFM, Carr PR, McNeil JJ. Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication. Hypertension 2022; 79:2051-2061. [PMID: 35722878 PMCID: PMC9378722 DOI: 10.1161/hypertensionaha.122.19356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported. METHODS Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls. RESULTS Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers. CONCLUSIONS Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.
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Affiliation(s)
- Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Victoria 3010 Australia
| | - Michael E. Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy; and, Department of Family Medicine, Carver College of Medicine. The University of Iowa, Iowa City, Iowa. USA
| | - Anna L Barker
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | | | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Johannes T Neumann
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Cardiology, University Heart & Vascular Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Thao Le Thi Phuong
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Lawrence J Beilin
- Medical School, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Thao Pham
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Enayet K Chowdhury
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Flavia M Cicuttini
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Julia FM Gilmartin-Thomas
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- College of Health and Biomedicine, and Institute for Health & Sport, Victoria University, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Prudence R Carr
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
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11
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Enes TB, Sanches C, Ayres LR, Rocha GM, Madureira LNGR, de Souza DA, Schneider C, Aquino JA, Baldoni AO. Factors associated with falls in frail older persons—a case control study in Brazil. AGEING INTERNATIONAL 2022. [DOI: 10.1007/s12126-022-09503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Velliou M, Sanidas E, Zografou A, Papadopoulos D, Dalianis N, Barbetseas J. Antihypertensive Drugs and Risk of Bone Fractures. Drugs Aging 2022; 39:551-557. [PMID: 35754069 DOI: 10.1007/s40266-022-00955-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/28/2022]
Abstract
Antihypertensive drugs are among the most documented regimens worldwide with an overall survival and cardioprotective benefit. However, there is evidence that they cause symptoms of orthostatic hypotension (i.e., dizziness and syncope) placing patients at risk for falls and fall-related injuries such as bone fractures. Moreover, it seems that they might impact bone metabolism and architecture impairing bone health. The aim of this review was to summarize the accumulative literature exploring any potential association between several antihypertensive medications including diuretics, renin-angiotensin-aldosterone system inhibitors, beta-blockers and calcium channel blockers and the risk of fractures.
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Affiliation(s)
- Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, Athens, Greece.
| | - Elias Sanidas
- Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Aliki Zografou
- Department of Internal Medicine, Sismanogleio General Hospital, Athens, Greece
| | | | | | - John Barbetseas
- Department of Cardiology, LAIKO General Hospital, Athens, Greece
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13
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Kraut R, Lundby C, Babenko O, Kamal A, Sadowski CA. Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100166. [PMID: 38559885 PMCID: PMC10978346 DOI: 10.1016/j.ahjo.2022.100166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 04/04/2024]
Abstract
Purpose of review The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.
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Affiliation(s)
- Roni Kraut
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Oksana Babenko
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Ahmad Kamal
- Faculty of Science, University of Alberta, Edmonton, Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
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14
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Abstract
INTRODUCTION The use of medications with anticholinergic (ACh) properties is associated with numerous adverse effects especially in older adults. Emerging evidence suggests the presence of long-term effects with ACh use. AREAS COVERED Our article presents an overview of ACh effects and falls in older individuals including examination of emerging evidence on ACh use and cumulative exposure on short-term and long-term falls risk. The databases CINAHL, MEDLINE, EMBASE, and Web of Science were searched for articles published from January 2002 to December 2021. EXPERT OPINION Anticholinergic side effects include muscle weakness, blurred vision, and mental confusion which are likely to lead to increased falls risk. Many commonly used medications such as beta-blockers, calcium-channel blockers, and antihistamines are now known to have mild ACh properties. With polypharmacy now considered unavoidable in older patients, the cumulative effects of the use of multiple drugs with mild ACh properties may also lead to increased falls risk. The relationship between ACh drugs and falls may also be irreversible as ACh effects may extend beyond the period of drug use, due to cognitive and physical deconditioning following the initial exposure to ACh drugs. Future long-term studies with accurate quantification of cumulative ACh exposure and measurement of actual falls outcomes are urgently required.
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Affiliation(s)
- Xiang Jiang Xu
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Selangor, Malaysia
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15
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Ho VS, Cenzer IS, Nguyen BT, Lee SJ. Time to benefit for stroke reduction after blood pressure treatment in older adults: A meta-analysis. J Am Geriatr Soc 2022; 70:1558-1568. [PMID: 35137952 PMCID: PMC9106841 DOI: 10.1111/jgs.17684] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/24/2021] [Accepted: 01/09/2022] [Indexed: 12/19/2022]
Abstract
Background Hypertension treatment in older adults can decrease mortality, cardiovascular events, including heart failure, cognitive impairment, and stroke risk, but may also lead to harms such as syncope and falls. Guidelines recommend targeting preventive interventions with immediate harms and delayed benefits to patients whose life expectancy exceeds the intervention's time to benefit (TTB). Our objective was to estimate a meta‐analyzed TTB for stroke prevention after initiation of more intensive hypertension treatment in adults aged ≥65 years. Methods Studies were identified from two Cochrane systematic reviews and a search of MEDLINE and Google Scholar for subsequent publications until August 31, 2021. We abstracted data from randomized controlled trials comparing standard (untreated, placebo, or less intensive treatment) to more intensive treatment groups in older adults (mean age ≥ 65 years). We fit Weibull survival curves and used a random‐effects model to estimate the pooled annual absolute risk reduction (ARR) between control and intervention groups. We applied Markov chain Monte Carlo methods to determine the time to ARR thresholds (0.002, 0.005, and 0.01) for a first stroke. Results Nine trials (n = 38,779) were identified. The mean age ranged from 66 to 84 years and study follow‐up times ranged from 2.0 to 5.8 years. We determined that 1.7 (95%CI: 1.0–2.9) years were required to prevent 1 stroke for 200 persons (ARR = 0.005) receiving more intensive hypertensive treatment. Heterogeneity was found across studies, with those focusing on tighter systolic blood pressure control (SBP < 150 mmHg) showing longer TTB. For example, in the SPRINT study (baseline SBP = 140 mmHg, achieved SBP = 121 mmHg), the TTB to avoid 1 stroke for 200 patients treated was 5.9 years (95%CI: 2.2–13.0). Conclusions More intensive hypertension treatment in 200 older adults prevents 1 stroke after 1.7 years. Given the heterogeneity across studies, the TTB estimates from individual studies may be more relevant for clinical decision‐making than our summary estimate. See related Editorial by Mark A. Supiano in this issue.
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Affiliation(s)
- Vanessa S Ho
- College of Medicine, California Northstate University, Elk Grove, California, USA.,Medical Student Training in Aging Research (MSTAR) Program, Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Irena S Cenzer
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Brian T Nguyen
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Northern California Institute for Research and Education, San Francisco, California, USA
| | - Sei J Lee
- Medical Student Training in Aging Research (MSTAR) Program, Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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16
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Smith H. Role of medicines management in preventing falls in older people. Nurs Older People 2022; 34:e1376. [PMID: 35080169 DOI: 10.7748/nop.2022.e1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/09/2022]
Abstract
Falls are common in older people and are a cause of preventable morbidity and mortality. As well as causing injury, falls can result in pain, distress, loss of confidence, loss of independence and increased mortality. Older people are more likely to visit an emergency department following a fall, therefore these incidents place a high burden on these patients and their carers, as well as on healthcare systems. Appropriate risk assessment accompanied by multifactorial falls prevention interventions can reduce the risk of falls. Assessments should include a medication review because various medicines, sometimes referred to as 'falls risk increasing drugs', can precipitate or contribute to falls. This article examines some of the medicines in this group that can contribute to falls, serious injuries and fractures in older people. It also discusses the importance of medicines management as part of falls risk assessment and prevention interventions.
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Affiliation(s)
- Heather Smith
- NHS Leeds Clinical Commissioning Group embedded in Leeds GP Confederation Clinical Pharmacy Team, Leeds, England
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17
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Hauge SC, Abrahamsen B, Gislason G, Olesen JB, Hommel K, Hansen D. Diabetes increases the risk of bone fractures in patients on kidney replacement therapy: A Danish national cohort study. Bone 2021; 153:116158. [PMID: 34461286 DOI: 10.1016/j.bone.2021.116158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients treated with dialysis or living with a kidney transplant (kidney replacement therapy, KRT) have an increased risk of bone fracture. Patients with diabetes also have an increased risk of fracture. The aim of this study was to investigate whether the presence of diabetes in patients on KRT aggravates the risk of fracture. METHODS Nationwide Danish registries were used in this retrospective cohort study. All prevalent adult patients on hemodialysis (HD) or peritoneal dialysis (PD) on 1st of January 2000 and all incident patients starting KRT (HD, PD, kidney transplanted (KTX)) until 31st of December 2011 were included in the KRT group. Adult persons not on KRT and without diabetes on 1st of January 2000 were used as a reference group. Patients were separated in groups with and without (+/-) diabetes. They were followed until first fracture, emigration, death, or end-of-study on 31st of December 2016. RESULTS A total of 4,074,085 not on KRT +/- diabetes and 9053 patients on KRT +/- diabetes were included. Comparing the different groups with diabetes to the corresponding group without diabetes, the unadjusted HR (95% CI) for any first fracture were 1.2 (1.0-1.3) in the HD population, 1.4 (1.1-1.7) in the PD population, and 1.7 (1.4-2.2) in the KTX population. Further adjustments for age, sex, prior fractures, comorbidity and medication did not change these results significantly. CONCLUSIONS Diabetes increases the risk of fracture in patients on KRT.
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Affiliation(s)
- Sabina Chaudhary Hauge
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
| | - Bo Abrahamsen
- Department of Medicine, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.; Institute of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3. Floor, 5000 Odense C, Copenhagen, Denmark; NDORMS, Botnar Centre, Oxford University, Windmill Road, Oxford, OX3 7LD, United Kingdom
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark; The Danish Heart Foundation, Vognmagergade 7, 3. Floor, 1120 Copenhagen K, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Kristine Hommel
- Department of Medicine, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
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18
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Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 304] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
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Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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19
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Goldstein DW, Hajduk AM, Song X, Tsang S, Geda M, McClurken JB, Tinetti ME, Krumholz HM, Chaudhry SI. Falls in older adults after hospitalization for acute myocardial infarction. J Am Geriatr Soc 2021; 69:3476-3485. [PMID: 34383963 DOI: 10.1111/jgs.17398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND After hospitalization for acute myocardial infarction (AMI), older adults may be at increased risk for falls due to deconditioning, new medications, and worsening health status. Our primary objective was to identify risk factors for falls after AMI hospitalization among adults over age 75. METHODS We used data from the Comprehensive Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective cohort study of 3041 adults age 75 and older hospitalized with AMI at 94 community and academic medical centers across the United States. In-person interviews and physical assessments, as well as medical record review, were performed to collect demographic, clinical, functional, and psychosocial data. Falls were self-reported in telephone interviews and medically serious falls (those associated with emergency department use or hospitalization) were determined by medical record adjudication. Backward selection was used to identify predictors of fall risk in logistic regression analysis. RESULTS A total of 554 (21.6%) participants reported a fall and 191 (6.4%) had a medically serious fall within 6 months of discharge. Factors independently associated with self-reported falls included impaired mobility, prior fall history, longer hospital stay, visual impairment, and weak grip. Factors independently associated with medically serious falls included older age, polypharmacy, impaired functional mobility, prior fall history, and living alone. CONCLUSIONS Among older patients hospitalized for AMI, falls are common in the 6 months following discharge and associated with demographic, functional, and clinical factors that are readily identifiable. Fall risk should be considered in post-AMI clinical decision-making and interventions to prevent falls should be evaluated.
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Affiliation(s)
- David W Goldstein
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexandra M Hajduk
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Xuemei Song
- University of Texas Health, San Antonio, Texas, USA
| | - Sui Tsang
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Mary Geda
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - James B McClurken
- Department of Cardiothoracic Surgery, Doylestown Health, Doylestown, Pennsylvania, USA
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Section of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States
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20
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Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis. BMJ 2021; 372:n189. [PMID: 33568342 PMCID: PMC7873715 DOI: 10.1136/bmj.n189] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between antihypertensive treatment and specific adverse events. DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. INFORMATION SOURCES Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. MAIN OUTCOME MEASURES The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2). RESULTS Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. CONCLUSIONS This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. REGISTRATION PROSPERO CRD42018116860.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ben Paxton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Emma Fox
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
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21
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Sale JEM, Frankel L, Bogoch E, Gignac M, Hawker G, Elliot-Gibson V, Jain R, Funnell L. Few fragility fracture patients perceive that their bone health is affected by their comorbidities and medications. Osteoporos Int 2020; 31:2047-2055. [PMID: 32504095 DOI: 10.1007/s00198-020-05409-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 04/01/2020] [Indexed: 12/15/2022]
Abstract
UNLABELLED We examined fragility fracture patients' perceptions of associations between bone health and other chronic conditions and medications. Awareness of the associations between bone health and these conditions and medications was low. Providers should increase patients' awareness of these associations in order to minimize the risk of future fracture. INTRODUCTION Among patients with a fragility fracture presenting with at least one other chronic health condition, we examined (1) perceptions of the association between bone health and their other health conditions, and (2) perceptions of the association between bone health and prescribed medications taken for other health conditions. METHODS We identified fragility fracture patients presenting to a Canadian urban fracture clinic with at least one self-reported chronic health condition (in addition to bone fragility). In-depth interviews, 60-90 min in duration, were conducted. Our qualitative methodology was informed by saliency analysis. RESULTS We interviewed 26 patients (21 females, 5 males) aged 45 to 84 years old. Participants were taking 1-13 medications each and presented with a variety of comorbidities (range 1-7). All participants described at least one condition or medication they were currently taking for which there existed evidence of a negative effect on bone health (increased risk of fracture, bone loss, falling). Two participants perceived a correct association between their other health conditions and compromised bone health, and four participants perceived a correct association between their medications and compromised bone health. CONCLUSION All patients reported a chronic health condition and/or were taking at least one medication that potentially compromised their bone health. Patient awareness of the association between bone health and other health conditions and prescribed medications was low. Health care providers should increase patients' awareness of the bone health significance of their chronic conditions and medications in order to minimize the risk of future fracture.
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Affiliation(s)
- J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
- Institute of Health Policy, Management & Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, Ontario, M5T 3M6, Canada.
| | - L Frankel
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - E Bogoch
- Department of Surgery, University of Toronto, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - M Gignac
- Institute for Work & Health, Suite 800 - 481 University Avenue, Toronto, Ontario, M5G 2E9, Canada
| | - G Hawker
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - V Elliot-Gibson
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - R Jain
- Osteoporosis Canada, Suite 201 - 250 Ferrand Drive, Toronto, Ontario, M3C 3G8, Canada
| | - L Funnell
- Osteoporosis Canada, Suite 201 - 250 Ferrand Drive, Toronto, Ontario, M3C 3G8, Canada
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22
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Caballero-Mora MA, Rodríguez Mañas L, Valdés-Aragonés M, García-Sánchez I, Alonso-Bouzon C, Castro Rodríguez M, Nuñez-Jimenez L, Esteban A, Rodriguez-Laso A. Factors associated with impairment in gait speed in older people with clinically normal gait. A cross-sectional study. Aging Clin Exp Res 2020; 32:1043-1048. [PMID: 30989508 DOI: 10.1007/s40520-019-01187-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Health professionals commonly use gait speed in the evaluation of functional status in older people. However, only a limited number of studies have assessed gait speed in the absence of disorders of gait, using confounding factors and exclusion criteria coming from studies conducted in younger people. Our study aims to analyse which factors are associated with gait speed in older people with normal clinical gait. METHODS An observational cross-sectional study was conducted in 119 community-dwelling residents without relevant comorbidities (Charlson index < 2), preserved function (Barthel > 85) and normal gait by visual exploration. Exclusion criteria included suffering from any illness that could modify the characteristics of gait, terminal status or the presence of an acute medical illness in the past 3 months. We used a stepwise linear regression of several variables (sociodemographic characteristics, cognition, body composition, drugs, falls, sarcopenia, frailty and physical activity) on 6-metre gait speed. RESULTS The mean age was 78 years (range 70-96 years) and 71.4% were women. Variables that remained associated with gait speed in the multivariate final model were age (B = - 0.020, p < 0.001); gender (B = - 0.184, p < 0.001); waist-to-height ratio (B = - 0.834, p = 0.002); number of falls (B = - 0.049, p = 0.003) and the number of Fried's frailty criteria (B = - 0.064, p = 0.019). CONCLUSION Falls, frailty and the waist-to-height ratio modify gait speed in older people with normal gait. Studies analysing the potential effect of several factors on gait speed should consider them as confounding factors.
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Affiliation(s)
- M A Caballero-Mora
- Servicio de Geriatría, Geriatric Department, Hospital Universitario de Getafe, Ctra de Toledo Km 12.5, 28905, Getafe, Spain.
- Fundación de Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain.
- CIBER de Fragilidad y Envejecimiento Saludable, Madrid, Spain.
| | - L Rodríguez Mañas
- Fundación de Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain
- CIBER de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - M Valdés-Aragonés
- Servicio de Geriatría, Geriatric Department, Hospital Universitario de Getafe, Ctra de Toledo Km 12.5, 28905, Getafe, Spain
- Fundación de Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain
| | - I García-Sánchez
- Fundación de Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain
| | - C Alonso-Bouzon
- Servicio de Geriatría, Geriatric Department, Hospital Universitario de Getafe, Ctra de Toledo Km 12.5, 28905, Getafe, Spain
| | - M Castro Rodríguez
- Servicio de Geriatría, Geriatric Department, Hospital Universitario de Getafe, Ctra de Toledo Km 12.5, 28905, Getafe, Spain
| | - L Nuñez-Jimenez
- Servicio de Geriatría, Geriatric Department, Hospital Universitario de Getafe, Ctra de Toledo Km 12.5, 28905, Getafe, Spain
| | - A Esteban
- CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - A Rodriguez-Laso
- Fundación de Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain.
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23
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Berry SD, Kiel DP, Colón-Emeric C. Antihypertensive Medication Use in Older Adults at Risk for Hip Fracture-Reply. JAMA 2019; 322:1609. [PMID: 31638673 DOI: 10.1001/jama.2019.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah D Berry
- Marcus Institute for Aging Research at Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Douglas P Kiel
- Marcus Institute for Aging Research at Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
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24
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Fernandes M, Olde Rikkert MGM. The new US and European guidelines in hypertension: A multi-dimensional analysis. Contemp Clin Trials 2019; 81:44-54. [PMID: 31002956 DOI: 10.1016/j.cct.2019.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/30/2019] [Accepted: 04/11/2019] [Indexed: 11/29/2022]
Abstract
The Systolic Blood Pressure Intervention Trial (SPRINT) compared the clinical outcomes between target systolic blood pressure (SBP) levels between 140 and 120 mmHg or lower. Both,the 2017 ACC/AHA and the 2018 ESC/ESH guidelines in hypertension are derived from the SPRINT trial and advise initiation and/or intensification of treatment at lower blood pressure thresholds. The ACC/AHA guidance supersedes the 2014 Eight Joint National Committee guideline (JNC-8) which advised initiation of treatment when the BP was 140/90 mmHg or higher; in adults 60 years or over, the target was 150/90 mmHg. Compared to JNC-8, the new guidelines lower the SBP target by 10 mmHg in patients under age of 60 years, and by 20 mmHg in the elderly. We performed a qualitative multi-dimensional analysis in order to answer two key questions: will the new guidelines deliver the stated benefits? and, will translation to the clinic be simple, risk-free, and affordable? A major investment by national healthcare administrations will be necessary for the initiation and support of this program but this decision can only be justified by a valid expectation of clinical benefit. At this time, a definitive answer is not available and a "wait and see" attitude appears appropriate and reasonable. In the interim, efforts are best directed to the immediate problem of untreated hypertension worldwide.
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25
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Hamza SA, Adly NN, Abdelrahman EE, Fouad IM. The relation between falls and medication use among elderly in assisted living facilities. Pharmacoepidemiol Drug Saf 2019; 28:849-856. [PMID: 30920085 DOI: 10.1002/pds.4775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/29/2018] [Accepted: 02/28/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Many elderly are concerned about falling transfer to assisted living facilities (ALF). Previous literatures studied the medication use and falls in the community, hospitals, or nursing homes, with scanty data about ALF. Therefore, the aim of the current case-control study was to assess the relation between medication use and falls among elderly in ALF. METHODS A matched case-control study was conducted. The study was conducted in ALF in Cairo, Egypt. The study participants were 188 individuals; they were subdivided into two groups: fallers and nonfallers; timed up and go test (TUGT) was performed by all subjects. Medication data were collected according to the fall risk-increasing drugs list and the list of drugs that cause or worsen orthostatism. Other fall risk factors, as suggested by American Geriatric Society, were assessed. RESULTS The use of vasodilators, diuretics, alpha blockers, opioids, antipsychotics, and sedative hypnotics were more common in fallers than in nonfallers (P < 0.001, P = 0.03, P < 0.001, P = 0.013, P < 0.001, and P < 0.001, respectively). Vasodilators, alpha blockers, and antipsychotics were significant predictors of falls even after adjustment for the possible confounding factors. Vasodilators, alpha blockers, opioids, sedative hypnotics, and recent dose changes in oral hypoglycemics were significant predictors of higher TUGT after adjustment for the possible confounding factors. CONCLUSION The current study supported the risk of psychotropic and cardiovascular medications, with especial emphasis on vasodilators, alpha blockers, and antipsychotics, with raising concern about opioids, sedative hypnotics, and recent dose change in oral hypoglycemics.
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Affiliation(s)
- Sarah Ahmed Hamza
- Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nermien Naim Adly
- Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ekramy Essa Abdelrahman
- Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ibrahim Mohamed Fouad
- Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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26
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Kahlaee HR, Latt MD, Schneider CR. Comment on: A Systematic Review and Meta-Analyses of the Association Between Anti-hypertensive Classes and the Risk of Falls Among Older Adults. Drugs Aging 2019; 36:93-94. [DOI: 10.1007/s40266-018-0607-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Lim KK, Ang HT, Kwan YH, Tan CS, Ostbye T, Low LL. Authors' Reply to Kahlaee et al: "A Systematic Review and Meta-Analyses of the Association Between Anti-hypertensive Classes and the Risk of Falls Among Older Adults". Drugs Aging 2018; 36:95-101. [PMID: 30421390 DOI: 10.1007/s40266-018-0608-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ka Keat Lim
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Republic of Singapore
| | - Hui Ting Ang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Republic of Singapore
| | - Yu Heng Kwan
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Republic of Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Tahir Foundation Building, 12 Science Drive 2, #10-01, Singapore, 117549, Republic of Singapore
| | - Truls Ostbye
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Republic of Singapore
| | - Lian Leng Low
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Republic of Singapore. .,Department of Family Medicine and Continuing Care, Singapore General Hospital, 20 College Road, Singapore, 169856, Republic of Singapore.
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28
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Juraschek SP, Appel LJ, Miller ER, Mukamal KJ, Lipsitz LA. Hypertension Treatment Effects on Orthostatic Hypotension and Its Relationship With Cardiovascular Disease. Hypertension 2018; 72:986-993. [PMID: 30354704 PMCID: PMC6214359 DOI: 10.1161/hypertensionaha.118.11337] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although orthostatic hypotension (OH) is often considered a contraindication to blood pressure (BP) treatment, evidence is lacking. We examined the effect of BP goal or initial medication choice on OH in AASK (African American Study of Kidney Disease and Hypertension), a 2×3 factorial trial. Blacks with chronic kidney disease attributed to hypertension were randomly assigned 1 of 2 BP goals: intensive (mean arterial pressure, ≤92 mm Hg) or standard (mean arterial pressure, 102-107 mm Hg) and 1 of 3 initial medications (ramipril, metoprolol, and amlodipine). Postural changes in systolic BP, diastolic BP, or heart rate (HR) were determined after 2 minutes and 45 seconds of standing. OH was assessed each visit and defined using the consensus definition (drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg). Median follow-up was 4 years. Outcomes were congestive heart failure, stroke, nonfatal cardiovascular disease (CVD), fatal CVD, any CVD (composite of preceding events), and all-cause mortality. There were 1094 participants (mean age, 54.5±10.7 years; 38.8% female; OH was assessed at 52 864 visits). Mean seated systolic BP, diastolic BP, and HR were 150.3±23.9 mm Hg, 95.5±14.2 mm Hg, and 72.0±12.6 bpm, respectively. A more intensive BP goal did not alter the distributions of standing BP and was not associated with OH, but metoprolol was associated with systolic OH compared with ramipril (odds ratio, 1.68; 95% CI, 1.15-2.46) and amlodipine (odds ratio, 1.94; 95% CI, 1.09-3.44). Although consensus OH was associated with stroke (HR, 5.01; 95% CI, 1.80-13.92), nonfatal CVD (HR, 2.28; 95% CI, 1.21-4.30), and any CVD event (HR, 2.12; 95% CI, 1.12-3.98), neither BP goal or medication altered this risk. Concerns about causing OH or its CVD consequences should not deter a lower BP goal among adults with chronic kidney disease attributed to hypertension.
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Affiliation(s)
- Stephen P Juraschek
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.P.J., K.J.M., L.A.L.)
- The Johns Hopkins University School of Medicine, Department of Medicine, Division of General Internal Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD (S.P.J., L.J.A., E.R.M.)
| | - Lawrence J Appel
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.P.J., K.J.M., L.A.L.)
- The Johns Hopkins University School of Medicine, Department of Medicine, Division of General Internal Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD (S.P.J., L.J.A., E.R.M.)
| | - Edgar R Miller
- The Johns Hopkins University School of Medicine, Department of Medicine, Division of General Internal Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD (S.P.J., L.J.A., E.R.M.)
| | - Kenneth J Mukamal
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.P.J., K.J.M., L.A.L.)
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29
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Cai A, Calhoun DA. Antihypertensive Medications and Falls in the Elderly. Am J Hypertens 2018; 31:281-283. [PMID: 29186306 DOI: 10.1093/ajh/hpx203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anping Cai
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - David A Calhoun
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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