Orthostatic hypotension, cognition and structural brain imaging in hemodynamically impaired patients

BACKGROUND

Orthostatic hypotension (OH) is associated with an increased risk of dementia, potentially attributable to cerebral hypoperfusion. We investigated which patterns and characteristics of OH are related to cognition or to potentially underlying structural brain injury in hemodynamically impaired patients and healthy reference participants.

METHODS

Participants with carotid occlusive disease or heart failure, and reference participants from the Heart-Brain Connection Study underwent OH measurements, neuropsychological assessment and brain MRI. We analyzed the association between OH, global cognitive functioning, white matter hyperintensity (WMH) volume and brain parenchymal fraction with linear regression. We stratified by participant group, severity and duration of OH, chronotropic incompetence and presence of orthostatic symptoms.

RESULTS

Of 337 participants (mean age 67.3 ± 8.8 years, 118 (35.0%) women), 113 (33.5%) had OH. Overall, presence of OH was not associated with cognitive functioning (β: -0.12 [-0.24-0.00]), but we did observe worse cognitive functioning in those with severe OH (≥ 30/15 mmHg; β: -0.18 [-0.34 to -0.02]) and clinically manifest OH (β: -0.30 [-0.52 to -0.08]). These associations did not differ significantly by OH duration or chronotropic incompetence, and were similar between patient groups and reference participants. Similarly, both severe OH and clinically manifest OH were associated with a lower brain parenchymal fraction, and severe OH also with a somewhat higher WMH volume.

CONCLUSIONS

Severe OH and clinically manifest OH are associated with worse cognitive functioning. This supports the notion that specific patterns and characteristics of OH determine its impact on brain health.

Hypotension with neurovascular changes and cognitive dysfunction: An epidemiological, pathobiological, and treatment review

ABSTRACT

Hypotension is a leading cause of age-related cognitive impairment. The available literature evidences that vascular factors are associated with dementia and that hypotension alters cerebral perfusion flow and can aggravate the neurodegeneration of Alzheimer's disease (AD). Despite the discovery of biomarkers and the recent progress made in neurovascular biology, epidemiology, and brain imaging, some key issues remain largely unresolved: the potential mechanisms underlying the neural deterioration observed in AD, the effect of cerebrovascular alterations on cognitive deficits, and the positive effects of hypotension treatment on cognition. Therefore, further well-designed studies are needed to unravel the potential association between hypotension and cognitive dysfunction and reveal the potential benefits of hypotension treatment for AD patients. Here, we review the current epidemiological, pathobiological, and treatment-related literature on neurovascular changes and hypotension-related cognitive dysfunction and highlight the unsettled but imminent issues that warrant future research endeavors.

Slower speed of blood pressure recovery after standing is associated with accelerated brain aging: Evidence from The Irish Longitudinal Study on Ageing (TILDA)

Background

Impaired recovery of blood pressure (BP) in response to standing up is a prevalent condition in older individuals. We evaluated the relationship between the early recovery of hemodynamic responses to standing and brain health in adults over 50.

Methods

Participants from The Irish Longitudinal Study on Ageing (TILDA) (n=411; age 67.6 ± 7.3 years; 53.4 % women) performed an active stand challenge while blood pressure and heart rate were continuously monitored. The recovery of these parameters was determined as the slope of the BP and HR response, following the initial drop/rise after standing. We have previously reported a novel and validated measure of brain ageing using MRI data, which measures the difference between biological brain age and chronological age, providing a brain-predicted age difference (brainPAD) score.

Results

Slower recovery of systolic and diastolic BP was found to be significantly associated with higher brainPAD scores (i.e., biologically older brains), where a one-year increase in brainPAD was associated with a decrease of 0.02 mmHg/s and 0.01 mmHg/s in systolic and diastolic BP recovery, respectively, after standing. Heart rate (HR) recovery was not significantly associated with brainPAD score.

Conclusion

These results demonstrate that slower systolic and diastolic BP recovery in the early phase after standing is associated with accelerated brain aging in older individuals. This suggests that the BP response to standing, measured using beat-to-beat monitoring, has the potential to be used as a marker of accelerated brain aging, relying on a simple procedure and devices that are easily accessible.

Impact of Cardiac Autonomic Dysfunction on Cognitive Event-Related Potential in Type 2 Diabetes Mellitus Patients: A Cross-Sectional Study

Introduction

Type 2 diabetes mellitus (T2DM) is a chronic metabolic condition that is responsible for various long-term complications. Cognitive impairment is one of the most common complications, but the underlying mechanisms are still undetermined. The autonomic imbalance is a major cause for CVS morbidity in T2DM which could also potentially affect cognition. But there is sparse data available in the literature to prove the association between autonomic dysfunction and cognitive impairment.

Methodology

We recruited 40 T2DM patients and 40 healthy controls. The assessment of cognitive functions was done by cognitive P300 event-related potential (ERP) and MoCA. Heart rate variability (HRV) was done to assess autonomic function.

Results

The P300 ERP latency in Fz, Cz and Pz sites was significantly prolonged in T2DM patients (P < 0.001). We found moderate correlation is present between P300 latency and total power (r = -0.466, P < 0.01) and LFnu (r = -0.423, P < 0.01) in T2DM patients. The total power and HbA1C show independent association with P300 latency after adjustment for confounding factors like age and duration of diabetes (P < 0.05).

Conclusion

As the incidence of Alzheimer's disease is rising among T2DM patients increasing their dependency, making necessary lifestyle measures at earliest to improve autonomic balance may prevent or delay the onset of cognitive decline and alleviate its consequences and improve the quality of life in T2DM patients.

Autonomic nervous system and postural control regulation during orthostatic test as putative markers of physical resilience among community-dwelling older adults

INTRODUCTION

We examined whether autonomic nervous system (ANS) and postural control regulation during orthostatic test reflect physical resilience by studying their associations with maximal walking speed and mortality.

METHODS

The participants were community-dwelling Finnish men (n = 303) and women (n = 386) aged 75, 80, and 85 years at baseline. Systolic and diastolic blood pressure (BP), heart rate, heart rate variability (HRV), respiratory rate, and postural sway were obtained using a digital sphygmomanometer, a single-channel ECG, and thigh- and chest-worn accelerometers. Linear and Cox regression models were used to estimate the associations of the physiological indices with maximal 10-m walking speed and 5-year mortality separately for sexes.

RESULTS

Better maintenance of BP under orthostatic stress was associated with faster walking speed in women and lower mortality hazard in men. Greater HRV in terms of low frequency power and lower respiration rate in supine position and smaller orthostatic changes in these were associated with faster walking speed especially in women. Less postural sway after standing up was associated with faster walking speed in women (-0.057, SE 0.022, p = 0.011) and more postural sway with increased mortality hazard in men (HR 1.71, 95 % CI 1.20-2.43) even after controlling for BP responses.

CONCLUSIONS

In addition to ANS regulation at rest and under stress, adaptation of postural control system to orthostasis may be used in quantifying older adults' physical resilience. Wearable sensors capturing stimulus-response patterns and natural fluctuations of body functions may provide opportunities to monitor and incorporate different subsystems' resilience also in free-living conditions.

At-Home Blood Pressure Measurements Provide Better Assessments of Orthostatic Hypotension in Parkinson's Disease

Orthostatic hypotension (OH) is common in Parkinson's Disease (PD). It is intermittent, exacerbated by stressors including meals, medications, and dehydration, and frequently is unrecognized. Although intermittent, assessment is usually by a single "in clinic" BP measurement. This study examines whether 10 home measurements are more sensitive in detecting OH than a single "in clinic" measurement. Participants (44 people with PD and 16 controls) were instructed to measure lying and standing BP at home. BP was measured on five consecutive days upon waking and before bedtime. Symptoms were also assessed using the Movement Disorder Society United Parkinson's Disease Rating Scale and the Non-Motor Questionnaire. While a postural drop in systolic BP (≥20 mmHg) was recorded "in clinic" in thirteen of the forty-four PD participants, a postural drop was found in at least one of the ten home measurements in twenty-eight of the forty-four participants. Morning hypertension and variability in lying systolic BP was more common in these subjects than in those without a postural drop or the controls. A greater number of measurements of lying and standing BP are more likely to reveal orthostatic hypotension, variation in systolic BP, and hypertension than a single office measurement in people with PD.

A Review of Heart Rate and Blood Pressure Responses to Active Standing in Healthy Adults

OBJECTIVES

This review outlines the normal heart rate and blood pressure response to active standing, the physiological mechanisms governing these, and the effect of ageing on the responses.

METHODS

A literature search was conducted to identify articles investigating the normal heart rate and/or blood pressure response to standing.

RESULTS

Heart rate when standing increases and then decreases and recovers to baseline. Blood pressure responses are inverse. Skeletal muscle contraction and the baroreceptor reflex drive this. With ageing, heart rate response attenuates and the initial blood pressure response increases.

DISCUSSION

Normal heart rate and blood pressure responses are attributed to the baroreceptor reflex and skeletal muscle contraction. Decreased muscle strength and baroreceptor sensitivity are associated with ageing, suggesting a possible benefit in improving skeletal muscle strength to maintain an efficient response. Understanding these responses and their variation with ageing is clinically relevant and may be beneficial in improving rehabilitation outcomes.

Cognitive profile in idiopathic autonomic failure: relation with white matter hyperintensities and neurofilament levels

OBJECTIVE

To disclose the nature of cognitive deficits in a cohort of patients with idiopathic autonomic failure (IAF) by exploring the relation among cognitive functions, cardiovascular autonomic failure (AF) and clinical progression to another α-synucleinopathy (phenoconversion).

METHODS

We retrospectively identified all patients with a clinical diagnosis of IAF who underwent a comprehensive neuropsychological evaluation, clinical examination and cardiovascular autonomic tests from the IAF-BO cohort. Brain magnetic resonance imaging (MRI) studies and cerebrospinal fluid (CSF) analysis, including neurofilament light chain (NfL), Alzheimer disease core biomarkers, and α-synuclein seeding activity were further evaluated when available. Correlations among cognitive functions, clinical features, cardiovascular AF, cerebral white matter hyperintensities (WMH) load, and CSF biomarkers were estimated using Spearman correlation coefficient.

RESULTS

Thirteen out of 30 (43%) patients with IAF displayed cognitive deficits (CI) mainly concerning executive functioning. Seven out of 30 (23%) met the criteria for mild cognitive impairment (MCI). The diagnosis of CI and MCI was not associated with phenoconversion or autonomic function parameters, including duration and severity of neurogenic orthostatic hypotension, presence and severity of supine hypertension, and nocturnal dipper profile. Twenty patients underwent a brain MRI and CSF analysis. MCI was related to WMH load (r = 0.549) and NfL levels (r = 0.656), while autonomic function parameters were not associated with either WMH or NfL levels.

INTERPRETATION

Cardiovascular AF and phenoconversion, underlying the spreading of neurodegeneration to the central nervous system, were not independent drivers of cognitive dysfunction in IAF. We identified WMH load and NfL levels as potential biomarkers of the neural network disruption associated with cognitive impairment in patients with IAF.

Association between orthostatic blood pressure dysregulation and geriatric syndromes: a cross-sectional study

Background

Orthostatic blood pressure dysregulation, including orthostatic hypotension (OH) and orthostatic hypertension (OHT), is common in the elderly. The association between OH and, to a lesser extent, OHT with geriatric syndromes is controversial and little investigated.

Our objective was to assess the association between orthostatic blood pressure dysregulation and geriatric syndromes in an ambulatory outpatient population.

Methods

This observational study included all outpatients for whom a one-visit comprehensive geriatric assessment was performed during a year. OH was defined as a decrease of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) after 1 or 3 min of standing. OHT was defined as an increase of more than 20 mmHg in SBP after 1 or 3 min of standing. Comorbidities, drugs regimen, a history of previous falls, nutritional, frailty, functional and cognitive status were compared between patients with OHT or OH and controls (NOR).

Results

Five hundred thirty patients (mean age: 82.9 ± 5.1 years) were included. 19.6% had an OH and 22.3% an OHT. OHT patients were more frequently female, had more diabetes and a lower resting SBP than patients with NOR. OH patients had a higher resting SBP than NOR. After adjusting for age, sex, resting SBP and diabetes, OHT was associated with a low walking speed (OR = 1.332[1.009–1.758]; p = 0.043) and severe cognitive impairment at MMSe score (OR = 1.629[1.070–1.956]; p = 0.016) compared to NOR. Conversely, OH was associated with a lower grip strength (p = 0.016) than NOR.

Conclusion

OHT and OH are common in elderly but associated with different geriatric phenotypes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02844-8.

Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing

[Figure: see text].

Elderly Patient with Hypertension in General Practice: Clinical Features and Antihypertensive Therapy

The prevalence of arterial hypertension (AH) increases with age: among people over 60 years old this index is more than 2 times higher in the general population, 2/3 of people over 65 years old suffer from hypertension. Among patients 65–89 years old with hypertension, 2/3 patients have isolated systolic hypertension (ISAG). Features of hypertension in the elderly patients are: lability of blood pressure (BP), increasing frequency of pseudohypertension, high frequency of «white coat hypertension», decreased sensitivity of pressor factors for antihypertensive drugs, high frequency of resistant to treatment of hypertension. The new recommendations of the European Society of Cardiology for the diagnosis and treatment of hypertension emphasize 2 groups of elderly patients: 65–79 years old and ≥80 years old, which described the epidemiological features, the prevalence of risk factors for cardiovascular events, blood pressure levels for antihypertensive therapy and target blood pressure, and the recommended principles of drug therapy that are different from young and middle-aged patients. For most patients, fixed combinations are indicated as starting AGT, but monotherapy is recommended for the treatment of hypertension in very elderly patients (over 80 years old) and elderly patients over 65 years old with senile asthenia. The decreasing of blood pressure should be gradual, taking into consideration the increased risk of orthostatic reactions at this age. European and American experts recommend os first-line drugs low doses of thiazide diuretics and calcium channel antagonists (mainly dihydropyridine), which are especially indicated in isolated systolic arterial hypertension to effectively reduce the frequency of cardiovascular complications in the treatment of elderly patients with hypertension.

Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view

Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls. This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2-3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging. It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.

Orthostatic Blood Pressure Recovery Is Associated With the Rate of Cognitive Decline and Mortality in Clinical Alzheimer's Disease

Background

Impaired recovery of blood pressure (BP) after standing has been shown to be related to cognitive function and mortality in people without dementia, but its role in people with Alzheimer’s disease (AD) is unknown. The aim of this study was to investigate the association of the orthostatic BP response with cognitive decline and mortality in AD.

Methods

In this post hoc analysis of a randomized controlled trial (Nilvad), we measured the beat-to-beat response of BP upon active standing in mild-to-moderate AD. This included the initial drop (nadir within 40 seconds) and recovery after 1 minute, both expressed relative to resting values. We examined the relationship between a small or large initial drop (median split) and unimpaired (≥100%) or impaired recovery (<100%) with 1.5-year change in Alzheimer’s Disease Assessment—cognitive subscale (ADAS-cog) scores and all-cause mortality.

Results

We included 55 participants (age 73.1 ± 6.2 years). Impaired BP recovery was associated with higher increases in ADAS-cog scores (systolic: β [95% confidence interval] = 5.6 [0.4–10.8], p = .035; diastolic: 7.6 [2.3–13.0], p = .006). During a median follow-up time of 49 months, 20 participants died. Impaired BP recovery was associated with increased mortality (systolic: HR [95% confidence interval] = 2.9 [1.1–7.8], p = .039; diastolic: HR [95% confidence interval] = 5.5 [1.9–16.1], p = .002). The initial BP drop was not associated with any outcome. Results were adjusted for age, sex, and intervention group.

Conclusions

Failure to fully recover BP after 1 minute of standing is associated with cognitive decline and mortality in AD. As such, BP recovery can be regarded as an easily obtained marker of progression rate of AD.

Clinical Markers May Identify Patients at Risk for Early Parkinson's Disease Dementia: A Prospective Study

BACKGROUND

The study aims at identifying features predictive of early onset of dementia in Parkinson's disease (PD).

METHODS

103 non-demented PD patients were evaluated on various scales at baseline and 89 patients at 3-year follow-up.

RESULTS

By the end of the study 43.8% of patients developed dementia. The development of dementia was linked to the baseline Mini Mental State Examination score (Pearson coefficient r = .404, p = 0.013), the presence of autonomic dysfunctions (r = -.621, p < 0.001) and insomnia (r = -.526, p = 0.001). A binary logistic regression analysis showed that the development of dementia was correlated strongly with the presence of autonomic dysfunctions (95% CI 2.60 to 52.83, p < 0.001), and insomnia (95% CI 0.60 to 0.95, p = 0.017).

CONCLUSION

Patients with signs of autonomic dysfunction and insomnia are at higher risk for developing dementia and deserve closer monitoring of cognitive symptoms.

Routine assessment of cognitive function in older patients with hypertension seen by primary care physicians: why and how-a decision-making support from the working group on 'hypertension and the brain' of the European Society of Hypertension and from the European Geriatric Medicine Society

: The guidelines on hypertension recently published by the European Societies of Hypertension and Cardiology, have acknowledged cognitive function (and its decline) as a hypertension-mediated organ damage. In fact, brain damage can be the only hypertension-mediated organ damage in more than 30% of hypertensive patients, evolving undetected for several years if not appropriately screened; as long as undetected it cannot provide either corrective measures, nor adequate risk stratification of the hypertensive patient.The medical community dealing with older hypertensive patients should have a simple and pragmatic approach to early identify and precisely treat these patients. Both hypertension and cognitive decline are undeniably growing pandemics in developed or epidemiologically transitioning societies. Furthermore, there is a clear-cut connection between exposure to the increased blood pressure and development of cognitive decline.Therefore, a group of experts in the field from the European Society of Hypertension and from the European Geriatric Medicine Society gathered together to answer practical clinical questions that often face the physician when dealing with their hypertensive patients in a routine clinical practice. They elaborated a decision-making approach to help standardize such clinical evaluation.

Is Baseline Orthostatic Hypotension Associated With a Decline in Global Cognitive Performance at 4-Year Follow-Up? Data From TILDA (The Irish Longitudinal Study on Ageing)

Background It is postulated that orthostatic hypotension ( OH ), a reduction in blood pressure (≥20/10 mm Hg) within 3 minutes of standing, may increase cognitive decline because of cerebral hypoperfusion. This study assesses the impact of OH on global cognition at 4-year follow-up, and the impact of age and hypertension on this association. Methods and Results Data from waves 1 and 3 of TILDA (The Irish Longitudinal Study on Ageing) were used. Baseline blood pressure response to active stand was assessed using beat-to-beat blood pressure monitoring. Two measures of OH were used-at 40 seconds ( OH 40) and 110 seconds ( OH 110). Global cognition was measured using the Montreal Cognitive Assessment. Mixed-effects Poisson regression assessed whether baseline OH was associated with a decline in global cognition at 4-year follow-up. The analysis was repeated, stratifying by age (age 50-64 years and age ≥65 years), and including an interaction between OH and hypertension. Baseline OH 110 was associated with an increased error rate in Montreal Cognitive Assessment at follow-up (incident rate ratio 1.17, P=0.028). On stratification by age, the association persists in ages 50 to 64 years (incident rate ratio 1.25, P=0.048), but not ages ≥65 years. Including an interaction with hypertension found those with co-existent OH 110 and hypertension (incident rate ratio 1.27, P=0.011), or OH 40 and hypertension (incident rate ratio 1.18, P=0.017), showed an increased error rate; however, those with isolated OH 110, OH 40, or isolated hypertension did not. Conclusions OH is associated with a decline in global cognition at 4-year follow-up, and this association is dependent on age and co-existent hypertension.

A practical guide to active stand testing and analysis using continuous beat-to-beat non-invasive blood pressure monitoring

PURPOSE

The average adult stands approximately 50-60 times per day. Cardiovascular responses evoked during the first 3 min of active standing provide a simple means to clinically assess short-term neural and cardiovascular function across the lifespan. Clinically, this response is used to identify the haemodynamic correlates of patient symptoms and attributable causes of (pre-)syncope, and to detect autonomic dysfunction, variants of orthostatic hypotension, postural orthostatic tachycardia syndrome and orthostatic hypertension.

METHODS

This paper provides a set of experience/expertise-based recommendations detailing current state-of-the-art measurement and analysis approaches for the active stand test, focusing on beat-to-beat BP technologies. This information is targeted at those interested in performing and interpreting the active stand test to current international standards.

RESULTS

This paper presents a practical step-by-step guide on (1) how to perform active stand measurements using beat-to-beat continuous blood pressure measurement technologies, (2) how to conduct an analysis of the active stand response and (3) how to identify the spectrum of abnormal blood pressure and heart rate responses which are of clinical interest.

CONCLUSION

Impairments in neurocardiovascular control are an attributable cause of falls and syncope across the lifespan. The simple active stand test provides the clinician with a powerful tool for assessing individuals at risk of such common disorders. However, its simplicity belies the complexity of its interpretation. Care must therefore be taken in administering and interpreting the test in order to maximise its clinical benefit and minimise its misinterpretation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Orthostatic hypotension and dementia incidence: links and implications

Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.

Detecting Risk Of Postural hypotension (DROP): derivation and validation of a prediction score for primary care

OBJECTIVES

Falls are a common problem in older people. Postural hypotension contributes to falls but is often asymptomatic. In the absence of symptoms, postural hypotension is only infrequently checked for in clinical practice. We undertook this study to derive, validate and explore the prospective associations of a prediction tool to identify people likely to have unrecognised postural hypotension.

DESIGN AND SETTING

Cross-sectional and prospective multivariable cohort analysis.

PARTICIPANTS

1317 participants of the Invecchiare in Chianti study, a population-based cohort representative of the older Italian population.

PRIMARY OUTCOME MEASURES

Predictive value of score to suggest presence of postural hypotension.

METHODS

Subjects were randomised 1:1 to derivation or validation cohorts. Within the derivation cohort, univariable associations for candidate predictors of postural hypotension were tested. Variables with p<0.1 entered multivariable linear regression models. Factors retaining multivariable significance were incorporated into unweighted and weighted Detecting Risk Of Postural hypotension (DROP) scores. These scores were tested in the validation cohort against prediction of postural hypotension, cognitive decline and mortality over 9 years of follow-up.

RESULTS

Postural hypotension was present in 203 (15.4%) of participants. Factors predicting postural hypotension were: digoxin use, Parkinson's disease, hypertension, stroke or cardiovascular disease and an interarm systolic blood pressure difference. Area under the curve was consistent at 0.65 for all models, with significant ORs of 1.8 to 2.4 per unit increase in score for predicting postural hypotension. For a DROP score ≥1, five cases need to be tested to identify one with postural hypotension.Increasing DROP scores predicted mortality (OR 1.8 to 2.8 per unit rise) and increasing rates of decline of Mini Mental State Examination score (analysis of variance p<0.001) over 9 years of follow-up.

CONCLUSIONS

The DROP score provides a simple method to identify people likely to have postural hypotension and increased risks to health who require further evaluation.

Cognitive Status, Gray Matter Atrophy, and Lower Orthostatic Blood Pressure in Older Adults

BACKGROUND

Associations between orthostatic blood pressure and cognitive status (CS) have been described with conflicting results.

OBJECTIVE

We hypothesize that long-term exposure to lower orthostatic blood pressure is related to having worse CS later in life and that atrophy of regions involved in central regulation of autonomic function mediate these associations.

METHODS

Three-to-four measures of orthostatic blood pressure were obtained from 1997-2003 in a longitudinal cohort of aging, and average systolic orthostatic blood pressure response (ASOBPR) was computed as % change in systolic blood pressure from sit-to-stand measured at one minute post stand. CS was determined in 2010-2012 by clinician-adjudication (n = 240; age = 87.1±2.6; 59% women; 37% black) with a subsample also undergoing concurrent structural neuroimaging (n = 129). Gray matter volume of regions related to autonomic function was measured. Multinomial regression was used to compare ASOBPR in those who were cognitively intact versus those with a diagnosis of mild cognitive impairment or dementia, controlling for demographics, trajectories of seated blood pressure, incident cardiovascular risk/events and medications measured from 1997 to 2012. Models were repeated in the subsample with neuroimaging, before and after adjustment for regional gray matter volume.

RESULTS

There was an inverse association between ASOBPR and probability of dementia diagnosis (9% lower probability for each % point higher ASOBPR: OR 0.91, CI95%  = 0.85-0.98; p = 0.01). Associations were similar in the subgroup with neuroimaging before and after adjustment for regional gray matter volume.

CONCLUSION

ASOBPR may be an early marker of risk of dementia in older adults living in the community.

Orthostatic hypotension associated with executive dysfunction in mild cognitive impairment

INTRODUCTION

Midlife hypertension is associated with dementia in longitudinal studies while chronic hypotension in the elderly is associated with dementia onset. Orthostatic hypotension could influence cognitive performance in the elderly. The objective of this study was to assess the relationship between orthostatic hypotension and cognitive functions.

METHODS

Consecutive participants with complete neuropsychological evaluation from a Memory Clinic were included. Orthostatic hypotension (OH) was defined by a fall≥20/10mmHg systolic/diastolic pressure. Participants were classified into one of 3 groups: 1) subjective cognitive impairment (SCI), 2) mild cognitive impairment (MCI), and 3) dementia. Neuropsychological tests were analyzed for patients with and without OH.

RESULTS

One hundred and twenty participants were included, of which 16 (13%) were classified as SCI, 42 (35%) as MCI, and 63 (52%) with dementia. Prevalence of OH was 0% for the SCI group, 26% (n=11) for the MCI group, and 38% (n=24) for the dementia group. Age, sex, education, and brief cognitive test scores (MMSE & MoCA) were not different between groups with or without OH. In the MCI group, OH was associated with lower cognitive performance in several executive functions tests: visual working memory (p<0.001), processing speed (p=0.006), Stroop flexibility (p=0.030) and Trail-Making Test part B (p=0.024). There was no difference in episodic memory performance. OH was associated with a diagnosis of hypertension and the use of antihypertensive medication. No differences were observed in vascular brain injury between groups with and without OH.

CONCLUSIONS

This study found that orthostatic hypotension prevalence is correlated to severity of cognitive deficits in a Memory Clinic. In MCI, OH is associated with lower performance in executive functions. OH could represent an under-recognized correlate of cognitive performance.

Defining the Relationship Between Hypertension, Cognitive Decline, and Dementia: a Review

Hypertension is a highly prevalent condition which has been established as a risk factor for cardiovascular and cerebrovascular disease. Although the understanding of the relationship between cardiocirculatory dysfunction and brain health has improved significantly over the last several decades, it is still unclear whether hypertension constitutes a potentially treatable risk factor for cognitive decline and dementia. While it is clear that hypertension can affect brain structure and function, recent findings suggest that the associations between blood pressure and brain health are complex and, in many cases, dependent on factors such as age, hypertension chronicity, and antihypertensive medication use. Whereas large epidemiological studies have demonstrated a consistent association between high midlife BP and late-life cognitive decline and incident dementia, associations between late-life blood pressure and cognition have been less consistent. Recent evidence suggests that hypertension may promote alterations in brain structure and function through a process of cerebral vessel remodeling, which can lead to disruptions in cerebral autoregulation, reductions in cerebral perfusion, and limit the brain's ability to clear potentially harmful proteins such as β-amyloid. The purpose of the current review is to synthesize recent findings from epidemiological, neuroimaging, physiological, genetic, and translational research to provide an overview of what is currently known about the association between blood pressure and cognitive function across the lifespan. In doing so, the current review also discusses the results of recent randomized controlled trials of antihypertensive therapy to reduce cognitive decline, highlights several methodological limitations, and provides recommendations for future clinical trial design.

Graded Association Between Kidney Function and Impaired Orthostatic Blood Pressure Stabilization in Older Adults

Background

Impaired orthostatic blood pressure (BP) stabilization is highly prevalent in older adults and is a predictor of end‐organ injury, falls, and mortality. We sought to characterize the relationship between postural BP responses and the kidney.

Methods and Results

We performed a cross‐sectional analysis of 4204 participants from The Irish Longitudinal Study on Ageing, a national cohort of community‐dwelling adults aged ≥50 years. Beat‐to‐beat systolic and diastolic BP were measured during a 2‐minute active stand test. The primary predictor was cystatin C estimated glomerular filtration rate (eGFR) categorized as follows (mL/min per 1.73 m²): ≥90 (reference, n=1414); 75 to 89 (n=1379); 60 to 74 (n=942); 45 to 59 (n=337); <45 (n=132). We examined the association between eGFR categories and (1) sustained orthostatic hypotension, defined as a BP drop exceeding consensus thresholds (systolic BP drop ≥20 mm Hg±diastolic BP drop ≥10 mm Hg) at each 10‐second interval from 60 to 110 seconds inclusive; (2) pattern of BP stabilization, characterized as the difference from baseline in mean systolic BP/diastolic BP at 10‐second intervals. The mean age of subjects was 61.6 years; 47% of subjects were male, and the median eGFR was 82 mL/min per 1.73 m². After multivariable adjustment, participants with eGFR <60 mL/min per 1.73 m² were approximately twice as likely to have sustained orthostatic hypotension (P=0.008 for trend across eGFR categories). We observed a graded association between eGFR categories and impaired orthostatic BP stabilization, particularly within the first minute of standing.

Conclusions

We report a novel, graded relationship between diminished eGFR and impaired orthostatic BP stabilization. Mapping the postural BP response merits further study in kidney disease as a potential means of identifying those at risk of hypotension‐related events.

Sub-clinical orthostatic hypotension is associated with greater subjective memory impairment in older adults

INTRODUCTION

Orthostatic blood pressure (BP) is a measure of cardiovascular autonomic function. Orthostatic BP dysregulation may lie on the causal pathway to dementia. Subjective memory impairment (SMI) is commonly reported by older people some of whom may progress to dementia. We hypothesised that sub-clinical orthostatic hypotension would be associated with SMI and explored these associations according to sex.

METHODS

Cross-sectional analysis of data from 4340 participants aged 50 and over collected during the first wave (2009-2011) of the cohort study, The Irish Longitudinal Study on Ageing. Subjective memory was rated according to a 5-point scale ranging from 'poor' to 'excellent'. BP was measured during orthostatic stress using continuous non-invasive beat-to-beat recording over 2 min.

RESULTS

2% reported 'poor' subjective memory, 12.3% 'fair' , 38% 'good', 33% 'very good' and 14.6% 'excellent'. After controlling for several potential confounding factors including cardiovascular risk, objective cognition, and depressive symptoms mean systolic orthostatic BP was lowest in those with poor subjective memory: 92.2 mmHg (CI95% = 87.1, 97.3) versus excellent 99.3 mmHg (CI95% = 97.4, 101.2); p = 0.011. Further adjustment for supine systolic BP suggested that men with poor subjective memory reached the lowest average systolic orthostatic BP and had the greatest impairment in systolic orthostatic BP stabilisation to baseline levels at 10 s post-stand (-6.64 mmHg; CI95% = -11.49, -1.79; p = 0.007).

CONCLUSIONS

Sub-clinical orthostatic hypotension is associated with SMI, and there are sex-specific relationships evident in this population-based cohort. Subtle cardiovascular autonomic dysfunction may represent a modifiable risk marker at an early stage of cognitive decline in older adults. Copyright © 2016 John Wiley & Sons, Ltd.

Impaired Orthostatic Blood Pressure Recovery Is Associated with Unexplained and Injurious Falls

OBJECTIVES

Cardiovascular disorders are recognized as important modifiable risk factors for falls. However, the association between falls and orthostatic hypotension (OH) remains ambivalent, particularly because of poor measurement methods of previous studies. The goal was to determine for the first time to what extent OH (and variants) are risk factors for incident falls, unexplained falls (UF), injurious falls (IF) and syncope using dynamic blood pressure (BP) measurements in a population study.

DESIGN

Nationally representative longitudinal cohort study-The Irish Longitudinal Study on Ageing (TILDA)-wave 1 (2009-2011) with 2-year follow-up at wave 2 (2012-2013).

SETTING

Community-dwelling adults.

PARTICIPANTS

Four thousand one hundred twenty-seven participants were randomly sampled from the population of older adults aged ≥50 years resident in Ireland.

MEASUREMENTS

Continuous BP recordings measured during active stands were analyzed. OH and variants (initial OH and impaired orthostatic BP stabilization OH(40)) were defined using dynamic BP measurements. Associations with the number of falls, UF, IF, and syncope reported 2 years later were assessed using negative binomial and modified Poisson regression as appropriate.

RESULTS

Participants had a mean age of 61.5 (8.2) years (54.2% female). OH(40) was associated with increased relative risk of UF (RR: 1.52 95% CI: 1.03-2.26). OH was associated with all-cause falls (IRR: 1.40 95% CI: 1.01-1.96), UF(RR: 1.81 95% CI: 1.06-3.09), and IF(RR: 1.58 95% CI: 1.12-2.24). IOH was not associated with any outcome.

CONCLUSION

With the exception of initial orthostatic hypotension, beat-to-beat measures of impaired orthostatic BP recovery (delayed recovery OH (40) or sustained orthostatic hypotension OH) are independent risk factors for future falls, unexplained falls, and injurious falls.

Association of blood pressure in the supine position with target organ damage in subjects over 60 years old

Objective Toexplore the correlation between blood pressure in the supine position and target organ damage in subjects over 60 years of age. Methods In 2444 individuals, we investigated the association of systolic blood pressure (SBP) in the supine position with the target organ damage indices microalbuminuria (ALBU), brachial-ankle pulse wave velocity (baPWV), and carotid intima-media thickness (IMT). Supine hypertension (SH) is defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Subjects were assigned to either the SH group (1275 cases) or the non-SH group (1169 cases). Results The levels of ALBU, baPWV, and IMT, as well as the percentage of participants with ALBU > 30 mg/L, baPWV ≥ 1400 cm/s, and IMT ≥ 1 mm, were significantly higher in the SH group than in the non-SH group. Multivariate logistic regression analysis showed that SH was an independent risk factor for baPWV and IMT, but the relationship with ALBU was not statistically significant after correction for confounding factors. Conclusions SH is a risk factor for target organ damage, as expressed by the indices baPWV and IMT. The association of SH with kidney damage requires further study.

Orthostatic hypotension and drug therapy in patients at an outpatient comprehensive geriatric assessment unit

OBJECTIVE

To assess the rate of orthostatic hypotension and factors associated with it among elderly patients who underwent a comprehensive, ambulatory geriatric assessment.

METHODS

The study included patients 65 years and older who were assessed in the outpatient comprehensive geriatric assessment unit. Data were collected from the computerized medical record including sociodemographic data, lifestyle, falls, blood pressure, BMI, functional and cognitive status, medications, and comorbidity.

RESULTS

The study population consisted of 571 patients who underwent assessment over a nine-year period. The mean age was 83.7 ± 6.1, 35.9% were men, and 183 (32.1%) were diagnosed with orthostatic hypotension. Multiple drugs, in general, and multiple drugs with the potential to cause orthostatic hypotension in particular increased the risk for orthostatic hypotension after adjustment for age, sex, chronic comorbidity, and supine systolic blood pressure ≥150 mmHg [odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.03-1.14 and OR = 1.22, 95% CI: 1.08-1.37, respectively]. In addition, α-blockers and calcium channel blockers increased the risk for orthostatic hypotension after similar adjustments (OR = 1.82, 95% CI: 1.01-3.16 and OR = 1.66, 95% CI: 1.11-2.48, respectively). Similarly, two additional drug types increased the risk for orthostatic hypotension: selective serotonin reuptake inhibitors (OR = 2.09, 95% CI: 1.33-3.19) and tricyclic antidepressants (OR = 4.36, 95% CI: 1.85-10.06). There were no specific associations between age, cognitive and functional state, morbidity (as measured by the Charlson Comorbidity Index), and specific diseases, and orthostatic hypotension.

CONCLUSION

The results of the present study reinforce evidence of an association between drug therapy and orthostatic hypotension.

Orthostatic Changes in Blood Pressure and Cognitive Status in the Elderly

We studied a cohort of 1408 older subjects to explore whether postural changes in blood pressure (BP; defined as orthostatic hypo- or hypertension) can predict the onset of cognitive deterioration. Orthostatic hypotension was defined as a drop of 20 mm Hg in systolic or 10 mm Hg in diastolic BP and orthostatic hypertension as a rise of 20 mm Hg in systolic BP. Orthostatic BP values were grouped into quintiles for secondary analyses. Two cognitive assessments were considered: (1) cognitive impairment, that is, Mini-Mental State Examination scores ≤24/30, and (2) cognitive decline (CD), that is, a 3-point decrease in Mini-Mental State Examination score from the baseline to the follow-up. At the baseline, the prevalence of orthostatic hypotension and hypertension was 18.3% and 10.9%, respectively. At the follow-up (4.4±1.2 years), 286 participants were found cognitively impaired and 138 had a CD. Using logistic regression analysis adjusted for potential baseline confounders, participants with orthostatic hypertension were at significantly higher risk of CD (odds ratio =1.50; 95% confidence intervals =1.26–1.78). Neither orthostatic hypotension nor orthostatic hypertension raised the risk of developing a cognitive impairment. Using quintiles of orthostatic BP values, we found that both decreases and increases in systolic and diastolic BP raised the risk of CD, but not of cognitive impairment. In conclusion, we found that orthostatic hypertension predicts the onset of CD, but not of cognitive impairment in the elderly, whereas orthostatic hypotension predicts neither of these conditions. Further studies are needed to confirm our findings.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment

The prevalence of cognitive impairment and orthostatic hypotension (OH) increases with age, but the results of studies that assessed possible associations between them are inconsistent.The aim of this study is to assess possible associations between cognitive impairment and OH in patients ≥65 years of age who underwent a comprehensive geriatric assessment.A retrospective analysis was conducted of the computerized medical records of the study population from 2005 to 2013. Data collected included blood pressure measurements that enabled the calculation of OH, results of the mini-mental state examination (MMSE), results of the Montreal cognitive assessment (MoCA) test, and cognitive diagnoses that were determined over the course of the assessment.The rate of OH in the study population of 571 adults was 32.1%. The mean MMSE score was 22.5 ± 5.2 among participants with OH and 21.6 ± 5.8 among those without OH (P = 0.09). The absence of a significant association between OH and MMSE remained after adjusting the MMSE score for age and education level. The mean MoCA score was 16.4 ± 5.0 among participants with OH and 16.4 ± 4.8 among those without (P = 0.33). The prevalence of OH was 39% among participants without cognitive impairment, 28.9% among those with mild cognitive impairment (MCI), and 30.6% among those with dementia (P = 0.13).There was no association between OH and cognitive impairment in adults who underwent a comprehensive geriatric assessment.

Effects of Postprandial Blood Pressure on Gait Parameters in Older People

Postprandial hypotension (PPH), a fall in systolic blood pressure (SBP) within 2 h of a meal, may detrimentally affect gait parameters and increase the falls risk in older people. We aimed to determine the effects of postprandial SBP on heart rate (HR), gait speed, and stride length, double-support time and swing time variability in older subjects with and without PPH. Twenty-nine subjects were studied on three days: glucose (“G”), water and walk (“WW”), glucose and walk (“GW”). Subjects consumed a glucose drink on “G” and “GW” and water on “WW”. The “G” day determined which subjects had PPH. On “WW” and “GW” gait was analyzed. Sixteen subjects demonstrated PPH. In this group, there were significant changes in gait speed (p = 0.040) on “WW” and double-support time variability (p = 0.027) on “GW”. The area under the curve for the change in gait parameters from baseline was not significant on any study day. Among subjects without PPH, SBP increased on “WW” (p < 0.005) and all gait parameters remained unchanged on all study days. These findings suggest that by changing gait parameters, PPH may contribute to an increased falls risk in the older person with PPH.

Impaired orthostatic blood pressure recovery and cognitive performance at two-year follow up in older adults: The Irish Longitudinal Study on Ageing

BACKGROUND

Prospective investigations of the association between impaired orthostatic blood pressure (BP) regulation and cognitive decline in older adults are limited, and findings to-date have been mixed. The aim of this study was to determine whether impaired recovery of orthostatic BP was associated with change in cognitive function over a 2-year period, in a population based sample of community dwelling older adults.

METHODS

Data from the first two waves of the Irish Longitudinal Study on Ageing were analysed. Orthostatic BP was measured during a lying to standing orthostatic stress protocol at wave 1 using beat-to-beat digital plethysmography, and impaired recovery of BP at 40 s post stand was investigated. Cognitive function was assessed at wave 1 and wave 2 (2 years later) using the Mini-Mental State Exam (MMSE), verbal fluency and word recall tasks.

RESULTS

After adjustment for measured, potential confounders, and multiple imputation for missing data, the change in the number of errors between waves on the MMSE was 10 % higher [IRR (95 % CI) = 1.10 (0.96, 1.26)] in those with impaired recovery at 40 s. However, this was not statistically significant (p = 0.17). Impaired BP recovery was not associated with change in performance on any of the other cognitive measures.

CONCLUSIONS

There was no clear evidence for an association between impaired recovery of orthostatic BP and change in cognition over a 2-year period in this nationally representative cohort of older adults. Longer follow-up and more detailed cognitive testing would be advantageous to further investigate the relationship between orthostatic BP and cognitive decline.

Effect of orthostatic hypotension on sustained attention in patients with autonomic failure

INTRODUCTION

Orthostatic hypotension has been associated with impaired cognitive function, but cognitive function during orthostatic hypotension has hardly been studied. We studied the effect of orthostatic hypotension, induced by head-up tilt (HUT), on sustained attention in patients with autonomic failure.

METHODS

We studied the sustained attention to response task (SART) in the supine position and during HUT in 10 patients with autonomic failure and 10 age-matched and sex-matched controls. To avoid syncope, the tilting angle was tailored to patients to reach a stable systolic blood pressure below 100 mm Hg. Controls were all tilted at an angle of 60°. Cerebral blood flow velocity, blood pressure and heart rate were measured continuously.

RESULTS

In patients, systolic blood pressure was 61.4 mm Hg lower during HUT than in the supine position (p<0.001). Patients did not make more SART errors during HUT than in the supine position (-1.3 errors, p=0.3). Controls made 2.3 fewer errors during SART in the HUT position compared to the supine position (p=0.020). SART performance led to an increase in systolic blood pressure (+11.8 mm Hg, p=0.018) and diastolic blood pressure (+5.8 mm Hg, p=0.017) during SART in the HUT position, as well as to a trend towards increased cerebral blood flow velocity (+3.8 m/s, p=0.101).

DISCUSSION

Orthostatic hypotension in patients with autonomic failure was not associated with impaired sustained attention. This might partly be explained by the observation that SART performance led to a blood pressure increase. Moreover, the upright position was associated with better performance in controls and, to a lesser extent, also in patients.

Single Agent Antihypertensive Therapy and Orthostatic Blood Pressure Behaviour in Older Adults Using Beat-to-Beat Measurements: The Irish Longitudinal Study on Ageing

Background

Impaired blood pressure (BP) stabilisation after standing, defined using beat-to-beat measurements, has been shown to predict important health outcomes. We aimed to define the relationship between individual classes of antihypertensive agent and BP stabilisation among hypertensive older adults.

Methods

Cross-sectional analysis from The Irish Longitudinal Study on Ageing, a cohort study of Irish adults aged 50 years and over. Beat-to-beat BP was recorded in participants undergoing an active stand test. We defined grade 1 hypertension according to European Society of Cardiology criteria (systolic BP [SBP] 140-159mmHg ± diastolic BP [DBP] 90-99mmHg). Outcomes were: (i) initial orthostatic hypotension (IOH) (SBP drop ≥40mmHg ± DBP drop ≥20mmHg within 15 seconds [s] of standing accompanied by symptoms); (ii) sustained OH (SBP drop ≥20mmHg ± DBP drop ≥10mmHg from 60 to 110s inclusive); (iii) impaired BP stabilisation (SBP drop ≥20mmHg ± DBP drop ≥10mmHg at any 10s interval during the test). Outcomes were assessed using multivariable-adjusted logistic regression.

Results

A total of 536 hypertensive participants were receiving monotherapy with a renin-angiotensin-aldosterone-system inhibitor (n = 317, 59.1%), beta-blocker (n = 89, 16.6%), calcium channel blocker (n = 89, 16.6%) or diuretic (n = 41, 7.6%). A further 783 untreated participants met criteria for grade 1 hypertension. Beta-blockers were associated with increased odds of initial OH (OR 2.05, 95% CI 1.31–3.21) and sustained OH (OR 3.36, 95% CI 1.87–6.03) versus untreated grade 1 hypertension. Multivariable adjustment did not attenuate the results. Impaired BP stabilisation was evident at 20s (OR 2.59, 95% CI 1.58–4.25) and persisted at 110s (OR 2.90, 95% CI 1.64–5.11). No association was found between the other agents and any study outcome.

Conclusion

Beta-blocker monotherapy was associated with a >2-fold increased odds of initial OH and a >3-fold increased odds of sustained OH and impaired BP stabilisation, compared to untreated grade 1 hypertension. These findings support existing literature questioning the role of beta-blockers as first line agents for essential hypertension.

Orthostatic hypotension and orthostatic hypertension in American veterans

PURPOSE

Abnormal blood pressure (BP) response to orthostatic maneuvers may predict adverse health outcomes. Orthostatic hypotension (OH) is defined as a fall in BP of ≥20/10 mmHg, and orthostatic hypertension (OHTN) is defined as an increase in systolic BP (SBP) of ≥20 mmHg, with standing. Herein, we document the prevalence of OH and OHTN in American veterans.

METHODS

The influence of demographic characteristics, life habits, co-incident medical conditions, and prescription medication use on these prevalence rates and associations between abnormal orthostatic BP responses and severity of self-reported symptoms of fatigue, dizziness, trouble concentrating, and head and neck discomfort were determined.

RESULTS

286 veterans participated; 14 % were classified with OH, 22 % with OHTN, and 64 % with normal BP responses to standing (reference group). An increased prevalence of the diagnosis of diabetes mellitus (27 %) and hypertension (63 %) was noted, which did not differ by orthostatic BP classification. Veterans with OH were older than the reference group and were prescribed more antihypertensive medications than the reference and OHTN groups. While the prevalence of OH increased with age, the prevalence of OHTN was comparable in young (20-30 years) and old (70+ years) veterans (17 vs. 19 %, respectively). The severity of fatigue and dizziness was increased in veterans with OH and OHTN compared to the reference group.

CONCLUSION

These data suggest a relatively high prevalence of OH and OHTN, which is associated with increased self-reported severity of fatigue and dizziness in American veterans, findings which may adversely impact long-term health outcomes.

Clinical characteristics of supine hypertension in de novo Parkinson disease

PURPOSE

Supine hypertension is frequently associated with autonomic failure. However, its clinical characteristics in patients with Parkinson disease (PD) remain unclear. The present study aimed to clarify the characteristics of supine hypertension in patients with de novo PD.

METHODS

The subjects were 72 patients with de novo PD. We studied blood pressure and plasma norepinephrine levels after the patients rested for 20 min in the supine position. Changes in blood pressure were also examined on head-up tilt-table testing.

RESULTS

The disease duration was 1.7 ± 1.6 years (average ± SD). Thirty-three (45.8 %) patients had supine hypertension (defined as a blood pressure of ≥140/90 mmHg). Supine blood pressure positively correlated with the degree of orthostatic hypotension. Age and the proportion of patients with akinetic-rigid motor subtype or preexisting hypertension were higher among patients with supine hypertension than among those without supine hypertension. The Mini-Mental State Examination score was lower in patients with supine hypertension than in those without supine hypertension. Sex, disease duration, disease severity, and peripheral sympathetic nervous activity as evaluated by the cardiac uptake of (123)I-metaiodobenzylguanidine and the plasma norepinephrine level did not differ between patients with and those without supine hypertension.

CONCLUSION

Older age, akinetic-rigid motor subtype, and preexisting hypertension are independent risk factors for supine hypertension. Supine hypertension alone may be associated with milder peripheral sympathetic nervous denervation than orthostatic hypotension alone. As for global cognitive decline, supine hypertension is a far riskier comorbidity of early-stage PD than is orthostatic hypotension.

Environment as 'Brain Training': A review of geographical and physical environmental influences on cognitive ageing

Global ageing demographics coupled with increased urbanisation pose major challenges to the provision of optimal living environments for older persons, particularly in relation to cognitive health. Although animal studies emphasize the benefits of enriched environments for cognition, and brain training interventions have shown that maintaining or improving cognitive vitality in older age is possible, our knowledge of the characteristics of our physical environment which are protective for cognitive ageing is lacking. The present review analyses different environmental characteristics (e.g. urban vs. rural settings, presence of green) in relation to cognitive performance in ageing. Studies of direct and indirect associations between physical environment and cognitive performance are reviewed in order to describe the evidence that our living contexts constitute a measurable factor in determining cognitive ageing.

Recent syncope and unexplained falls are associated with poor cognitive performance

OBJECTIVE

To compare cognitive performance in participants with and without syncope and unexplained falls in a large population representative sample aged 50 years or older.

METHODS

Participants of the Irish longitudinal study on ageing (TILDA) were studied. Participants with a history of syncope and/or unexplained falls in the past 12 months were compared with those with no reported events. Cognitive performance was measured using the Montreal cognitive assessment (MoCA) score. Multivariate linear regression analysis controlling for potential confounders was performed to compare cognitive function by syncope and falls status.

RESULTS

Five thousand eight hundred and forty-six participants were analysed, median age 62 years (inter-quartile range=14), and 54% were female. Five hundred and forty-nine (9.4%) had a syncopal event and/or an unexplained fall in past 12 months. One hundred and two (1.8%) subjects had two-plus syncopal events in the same period. There was a significant association between syncope/falls history and lower MoCA score, following adjustment for all confounders (B=-0.4; -0.69, -0.11; P=0.006). Higher syncope burden was also associated with lower performance; however, this was largely explained by confounders. There was no age interaction with these findings.

CONCLUSION

Participants who experienced syncope and/or non-accidental falls in the previous year have poor global cognitive performance compared with case-controls. There was no effect of age on our results. Further investigation of the association between syncope burden, unexplained falls and cognitive decline is required to establish a relationship between these disorders.

Age-Related Normative Changes in Phasic Orthostatic Blood Pressure in a Large Population Study

Background—

In this report, we provide the first normative reference data and prevalence estimates of impaired orthostatic blood pressure (BP) stabilization, initial orthostatic hypotension, and orthostatic hypotension based on beat-to-beat blood pressure methods in a population-representative sample.

Methods and Results—

Participants were recruited from a nationally representative cohort study (≥50 years). Beat-to-beat systolic BP, diastolic BP, and heart rate records were analyzed among those who underwent an active stand test (n=4475). Normograms were estimated by use of generalized additive models for location, shape, and scale with Box-Cox power exponential distribution. Prevalence estimates of impaired BP stabilization, initial orthostatic hypotension, and orthostatic hypotension are reported. Orthostatic BP responses in adults aged 50 to 59 years stabilized within 30 seconds of standing, with older groups taking 30 seconds or longer. The total prevalence of impaired BP stabilization was 15.6% (95% confidence interval [CI], 14.1%–17.1%), increasing with age to 41.2% (95% CI, 30.0%–52.4%) in people ≥80 years old. Initial orthostatic hypotension occurred in 32.9% (95% CI, 31.2%–34.6%) of the population aged ≥50 years, with no age gradient evident. The prevalence of orthostatic hypotension was 6.9% (95% CI, 5.9%–7.8%) in the total population, increasing to 18.5% (95% CI, 9.0%–28.0%) in those aged ≥80 years old.

Conclusions—

Significant age-related differences exist in the time course of postural BP responses, with abnormal responses taking longer than 30 seconds to stabilize. Impaired BP stabilization is more common as we age, affecting more than two-fifths of the population aged ≥80 years, and may play a future role in the management of falls and syncope.

Predictors of dementia in Parkinson disease: a prospective cohort study

OBJECTIVE

We investigated an array of possible markers of early dementia in Parkinson disease.

METHODS

We performed a comprehensive assessment of autonomic, sleep, psychiatric, visual, olfactory, and motor manifestations in 80 patients with Parkinson disease who were dementia-free at baseline. After 4.4 years' follow-up, patients were evaluated for dementia. Predictive variables were assessed using logistic regression adjusting for disease duration, follow-up duration, age, and sex.

RESULTS

Of 80 patients, 27 (34%) developed dementia. Patients destined to develop dementia were older and more often male (odds ratio [OR] = 3.64, p = 0.023). Those with baseline mild cognitive impairment had increased dementia risk (OR = 22.5, p < 0.001). REM sleep behavior disorder at baseline dramatically increased dementia risk (OR = 49.7, p = 0.001); however, neither daytime sleepiness nor insomnia predicted dementia. Higher baseline blood pressure increased dementia risk (OR = 1.37 per 10 mm Hg, p = 0.032). Orthostatic blood pressure drop was strongly associated with dementia risk (OR = 1.84 per 10 mm Hg, p < 0.001); having a systolic drop of >10 mm Hg increased dementia odds 7-fold (OR = 7.3, p = 0.002). Abnormal color vision increased dementia risk (OR = 3.3, p = 0.014), but olfactory dysfunction did not. Among baseline motor variables, proportion of gait involvement (OR = 1.12, p = 0.023), falls (OR = 3.02, p = 0.042), and freezing (OR = 2.63, p = 0.013), as well as the Purdue Pegboard Test (OR = 0.67, p = 0.049) and alternate tap test (OR = 0.97, p = 0.033) predicted dementia.

CONCLUSION

Cardiovascular autonomic dysfunction, REM sleep behavior disorder, color discrimination ability, and gait dysfunction strongly predict development of dementia in Parkinson disease.

Syncope in the Elderly

A rapid change in ageing demographic is taking place worldwide such that healthcare professionals are increasingly treating old and very old patients. Syncope in the elderly is a challenging presentation that is under-recognised, particularly in the acute care setting. The reason for this is that presentation in the older person may be atypical: patients are less likely to have a prodrome, may have amnesia for loss of consciousness and events are frequently unwitnessed. The older patient thus may present with a fall rather than transient loss of consciousness. There is an increased susceptibility to syncope with advancing age attributed to age-related physiological impairments in heart rate and blood pressure, and alterations in cerebral blood flow. Multi-morbidity and polypharmacy in these complex patients increases susceptibility to syncope. Cardiac causes and more than one possible cause are also common. Syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs. In view of this, prompt assessment and early targeted intervention are recommended. The purpose of this article is to update the reader regarding the presentation and management of syncope in this rapidly changing demographic.