The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis

Prevalence and factors associated with falls in older adults in a Middle Eastern population: a retrospective cross-sectional study

OBJECTIVE

The main objective was to determine the prevalence of falls and associated factors in older adults living in Qatar.

STUDY DESIGN

Cross-sectional study.

METHODS

This is a cross-sectional study of older adults aged ≥60 years with at least one encounter with primary health care corporation (PHCC) in Qatar during the period 2017-2022. Data on documented falls, demographic variables, and medical comorbidities were extracted from all PHCCs in Qatar. Descriptive and inferential statistics were used to address the aim of the study.

RESULTS

A total of 68,194 older adults had at least one encounter with PHCC. The median age was 65.0 years, 58.9% were males, and 32.6% were Qatari nationality. A higher percentage of falls was found in individuals with hypertension (80%), diabetes (74.2%), and dyslipidemia (48.9%), which were also the most prevalent comorbidities. The prevalence of falls was 6.7% (95% CI 6.6-6.9). Compared to individuals aged 60-69 years, individuals aged 70-79, 80-89, and 90-99 had increased odds of falls by 1.6 (95% CI 1.5, 1.8), 2.5 (95% CI 2.2, 2.8), and 2.6 (95% CI 2.0, 3.3), respectively. Females and individuals of Qatari nationality had increased odds of fall by 1.5 (95% CI 1.4, 1.6) and 1.2 (95% CI 1.1, 1.3), respectively. Orthostatic hypotension, syncope, Parkinson's disease, and hip arthritis showed the strongest associations with falls.

CONCLUSIONS

Given the growing population of older adults in the Middle East and North African region, falls is a public health concern. The risk factors identified in this study suggest the need for proactive healthcare strategies tailored to the unique needs of older adult populations.

The effect of lower limb strengthening exercise on orthostatic blood pressure and the skeletal muscle pump in older people with orthostatic hypotension

INTRODUCTION

Activation of muscles during standing is recommended to activate the skeletal muscle pump, increasing venous return and increasing blood pressure (BP) in people with orthostatic hypotension (OH).

AIM

The aim of this study is to determine if increasing the strength of the lower limb muscles can improve the effectiveness of the venous pump and postural BP in older people with OH.

METHODS

Ten older people with OH underwent an 8-week lower limb strengthening intervention. Repeated measurements of orthostatic BP, calf venous ejection fraction (EF) and muscle strength took place before, during and after intervention.

RESULTS

The intervention increased calf muscle strength by 21% (interquartile range: 18-28), p = 0.018, from a median baseline of 38 (34-45) kg. Participants had normal levels of venous EF 64% (51-75) at baseline, with little to no venous reflux. The median ejection volume at baseline was 44 (36-58) mL per calf. Despite increasing muscle strength, venous EF did not increase (percentage change -10% (-16 to 24), p = 0.8) and systolic BP drop did not improve (percentage change 0% (-17 to 16), p = 1.0). Similarly, visual analysis of individual case-series trends revealed increasing muscle strength with no clinically meaningful change in EF or orthostatic BP.

CONCLUSIONS

Muscle strengthening exercise does not increase the effectiveness of the skeletal muscle pump and is not an efficacious intervention for OH. As there is little to no venous pooling in the calf during standing in older people with OH, below knee compression is unlikely to be clinically effective.

Effects of robotic rehabilitation using the Erigo® device on patients with neurological injury: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To systematically review the effects of robotic rehabilitation with the Erigo® device on patients with neurological injury on safety, spasticity, muscle strength, functionality, gait/balance, and changes in the level of consciousness.

METHODS

MEDLINE, SciELO, EMBASE, The Cochrane Library - CENTRAL and PEDro databases were consulted without the restriction of date and language. Randomized controlled trials that evaluated the robotic rehabilitation and compared it to conventional or placebo therapy, isolated or in association with other therapy, were selected. Studies in which the treatment time was less than 10 sessions were excluded. The risk of bias was assessed with the use of the RoB 2.0 tool.

RESULTS

Nine studies were included, totaling 347 patients. The robotic rehabilitation performed by the Erigo® device proved to be safe for neurological patients. The meta-analysis showed an improvement for spasticity (MD = 0.29; 95% CI = -0.49 to -0.08; I2 = 0%), but there was no significant increase in muscle strength in patients with stroke (MD = 0.25; CI 95% = -0.22 to -0,71; I2 = 0%). Erigo® showed inconclusive effects on functionality, gait/balance and level of consciousness in patients with severe acquired brain injury and vegetative or minimally conscious state. All studies present some concerns for the risk of bias.

CONCLUSION

Erigo® as a robotic rehabilitation strategy is safe for patients with acquired brain injury and appears to reduce spasticity in patients with stroke. The effects on muscle strength, functionality, gait and balance and level of consciousness remain uncertain and the methodological quality of the clinical trials included in this review is limited.

Effect of orthostatic hypotension on long-term prognosis of elderly patients with stable coronary artery disease: a retrospective cohort study

Background

The long-term prognosis of patients with stable coronary artery disease (CAD) combined with orthostatic hypotension (OH) has rarely been reported. This research was designed to examine whether OH increases the risk of all-cause mortality and cardiovascular death among patients with stable CAD.

Methods

We retrospectively analyzed retired military personnel over 65 years of age who were hospitalized at the General Hospital of Southern Theater Command of the Chinese People's Liberation Army between March and July 2010. A total of 924 patients with stable CAD were included, among whom 263 had OH. The risk of all-cause mortality and cardiovascular death in OH and non-OH groups were analyzed with the Cox proportional hazards models, and restricted cubic spline plots were utilized for subgroup analyses. Furthermore, competing risk models were applied for sensitivity analyses.

Results

The median age of the patients was 82.00 (80.00-85.00) years. Over 159 months of follow-up, the loss to follow-up rate was 2.27%, and all-cause mortality was observed in 574 (63.57%) patients, including 184 with OH. Moreover, cardiovascular death occurred in 127 patients (13.73%), with 58 cases associated with OH. Although the relationship between OH and all-cause mortality was non-significant [body mass index (BMI) < 25 group, adjusted hazard ratio (HR) = 1.10 with a 95% confidence interval (CI): 0.82-1.40; BMI ≥ 25 group, adjusted HR = 1.30, 95% CI: 0.98-1.70], it was independently related to a growing risk of cardiovascular death (adjusted HR = 1.80, 95% CI: 1.20-2.60). This finding was further validated by using a competing risk model (subdistribution HR = 1.74, 95% CI: 1.22-2.49). Moreover, age, low-density lipoprotein cholesterol, and frequency of hospital admissions were identified as risk factors of cardiovascular death among patients with OH (P < 0.05).

Conclusion

Our study, based on retired military personnel with stable CAD, found that OH led to a significantly higher risk of cardiovascular death, but it was not noticeably associated with all-cause mortality on long-term prognosis.

Associations of Orthostatic Hypotension and Frailty With Dementia and Mortality in Older Adults: A Population-Based Cohort Study

BACKGROUND

This study aimed to assess the associations of orthostatic hypotension (OH), in the presence or absence of frailty, with dementia and mortality in older adults.

METHODS

We conducted a 15-year population-based cohort study including 2 703 baseline dementia-free individuals from the Swedish National Study on Aging and Care in Kungsholmen. At baseline, OH was defined as a decline in systolic/diastolic blood pressure ≥20/10 mm Hg 1 minute after standing up from a supine position. Frailty status was defined following Fried's frailty phenotype. Dementia was diagnosed following the Diagnostic and Statistical Manual of Mental Disorders-fourth edition criteria. Multistate flexible parametric survival models were used to estimate associations of OH and frailty with dementia and mortality.

RESULTS

Robust people with OH (adjusted hazard ratio [HR] = 2.28; 95% confidence interval [CI] = 1.47-3.54) and frail people without OH (HR = 1.98; 95% CI = 1.40-2.82) or with OH (HR = 2.73; 95% CI = 1.82-4.10) had a higher dementia risk than OH-free and robust people. Moreover, frail people, independently of the presence of OH, had higher mortality rate than OH-free and robust people. In individuals who developed dementia during the follow-up period, neither OH nor frailty was significantly associated with mortality.

CONCLUSIONS

Older adults with OH, whether robust or frail, may have a higher dementia risk than those without OH. Older adults with OH, when having frailty, may have a higher mortality rate than those without OH. The concurrent assessments of OH and frailty may provide prognostic values in terms of dementia and mortality risk in older adults.

What is the prevalence of orthostatic hypotension in an Australasian emergency department population?

OBJECTIVE

Orthostatic hypotension (OH) is associated with increased morbidity and there is limited research on the prevalence in the Australian ED population. The aim was to determine the prevalence of OH in an Australian ED population. Secondary outcomes included any associations of OH with symptoms, presenting complaints, patient demographics, or hospital admission, and the timing of OH findings.

METHODS

Patients presenting to a regional Australasian ED underwent orthostatic measurements at 1, 3 and 5 min of standing following 5 min of supine bed rest. OH was defined as a drop in systolic and/or diastolic blood pressure by ≥20 and ≥10 mmHg, respectively.

RESULTS

Of the 312 patients who were enrolled in the study, 69 (22.1%, 95% confidence interval 17.7-27.2%) had OH and 76.8% of cases were detected after 3 min of standing. There was evidence of difference in the prevalence of OH with age (P < 0.001). Similarly, there was evidence of a difference in supine systolic and diastolic blood pressure measurements (P = 0.012 and P < 0.001, respectively) between orthostatic and normotensive subjects. No association was found with OH and hospital admission, presenting complaints or comorbid medical illnesses.

CONCLUSIONS

In this single Australian ED population, there was a high prevalence of OH (22.1%) with most cases detected within 3 min of standing. A higher-powered study across multiple sites would better substantiate these findings.

Frequency of Orthostatic Hypotension in Isolated REM Sleep Behavior Disorder

BACKGROUND AND OBJECTIVES

Although orthostatic hypotension (OH) can be an early feature of autonomic dysfunction in isolated REM sleep behavior disorder (iRBD), no large-scale studies have examined the frequency of OH in iRBD. In this study, we prospectively evaluated the frequency of OH in a large multicenter iRBD cohort.

METHODS

Participants 18 years or older with video polysomnogram-confirmed iRBD were enrolled through the North American Prodromal Synucleinopathy consortium. All participants underwent 3-minute orthostatic stand testing to assess the frequency of OH, and a Δ heart rate/Δ systolic blood pressure (ΔHR/ΔSBP) ratio <0.5 was used to define reduced HR augmentation, suggestive of neurogenic OH. All participants completed a battery of assessments, including the Scales for Outcomes in Parkinson Disease-Autonomic Dysfunction (SCOPA-AUT) and others assessing cognitive, motor, psychiatric, and sensory domains.

RESULTS

Of 340 iRBD participants (65 ± 10 years, 82% male), 93 (27%) met criteria for OH (ΔHR/ΔSBP 0.37 ± 0.28; range 0.0-1.57), and of these, 72 (77%) met criteria for OH with reduced HR augmentation (ΔHR/ΔSBP 0.28 ± 0.21; range 0.0-0.5). Supine hypertension (sHTN) was present in 72% of those with OH. Compared with iRBD participants without OH, those with OH were older, reported older age of RBD symptom onset, and had worse olfaction. There was no difference in autonomic symptom scores as measured by SCOPA-AUT.

DISCUSSION

OH and sHTN are common in iRBD. However, as patients may have reduced autonomic symptom awareness, orthostatic stand testing should be considered in clinical evaluations. Longitudinal studies are needed to clarify the relationship between OH and phenoconversion risk in iRBD.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov: NCT03623672; North American Prodromal Synucleinopathy Consortium.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Timing of orthostatic hypotension and its relationship with falls in older adults

BACKGROUND

There is inconsistent evidence on the optimal time after standing to assess for orthostatic hypotension. We determined the prevalence of orthostatic hypotension at different time points after standing in a population of older adults, as well as fall risk and symptoms associated with orthostatic hypotension.

METHODS

We performed a secondary analysis of the Study to Understand Fall Reduction and Vitamin D in You (STURDY), a randomized clinical trial funded by the National Institute on Aging, testing the effect of differing vitamin D3 doses on fall risk in older adults. STURDY occurred between July 2015 and May 2019. Secondary analysis occurred in 2022. Participants were community-dwelling adults, 70 years or older. In the orthostatic hypotension assessment, participants stood upright from supine position and underwent six standing blood pressure measurements (M1-M6) in two clusters of three measurements (immediately and 3 min after standing). Cox proportional hazard models were used to examine the relationship between orthostatic hypotension at each measurement and subsequent falls. Participants were followed until the earlier of their 24-month visit or study completion.

RESULTS

Orthostatic hypotension occurred in 32% of assessments at M1, and only 16% at M5 and M6. Orthostatic hypotension from average immediate (M1-3) and average delayed (M4-6) measurements, respectively, predicted higher fall risk (M1-3 = 1.65 [1.08, 2.52]; M4-6 = 1.73 [1.03, 2.91]) (hazard ratio [95% confidence interval]). However, among individual measurements, only orthostatic hypotension at M5 (1.84 [1.16, 2.93]) and M6 (1.85 [1.17, 2.91]) predicted higher fall risk. Participants with orthostatic hypotension at M1 (3.07 [1.48, 6.38]) and M2 (3.72 [1.72, 8.03]) were more likely to have reported orthostatic symptoms.

CONCLUSIONS

Orthostatic hypotension was most prevalent and symptomatic immediately within 1-2 min after standing, but more informative for fall risk after 4.5 min. Clinicians may consider both intervals when assessing for orthostatic hypotension.

Midodrine-Induced Nightmares in the Treatment of Orthostatic Hypotension: A Case Report

Background Midodrine was the first medication approved by the Food and Drug Administration (FDA) for the treatment of orthostatic hypotension. Pharmacologically, midodrine is a peripheral selective alpha-1-adrenergic agonist that can improve standing, sitting, and supine systolic blood pressure. Common side effects include bradycardia, supine hypertension, and paresthesia. A novel side effect of midodrine-induced nightmares has been reported in our patient. To our knowledge, this is the first reported case of midodrine-induced nightmares. Objective To investigate and report a clinically significant and unique drug adverse event of midodrine in the treatment of orthostatic hypotension. Case Presentation This report describes a case of persistent nightmares associated with midodrine use in an 83-year-old male who experienced frequent syncope episodes treated with midodrine for orthostatic hypotension (OH). After the initiation of midodrine, the patient complained of increased nightmares, which quickly led to his refusal of the medication, despite the initial improvements in his blood pressure. The timing of administration included an evening dose at 21:00. This novel adverse event of midodrine-induced nightmares will be highlighted and explored in this case report. Conclusion This case demonstrated a unique adverse event of nightmares caused by midodrine. It is hypothesized that autonomic dysfunction plays a role and further investigations should be conducted to confirm this theory. We hope that our case report highlights the importance of careful consideration when prescribing midodrine in older people with orthostatic hypotension.

Prospective association of occupational and leisure-time physical activity with orthostatic blood pressure changes in older adults

Orthostatic hypotension (OH) is common in older people. We examined the influence of self-reported occupational-related physical activity (PA) and leisure-time physical exercise (PE) on orthostatic response in a sample of older people over a 2 year period. Supine and orthostatic systolic blood pressure (sBP), diastolic blood pressure (dBP), and mean blood pressure (mBP) were assessed in response to Active Stand (AS) test in 205 older subjects (> 60 years old) at baseline and 2-year follow-up. OH was found in 24 subjects (11.71%) at baseline and 20 subjects (9.76%) after 2 years, with a significant degree of variability in the occurrence of OH after 2 years. Twenty-two subjects who had OH at baseline were free of it after 2 years, two subjects had persistent OH at baseline and after 2 years. After 2 years, adults with occupational PA showed no significant decrease of blood pressure in response to AS test, while lack of undertaking an occupation-related PA was significantly related with a greater decrease in sBP and mBP in response to AS testing in the 1st min. Occupation-related PA and leisure-time-related PE were related to an increase in the response of BP on AS in change between baseline and after 2 years. High between-subjects variance in OH over 2 years was noted. Occupations that involved continuous physical activity and leisure-time physical exercise in middle age were both protective for BP decline on orthostatic stress test within 2 years.

Characterizing Fall Circumstances in Community-Dwelling Older Adults: A Mixed Methods Approach

BACKGROUND

Understanding fall circumstances can help researchers better identify causes of falls and develop effective and tailored fall prevention programs. This study aims to describe fall circumstances among older adults from quantitative data using conventional statistical approaches and qualitative analyses using a machine learning approach.

METHODS

The MOBILIZE Boston Study enrolled 765 community-dwelling adults aged 70 years and older in Boston, MA. Occurrence and circumstances of falls (ie, locations, activities, and self-reported causes of falls) were recorded using monthly fall calendar postcards and fall follow-up interviews with open- and close-ended questions during a 4-year period. Descriptive analyses were used to summarize circumstances of falls. Natural language processing was used to analyze narrative responses from open-ended questions.

RESULTS

During the 4-year follow-up, 490 participants (64%) had at least 1 fall. Among 1 829 falls, 965 falls occurred indoors and 804 falls occurred outdoors. Commonly reported activities when the fall occurred were walking (915, 50.0%), standing (175, 9.6%), and going down stairs (125, 6.8%). The most commonly reported causes of falls were slip or trip (943, 51.6%) and inappropriate footwear (444, 24.3%). Using qualitative data, we extracted more detailed information on locations and activities, and additional information on obstacles related to falls and commonly reported scenarios such as "lost my balance and fell."

CONCLUSIONS

Self-reported fall circumstances provide important information on both intrinsic and extrinsic factors contributing to falls. Future studies are warranted to replicate our findings and optimize approaches to analyzing narrative data on fall circumstances in older adults.

The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study

BACKGROUND

Orthostatic hypotension (OH) is prevalent among community-dwelling older adults and is associated with multiple negative health outcomes. Older adults are susceptible to developing OH because aging alters autonomic nervous system function. Biofeedback is a noninvasive, nonpharmacological intervention that can modulate autonomic nervous system dysfunction in older adults.

OBJECTIVES

Our aim in this study was to examine the effect of a biofeedback-based integrated program on community-dwelling older adults with OH.

METHODS

We conducted a controlled pilot study. Community-dwelling older adults 65 years or older who had nonneurogenic OH were eligible. Data from 51 participants, comprising 27 in the intervention group and 24 in the control group, were analyzed. Weekly biofeedback-based integrated program consisting of biofeedback training along with group education about behavioral modification, physical activities, and telephone counseling was provided for 12 weeks. Orthostatic hypotension was evaluated by measuring the drop in systolic and diastolic blood pressure after postural changes. Autonomic nervous system function was measured using heart rate variability.

RESULTS

Among the indicators of heart rate variability, total power (P = .037) and low frequency (P = .017) increased significantly, suggesting that autonomic function improved. Severity of orthostatic symptoms (P < .001) and drops in systolic (P = .003) and diastolic (P = .012) blood pressure after postural changes decreased significantly in the intervention group.

CONCLUSION

Biofeedback-based integrated program was effective in improving autonomic nervous system function and alleviated OH. Therefore, biofeedback-based integrated program should be tested in a larger randomized controlled study with long-term follow-up.

The Impact of Head-Up Tilt Sleeping on Orthostatic Tolerance: A Scoping Review

To systematically summarize the evidence of head-up tilt sleeping (HUTS) on orthostatic tolerance, we conducted a systematic, predefined search in PubMed, OVID Embase, Cochrane and Web of Science. We included studies assessing the effect of HUTS on orthostatic tolerance and other cardiovascular measures and rated the quality with the American Academy of Neurology risk of bias tool. We included 10 studies (n = 185) in four groups: orthostatic hypotension (OH; 6 studies, n = 103), vasovagal syncope (1 study, n = 12), nocturnal angina pectoris (1 study, n = 10) and healthy subjects (2 studies, n = 58). HUTS duration varied (1 day-4 months) with variable inclinations (5°-15°). In two of six OH studies, HUTS significantly improved standing systolic blood pressure. Orthostatic tolerance was consistently enhanced in OH studies with higher angles (≥12°), in 2 out of 3 with smaller angles (5°) but also in one studying horizontal sleeping. In vasovagal syncope, HUTS significantly augmented resilience to extreme orthostatic stress. One study was rated as a class II risk of bias, one of Class II/III and eight of Class IV. The evidence favouring HUTS to improve orthostatic tolerance is weak due to variable interventions, populations, small samples and a high risk of bias. Despite this, we found some physiological signs suggesting a beneficial effect.

Capturing postural blood pressure dynamics with near-infrared spectroscopy-measured cerebral oxygenation

Orthostatic hypotension (OH) is highly prevalent in older adults and associated with dizziness, falls, lower physical and cognitive function, cardiovascular disease, and mortality. OH is currently diagnosed in a clinical setting with single-time point cuff measurements. Continuous blood pressure (BP) devices can measure OH dynamics but cannot be used for daily life monitoring. Near-infrared spectroscopy (NIRS) has potential diagnostic value in measuring cerebral oxygenation continuously over a longer time period, but this needs further validation. This study aimed to compare NIRS-measured (cerebral) oxygenation with continuous BP and transcranial Doppler-measured cerebral blood velocity (CBv) during postural changes. This cross-sectional study included 41 participants between 20 and 88 years old. BP, CBv, and cerebral (long channels) and superficial (short channels) oxygenated hemoglobin (O2Hb) were measured continuously during various postural changes. Pearson correlations between BP, CBv, and O2Hb were calculated over curves and specific characteristics (maximum drop amplitude and recovery). BP and O2Hb only showed good curve-based correlations (0.58-0.75) in the initial 30 s after standing up. Early (30-40 s) and 1-min BP recovery associated significantly with O2Hb, but no consistent associations were found for maximum drop amplitude and late (60-175 s) recovery values. Associations between CBv and O2Hb were poor, but stronger for long-channel than short-channel measurements. BP associated well with NIRS-measured O2Hb in the first 30 s after postural change. Stronger associations for CBv with long-channel O2Hb suggest that long-channel NIRS specifically reflects cerebral blood flow during postural transitions, necessary to better understand the consequences of OH such as intolerance symptoms.

Functional status associated with postural dizziness, but not postural hypotension, in older adults: a community-based study

BACKGROUND

Functional status, postural dizziness (PD), and postural hypotension (PH) were important issues in older adults. Only one study on the relationship for the three of them in female was without adjusting some important associated factors. This study was intended to investigate the association of PD and PH with functional status in older people of both genders.

METHODS

Based on a stratified randomized cluster sampling, 1361 subjects ≥ 65 years in the community were recruited from Tainan City, Taiwan, from 2000 to 2001. PH was defined as a decrease in systolic/diastolic blood pressure of ≥ 20/10 mm Hg after 1 or 2 min of standing. PD was defined by a positive response to dizziness-like symptoms after standing up from a supine position. Functional status included the activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

RESULTS

After adjusting other variables, ADL disability (OR: 1.84, 95% CI: 1.35-2.51) and IADL disability (OR: 1.62, 95% CI: 1.21-2.17) were associated with PD, but not PH. In male and female subgroups, ADL disability (male OR: 1.70, 95% CI: 1.08-2.67; female OR 1.96, 95% CI: 1.26-3.07) was associated with PD. In male, IADL disability was associated with PD (OR: 2.32, 95% CI: 1.36-3.95).

CONCLUSIONS

Impaired functional status, shown using ADLs or IADLs, was positively associated with PD, but not PH in older adults ≥ 65 years. Clinically, it may be important to evaluate PD in older adults with ADL or IADL disability.

Hospital Admission Due to Hypotension in Australia and in England and Wales

OBJECTIVES

Hypotension is overlooked because it is often harmless, easily reversed, and can have few or even no symptoms. However, complications of untreated hypotension are dangerous and can result in death. The aim of this study was to examine the trend of hospital admission due to hypotension in Australia and in England and Wales between 1999 and 2020.

METHOD

This was a secular trend analysis study that examined the hospitalisation pattern for hypotension in Australia, England, and Wales between 1999 and 2020. Hospitalisation data were obtained from the National Hospital Morbidity Database in Australia, Hospital Episode Statistics database in England, and Patient Episode Database for Wales. We analysed the variation in hospitalisation rates using the Pearson chi-square test for independence.

RESULTS

Our study showed that hypotension hospital admission rates increased significantly between 1999 and 2020 by 168%, 398%, and 149% in Australia, England, and Wales, respectively. The most common hypotension hospital admissions reason was orthostatic hypotension. All types of hypotension-related hospital admissions in Australia, England, and Wales were directly related to age, more common among the age group 75 years and above. Bed-days hypotension hospital admission patients accounted for 84.6%, 99.5%, and 99.7% of the total number of hypotension hospital admissions in Australia, England, and Wales.

CONCLUSION

In the past two decades, orthostatic hypotension was the most prevalent type of hypotension that required hospitalization in Australia, England, and Wales. Age was identified as the primary risk factor for hypotension across all causes. Future research should focus on identifying modifiable risk factors for hypotension and developing strategies to reduce the burden of orthostatic hypotension.

Randomised controlled trials of antihypertensive therapy: does exclusion of orthostatic hypotension alter treatment effect? A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Management of antihypertensive therapy is challenging in patients with symptomatic orthostatic hypotension, a population often excluded from randomised controlled trials of antihypertensive therapy. In this systematic review and meta-analysis, we sought to determine whether the association of antihypertensive therapy and adverse events (e.g. falls, syncope), differed among trials that included or excluded patients with orthostatic hypotension.

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials comparing blood pressure lowering medications to placebo, or different blood pressure targets on falls or syncope outcomes and cardiovascular events. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall in subgroups of trials that excluded patients with orthostatic hypotension and trials that did not exclude patients with orthostatic hypotension, and tested P for interaction. The primary outcome was fall events.

RESULTS

46 trials were included, of which 18 trials excluded orthostatic hypotension and 28 trials did not. The incidence of hypotension was significantly lower in trials that excluded participants with orthostatic hypotension (1.3% versus 6.2%, P < 0.001) but not incidences of falls (4.8% versus 8.8%; P = 0.40) or syncope (1.5% versus 1.8%; P = 0.67). Antihypertensive therapy was not associated with an increased risk of falls in trials that excluded (OR 1.00, 95% CI; 0.89-1.13) or included (OR 1.02, 95% CI; 0.88-1.18) participants with orthostatic hypotension (P for interaction = 0.90).

CONCLUSIONS

The exclusion of patients with orthostatic hypotension does not appear to affect the relative risk estimates for falls and syncope in antihypertensive trials.

Orthostatic hypotension, falls and in-hospital mortality among elderly patients with and without type 2 diabetes

OBJECTIVES

To evaluate the association of falls and in-hospital mortality with the presence of orthostatic hypotension and type 2 diabetes mellitus (T2D). The study also aims to identify whether the orthostatic hypotension assessed at 1 min or at 3 min can predict falls and mortality, as a secondary objective to identify the predictors of fall during hospitalization.

METHODS

We performed a prospective study with patients admitted to a university hospital. The risk of falls was assessed using the Morse questionnaire and the presence of falls was verified by the patient's medical records during hospitalization. The orthostatic hypotension was determined by measuring blood pressure at three times, considering as orthostatic hypotension the reduction of at least 20 mmHg in SBP or 10 mmHg in DBP. In-hospital mortality was consulted in the medical records.

RESULTS

Patients with orthostatic hypotension were slower on Timed Up and Go test (TUG) (12.26 ± 3.16 vs. 16.08 ± 5.96 s, P = 20 s) and presence of orthostatic hypotension. After adjustments, patients with T2D and orthostatic hypotension had a 2.7 times greater risk of in-hospital falls and 1.54 times greater odds of in-hospital mortality when compared with patients without T2D and orthostatic hypotension.

CONCLUSION

In this sample, sedentary patients and those with lower TUG had a higher risk of falls. The prevalence of falls was higher in patients with T2D. The association of T2D with orthostatic hypotension significantly increased both the risk of falls and the risk of in-hospital mortality.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing

BACKGROUND

Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up.

METHODS

OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures.

RESULTS

Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture.

DISCUSSION

The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Incidence of postural hypotension recorded in UK general practice: an electronic health records study

BACKGROUND

Postural hypotension is a common condition associated with adverse outcomes in older adults. General practice plays an important role in identification of the condition.

AIM

To examine the incidence of postural hypotension between 2008 and 2018 in general practice and how trends vary by age, sex, year, and social deprivation.

DESIGN AND SETTING

Retrospective cohort study using electronic health records from the IQVIA Medical Research Data (IMRD) between 2008 and 2018.

METHOD

Patients were included if they were aged ≥50 years. Incident postural hypotension was identified as a new (first) recording of a postural hypotension code. Recording of incident postural hypotension was estimated per 10 000 person-years at risk (PYAR) according to age, sex, year, and social deprivation. Incident rate ratios were estimated by multivariable Poisson regression.

RESULTS

Of 2 911 260 patients, 24 973 had an electronic record indicating a new diagnosis of postural hypotension between 2008 and 2018. This was equivalent to 17.9 cases per 10 000 PYAR in males (95% confidence interval [CI] = 17.6 to 18.2) and 16.2 cases per 10 000 PYAR in females (95% CI = 15.9 to 16.5). A significant age-sex interaction was identified. Recorded postural hypotension rate increased with age and social deprivation, and reduced between 2008 and 2018. The rate was higher in males compared with females, particularly in older age groups (>80 years).

CONCLUSION

To the authors' knowledge, this is the first study to quantify incident recorded postural hypotension in general practice. The rate is lower than expected compared with studies in screened older populations. Potential barriers to identification include underreporting, underdetection owing to lack of time and/or poorly standardised methods of measurement, and poor coding. Future research should investigate current practice and approaches for increased detection such as education, practical methods of screening, and standardised measurement of postural blood pressure.

Asymptomatic orthostatic hypotension and risk of falls in community-dwelling older people

INTRODUCTION

Many older people with orthostatic hypotension (OH) may not report typical symptoms of dizziness, light-headedness or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established.

METHODS

Continuous orthostatic blood pressure (BP) was measured during active stand using a Finometer at Wave 1 of The Irish Longitudinal Study on Ageing in participants aged ≥ 70 years.OH, with and without dizziness, was defined as a sustained drop in systolic BP ≥ 20 and/or diastolic BP ≥ 10 mm Hg at 30, 60 and 90 seconds post-standing.The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5).

RESULTS

Almost 11% (n = 934, mean age 75 years, 51% female) had OH, two-thirds of whom were asymptomatic.Dizziness was not associated with systolic BP drop at 30 (β = 1.54 (-1.27, 4.36); p = 0.256), 60 (β = 2.64 (-0.19, 5.47); p = 0.476) or 90 seconds (β = 2.02 (-0.91, 4.95); p = 0.176) after standing in adjusted models.Asymptomatic OH was independently associated with unexplained falls (odds ratio 2.01 [1.11, 3.65]; p = 0.022) but not explained falls (OR 0.93 [0.53, 1.62]; p = 0.797) during follow-up.

CONCLUSIONS

Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

CD-19 CART therapy and orthostatic hypotension: a single center retrospective cohort study

Background

Chimeric antigen receptor T-cell (CART) therapy is a form of cellular immunotherapy used to treat hematologic malignancies. Major adverse cardiovascular events have been seen in CART patients who have high grade CRS, higher baseline creatinine, and troponin elevation. However, the incidence and factors associated with orthostatic hypotension after CART therapy have not previously been reported in the literature.

Methods

We looked at patients who underwent CD-19 directed CART therapy at UPMC Shadyside hospital from April 1^st 2018 to December 1^st 2020. Patients were classified as having orthostatic hypotension if they had recorded orthostatic vital signs that were positive or provider notes indicated that vitals had been taken and were positive in the time period from discharge to 3 months post-CART. Data was analyzed with univariate and multivariate analysis using logistic regression.

Results

79% of patients had orthostatic hypotension after discharge from their CART hospitalization and 64% of those patients were symptomatic. Older age, lower BMI, lower ambulatory diastolic blood pressure and grade 2 CRS were associated with orthostatic hypotension in the univariate analysis. Older age and lower ambulatory systolic blood pressure were associated with orthostatic hypotension in the multivariate analysis. Symptomatic orthostatic hypotension was associated with a history of hypertension in both the univariate and multivariate analysis. Patients with symptoms also had a higher pre-CART ejection fraction but this association was not seen in the regression model.

Conclusion

There is a high incidence of orthostatic hypotension after CART therapy even after discharge. Therefore, orthostatic vitals signs and associated symptoms should be assessed in both the inpatient and outpatient setting. Older patients and patients with lower BMIs, lower ambulatory blood pressures, grade 2 CRS, or a history of hypertension may need closer monitoring.

Geriatric Pharmacotherapy Case Series: Neurogenic Orthostatic Hypotension

This case illustrates the pharmacist’s role in the outpatient management of neurogenic orthostatic hypotension (nOH) in a community-dwelling older person. In this case, the patient has a long-standing history of asymptomatic hypotension with recent onset of falls with temporary loss of consciousness prompting initiation of pharmacologic therapy. This case reviews nonpharmacological and pharmacological treatment options for older people with symptomatic nOH.

Preferential impairment of parasympathetic autonomic function in type 2 diabetes

OBJECTIVE

Cardiovascular autonomic neuropathy is a known complication in type 2 diabetes (T2D). However, the extent of sympathetic dysfunction and its relation to blood pressure (BP) dysregulation is insufficiently studied. We therefore assessed the cardiovascular sympathetic function using a standardized autonomic test-battery.

RESEARCH DESIGN AND METHODS

Forty T2D patients (mean age and duration of diabetes ±SD, 65.5 ± 7.3 and 9.5 ± 4.2 years) and 40 age- and gender-matched controls were examined through autonomic testing, assessing cardiovascular responses to deep breathing, Valsalva maneuver and tilt-table testing. Additionally, 24-hour oscillometric BP and self-reported autonomic symptoms on COMPASS-31 questionnaire was recorded.

RESULTS

Patients with T2D had reduced parasympathetic activity with reduced deep breathing inspiratory:expiratory-ratio (median [IQR] T2D 1.11 [1.08-1.18] vs. controls 1.18 [1.11-1.25] (p = 0.01)), and reduced heart rate variability (p < 0.05). We found no differences in cardiovascular sympathetic function measured through BP responses during the Valsalva maneuver (p > 0.05). 24-hour-BP detected reduced night-time systolic BP drop in T2D (9.8 % ± 8.8 vs. controls 15.8 % ± 7.7 (p < 0.01)) with more patients having reverse dipping. Patients with T2D reported more symptoms of orthostatic intolerance on the COMPASS-31 (p = 0.04).

CONCLUSIONS

Patients with T2D showed reduced parasympathetic activity but preserved short-term cardiovascular sympathetic function, compared to controls, indicating autonomic dysfunction with predominantly parasympathetic impairment. Despite this, T2D patients reported more symptoms of orthostatic intolerance in COMPASS-31 and had reduced nocturnal BP dipping, indicating that these are not a consequence of cardiovascular sympathetic dysfunction.

Implementation of exercise countermeasures during spaceflight and microgravity analogue studies: Developing countermeasure protocols for bedrest in older adults (BROA)

Significant progress has been made in the development of countermeasures to attenuate the negative consequences of prolonged exposure to microgravity on astronauts’ bodies. Deconditioning of several organ systems during flight includes losses to cardiorespiratory fitness, muscle mass, bone density and strength. Similar deconditioning also occurs during prolonged bedrest; any protracted time immobile or inactive, especially for unwell older adults (e.g., confined to hospital beds), can lead to similar detrimental health consequences. Due to limitations in physiological research in space, the six-degree head-down tilt bedrest protocol was developed as ground-based analogue to spaceflight. A variety of exercise countermeasures have been tested as interventions to limit detrimental changes and physiological deconditioning of the musculoskeletal and cardiovascular systems. The Canadian Institutes of Health Research and the Canadian Space Agency recently provided funding for research focused on Understanding the Health Impact of Inactivity to study the efficacy of exercise countermeasures in a 14-day randomized clinical trial of six-degree head-down tilt bedrest study in older adults aged 55–65 years old (BROA). Here we will describe the development of a multi-modality countermeasure protocol for the BROA campaign that includes upper- and lower-body resistance exercise and head-down tilt cycle ergometry (high-intensity interval and continuous aerobic exercise training). We provide reasoning for the choice of these modalities following review of the latest available information on exercise as a countermeasure for inactivity and spaceflight-related deconditioning. In summary, this paper sets out to review up-to-date exercise countermeasure research from spaceflight and head-down bedrest studies, whilst providing support for the proposed research countermeasure protocols developed for the bedrest study in older adults.

Diagnosis and treatment of orthostatic hypotension

Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.

A Comparison of Haemodynamic Responses between Head-Up Tilt and Lower Body Negative Pressure

Orthostatic intolerance (OI), a disorder of the autonomic nervous system, it is the development of symptoms when standing upright which are relieved when reclining. Head-up tilt (HUT) table test is a common test for assessing orthostatic tolerance. However, HUT is limited with low sensitivity and specificity. Another approach to stimulate the changing direction and value of the gravity field vector is the lower body negative pressure (LBNP) chamber. The aims of the study is to evaluate the physiological responses of healthy subjects on HUT and LBNP, and examine the relations of two tests. A total of 19 subjects were recruited. A validated wearable device, Sotera Visi Mobile was use to collect physiological signals simultaneously throughout the experiment procedures. Each subject went through a baseline supine rest, 70o of HUT test, another round of baseline supine rest, followed by activation of LBNP test. Three level of suction were applied, i.e. -30 mmHg, -40 mmHg, and -50 mmHg. In this pilot study, healthy subjects showed significantly increased of heart rate, and decreased of systolic blood pressure and diastolic blood pressure, in both HUT and LBNP tests. Although both tests are capable of stimulating a decreased blood volume in the central circulation, but the physiological responses behaved differently and shown only very week correlation. This suggesting that a combination of LBNP test with HUT test might work the best in orthostatic intolerance assessment.

Risk of Chronic Kidney Disease Associated With Orthostatic Hypotensive Stress: A Community-Based Korean Study

BACKGROUND

The relationship between orthostatic blood pressure (BP) changes and incident chronic kidney disease (CKD) has not been explored in Asian populations.

METHODS

We reviewed the data of 7,039 participants from the Ansung-Ansan cohort study. BP was measured in the supine position and 2 minutes after standing. The change in BP from the supine to upright position was defined as orthostatic BP change. Orthostatic systolic BP (SBP) decline was defined as an orthostatic SBP change of <-2 mm Hg. The primary outcome was the development of CKD, defined as the first event of an estimated glomerular filtration rate <60 ml/min/1.73 m2 at least twice during the follow-up period.

RESULTS

Of 7,039 participants, 949 (13.5 %) developed incident CKD over a mean of 11.9 years. Although orthostatic diastolic BP change was not associated with incident CKD, every 1 mm Hg increase in orthostatic SBP change was associated with a decreased risk of incident CKD (HR, 0.989; 95% CI, 0.982-0.995; P = 0.001). Orthostatic SBP decline was associated with an increased risk of incident CKD (HR, 1.337; 95% CI, 1.163-1.537; P < 0.001). Older age and diabetes were associated with increased odds of orthostatic SBP decline, whereas male sex and high body mass index were associated with decreased odds of orthostatic SBP decline. Subgroup analysis revealed that orthostatic SBP decline was associated with incident CKD only in non-diabetic participants.

CONCLUSIONS

Orthostatic SBP decline was independently associated with an increased risk of future incident CKD, whereas orthostatic DBP decline was not.

Orthostatic hypotension and mortality risk in geriatric outpatients: the impact of duration and magnitude of the blood pressure drop

INTRODUCTION

Orthostatic hypotension is a common condition associated with an increased mortality risk. This study investigates this association specifically in geriatric outpatients and additionally focuses on the duration and magnitude of orthostatic hypotension.

METHODS

In this observational prospective cohort study with geriatric outpatients from the Amsterdam Ageing cohort, we differentiated orthostatic hypotension in early orthostatic hypotension (EOH) and delayed/prolonged orthostatic hypotension (DPOH). The magnitude of drop in both SBP and DBP after either 1 or 3 min was quantified. Mortality data was obtained from the Dutch municipal register. Cox proportional hazard models were used to determine the association between orthostatic hypotension and mortality, adjusted for sex and age (model 1), additionally adjusted for orthostatic hypotension-inducing drugs + SBP (model 2) and the presence of cardiovascular disease and diabetes (model 3). Stratified analyses in patients with geriatric deficits were performed.

RESULTS

We included 1240 patients (mean age 79.4 ± 6.9 years, 52.6% women). Prevalence of orthostatic hypotension was 443 (34.9%); 148 (11.9%) patients had EOH and 285 (23%) DPOH. DPOH was associated with a higher mortality risk [hazard ratio, 95% CI 1.69 (1.28-2.22)] whereas EOH was not associated with mortality risk. This association did not differ in patients with geriatric deficits. Furthermore, the magnitude of drop in both SBP and DBP was associated with a higher mortality risk.

CONCLUSION

The presence of DPOH and the magnitude of both systolic and diastolic orthostatic hypotension are related to an increased mortality risk in geriatric outpatients. Whether the duration of orthostatic hypotension and magnitude of the drop in blood pressure is causally related to mortality risk or whether it is a sign of decreased resilience remains to be elucidated.

Orthostatic blood pressure changes and diabetes duration

To determine the prevalence and the associated clinical characteristics of orthostatic hypotension and orthostatic hypertension in patients with diabetic sensorimotor polyneuropathy (DSP).

METHODS

A single-center retrospective cross-sectional study was conducted on 200 DSP patients who had 3-minute orthostatic measures as part of the standard clinic evaluation. We measured the heart rate (HR) and blood pressure (BP) supine and again after 3 min of standing.

RESULTS

The prevalence of orthostatic hypotension was 19.5% and that of orthostatic hypertension was 23%. Subjects with orthostatic hypotension had significantly longer diabetes duration than subjects who were normotensive and those with orthostatic hypertension. Quantitatively, BP changes from supine to standing correlated with diabetes duration (R = 0.306; P = 0.0582) and age (R = 0.434; P = 0.006) in subjects with orthostatic hypotension.

CONCLUSIONS

Orthostatic hypertension and orthostatic hypotension are frequent in patients with DSP. Orthostatic hypertension is associated with shorter diabetes duration than orthostatic hypotension.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens

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.

Blood pressure and heart rate responses to orthostatic challenge and Valsalva manoeuvre in mild cognitive impairment with Lewy bodies

OBJECTIVES

Orthostatic hypotension is a common feature of normal ageing, and age-related neurodegenerative diseases, in particular the synucleinopathies including dementia with Lewy bodies. Orthostatic hypotension and other abnormal cardiovascular responses may be early markers of Lewy body disease. We aimed to assess whether abnormal blood pressure and heart rate responses to orthostatic challenge and Valsalva manoeuvre would be more common in mild cognitive impairment with Lewy bodies (MCI-LB) than MCI due to Alzheimer's disease (MCI-AD).

METHODS

MCI patients (n = 89) underwent longitudinal clinical assessment with differential classification of probable MCI-LB, possible MCI-LB, or MCI-AD, with objective autonomic function testing at baseline. Blood pressure and heart rate responses to active stand and Valsalva manoeuvre were calculated from beat-to-beat cardiovascular data, with abnormalities defined by current criteria, and age-adjusted group differences estimated with logistic models.

RESULTS

Orthostatic hypotension and abnormal heart rate response to orthostatic challenge were not more common in probable MCI-LB than MCI-AD. Heart rate abnormalities were likewise not more common in response to Valsalva manoeuvre in probable MCI-LB. An abnormal blood pressure response to Valsalva (delayed return to baseline/absence of overshoot after release of strain) was more common in probable MCI-LB than MCI-AD. In secondary analyses, magnitude of blood pressure drop after active stand and 10-s after release of Valsalva strain were weakly correlated with cardiac sympathetic denervation.

CONCLUSIONS

Probable MCI-LB may feature abnormal blood pressure response to Valsalva, but orthostatic hypotension is not a clear distinguishing feature from MCI-AD.

Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms

BACKGROUND

Orthostatic hypotension (OH) based on a change from seated-to-standing blood pressure (BP) is often used interchangeably with supine-to-standing BP.

METHODS

The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in adults aged ≥70 years at high risk of falls. OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mmHg, measured at pre-randomization, 3-, 12-, and 24-month visits with each of 2 protocols: seated-to-standing and supine-to-standing. Participants were asked about orthostatic symptoms, and falls were ascertained via daily fall calendar, ad hoc reporting, and scheduled interviews.

RESULTS

Among 534 participants with 993 paired supine and seated assessments (mean age 76 ± 5 years, 42% women, 18% Black), mean baseline BP was 130 ± 19/68 ± 11 mmHg; 62% had a history of high BP or hypertension. Mean BP increased 3.5 (SE, 0.4)/2.6 (SE, 0.2) mmHg from sitting to standing, but decreased with supine to standing (mean change: -3.7 [SE, 0.5]/-0.8 [SE, 0.3] mmHg; P-value < 0.001). OH was detected in 2.1% (SE, 0.5) of seated versus 15.0% (SE, 1.4) of supine assessments (P < 0.001). While supine and seated OH were not associated with falls (HR: 1.55 [0.95, 2.52] vs 0.69 [0.30, 1.58]), supine systolic OH was associated with higher fall risk (HR: 1.77 [1.02, 3.05]). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month (P-values < 0.03), while sitting OH was not associated with any symptoms (P-values ≥ 0.40).

CONCLUSION

Supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH.

Assessment of autonomic symptoms may assist with early identification of mild cognitive impairment with Lewy bodies

OBJECTIVES

Autonomic symptoms are a common feature of the synucleinopathies, and may be a distinguishing feature of prodromal Lewy body disease. We aimed to assess whether the cognitive prodrome of dementia with Lewy bodies, mild cognitive impairment (MCI) with Lewy bodies (MCI-LB), would have more severe reported autonomic symptoms than cognitively healthy older adults, with MCI due to Alzheimer's disease (MCI-AD) also included for comparison. We also aimed to assess the utility of an autonomic symptom scale in differentiating MCI-LB from MCI-AD.

METHODS

Ninety-three individuals with MCI and 33 healthy controls were assessed with the Composite Autonomic Symptom Score 31-item scale (COMPASS). Mild cognitive impairment patients also underwent detailed clinical assessment and differential classification of MCI-AD or MCI-LB according to current consensus criteria. Differences in overall COMPASS score and individual symptom sub-scales were assessed, controlling for age.

RESULTS

Age-adjusted severity of overall autonomic symptomatology was greater in MCI-LB (Ratio = 2.01, 95% CI: 1.37-2.96), with higher orthostatic intolerance and urinary symptom severity than controls, and greater risk of gastrointestinal and secretomotor symptoms. MCI-AD did not have significantly higher autonomic symptom severity than controls overall. A cut-off of 4/5 on the COMPASS was sensitive to MCI-LB (92%) but not specific to this (42% specificity vs. MCI-AD and 52% vs. healthy controls).

CONCLUSIONS

Mild cognitive impairment with Lewy bodies had greater autonomic symptom severity than normal ageing and MCI-AD, but such autonomic symptoms are not a specific finding. The COMPASS-31 may therefore have value as a sensitive screening test for early-stage Lewy body disease.

Strategies to improve uptake and adherence of non-pharmacologic interventions for orthostatic hypotension in older people: a qualitative study

Aim

To identify specific behavioural change techniques to promote uptake and adherence with non-pharmacologic interventions for older adults with OH.

Findings

Specific behaviour change strategies, derived from older people with orthostatic hypotension, include biofeedback, rehearsal, embedding into daily routine and patient education.

Message

Evidence-based behaviour change strategies may be used to improve uptake and adherence to non-drug therapies for older people with orthostatic hypotension.

Purpose

Non-pharmacologic therapies are a safe and effective treatment for orthostatic hypotension (OH) in older adults. However, adherence to non-drug therapies is challenging and may require specific behaviour change approaches to promote uptake and adherence. The study aim is to identify specific behavioural change techniques to promote uptake and adherence with non-pharmacologic interventions for older adults with OH.

Methods

Forty semi-structured, qualitative interviews were performed in 25 older adults with OH. Each participant experienced bolus-water drinking, physical counter-manoeuvres and compression garments during two efficacy studies. Emergent themes were identified through framework analysis, based on The Behaviour Change Technique Taxonomy.

Results

Several themes to encourage uptake and adherence arose. Motivation to adhere with an intervention may be improved by demonstrating its effectiveness, either through symptom monitoring or biofeedback. Practising or rehearsing how to use an intervention may improve self-efficacy and promote habit formation. Embedding therapies into daily life so that they become second nature was felt to be a useful strategy. Educating older adults about why they are being asked to use a therapy and demonstrating how to use it is important. More specific barriers may be overcome by encouraging a personal problem-solving approach.

Conclusion

These specific behaviour change techniques, derived by older people with OH and based on evidence-based approaches, provide useful strategies to improve the uptake and adherence of non-drug therapies in the treatment of OH.

Trial registration

ISRCTN15084870.

A community-based cross-sectional survey of orthostatic hypotension among elderly from south India

BACKGROUND

Orthostatic hypotension (OH) increases the risk of falls and associated morbidity and mortality in elderly. Hence, determining the prevalence of OH and its associated factors is important, especially in understudied LMIC settings.

METHODS

A community-based cross-sectional study was conducted among randomly selected 240 community-dwelling elderly from Thiruvananthapuram, Kerala. The OH symptoms were assessed by standard clinical measurements and frailty was assessed by modified Fried frailty phenotype. Logistic regression analysis was conducted to assess the factors associated with OH.

RESULTS

The prevalence of OH and frailty among participants was 9.6 and 29.2 percent respectively. In the first minute, OH was associated with increased odds of falls (OR = 1.97 [95%CI = 1.05, 3.72]). Increase in number of co-morbidities (OR_adj = 1.82 [95%CI = 1.36, 2.48]), number of medicines used (OR_adj = 1.73 [95%CI = 1.28, 2.34]), and orthostatic intolerance (OR_adj = 3.67 [95%CI = 1.13, 11.94]) increased the odds of having OH. Elderly with diabetes (OR_adj = 4.81 [95%CI = 1.57, 14.77]), hypertension (OR_adj = 4.97 [95%CI = 1.01, 24.46]) and cognitive impairment (OR_adj = 5.01 [95%CI = 1.40, 18.51]) were at a higher odds of having OH.

CONCLUSIONS

OH and frailty are prevalent in community dwelling elderly in Thiruvananthapuram district. Frailty may be a risk factor for OH in the first minute. The number of co-morbidities may be an independent risk factor for OH. Hence, elderly people with comorbidities and cognitive impairment may be actively assessed for OH to prevent falls and associated injuries.

Drug-induced orthostatic hypotension: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Drug-induced orthostatic hypotension (OH) is common, and its resulting cerebral hypoperfusion is linked to adverse outcomes including falls, strokes, cognitive impairment, and increased mortality. The extent to which specific medications are associated with OH remains unclear.

METHODS AND FINDINGS

We conducted a systematic review and meta-analysis to evaluate the extent to which specific drug groups are associated with OH. EMBASE, MEDLINE, and Web of Science databases were searched from inception through 23 November 2020. Placebo-controlled randomised controlled trials (RCTs) on any drug reporting on OH as an adverse effect in adults (≥18 years) were eligible. Three authors extracted data on the drug, OH, dose, participant characteristics, and study setting. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to appraise evidence. Summary odds ratios (ORs) were estimated for OH using fixed effects Mantel-Haenszel statistics. We conducted subgroup analysis on validity of OH measurement, drug dose, risk of bias, age, and comorbidity. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to summarise the certainty of evidence. Of 36,940 citations, 69 eligible RCTs were included in the meta-analysis comprising 27,079 participants. Compared with placebo, beta-blockers and tricyclic antidepressants were associated with increased odds of OH (OR 7.76 [95% CI 2.51, 24.03]; OR 6.30 [95% CI 2.86, 13.91]). Alpha-blockers, antipsychotics, and SGLT-2 inhibitors were associated with up to 2-fold increased odds of OH, compared to placebo. There was no statistically significant difference in odds of OH with vasodilators (CCBs, ACE inhibitors/ARBs, SSRIs), compared to placebo. Limitations of this study are as follows: data limited to placebo-controlled studies, (excluding head-to-head trials), many RCTs excluded older participants; therefore results may be amplified in older patients in the clinical setting. The study protocol is publicly available on PROSPERO (CRD42020168697).

CONCLUSIONS

Medications prescribed for common conditions (including depression, diabetes, and lower urinary tract symptoms) were associated with significantly increased odds of OH. Drugs causing sympathetic inhibition were associated with significantly increased odds of OH, while most vasodilators were associated with small nonsignificant differences in odds of OH, compared to placebo. Drugs targeting multiple parts of the orthostatic blood pressure (BP) reflex pathway (e.g. sympathetic inhibition, vasodilation, cardio-inhibitory effects) may carry cumulative risk, suggesting that individuals with polypharmacy could benefit from postural BP monitoring.

Orthostatic Hypotension in Male Hypertensive Patients: A Cross-Sectional Study at the University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia

Background

Orthostatic hypotension (OH) is defined as a fall in systolic blood pressure (SBP) ≥20 mmHg or diastolic BP (DBP) ≥10 mmHg within 3 minutes of standing. OH incidence is increased with hypertension, and management of these patients may pose challenges, as treatment of one can worsen the other.

Objective

This study aimed to determine the prevalence of OH and its associated factors among male hypertensive patients at the University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia.

Methods

A hospital-based cross-sectional design was employed. Seated BP was measured twice and the average of the two taken. After BP had been stabilized for 5 minutes, SBP within 3 minutes of standing was measured twice and the minimum of the two taken. A drop of ≥20 mmHg in SBP within 3 minutes of standing was taken as OH. All male hypertensive patients who were able to attain a standing position were included. Sociodemographic, anthropometric, and clinical status of the patients were taken using structured interviewer-administered questionnaires. Data were entered and analyzed using SPSS 21. Both bivariate and multivariate logistic regression analysis were done. P≤0.05 was considered statistically significant.

Results

The median age of study participants was 57 (25–96) years. The prevalence of OH was 17.6%. Uncontrolled hypertension (adjusted OR 2.08, 95% CI 1.125–3.872) and duration of hypertension ≥5 years (adjusted OR 2.04, 95% CI 1.069–3.895) were significantly associated with OH in hypertensive patients.

Conclusion

The prevalence of OH among male hypertensive patients was high. Hypertensive patients whose BP was uncontrolled and having had hypertension ≥5 years were risk factors of OH.

Orthostatic Hypotension and Orthostatic Intolerance Symptoms in Geriatric Rehabilitation Inpatients, RESORT

OBJECTIVES

Orthostatic hypotension (OH) and orthostatic intolerance symptoms are common in older community-dwelling adults and are associated with reduced quality of life and detrimental health outcomes. This study aimed to determine the prevalence, co-occurrence and determinants of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients.

DESIGN

Observational, longitudinal cohort, "REStORing the health of acutely unwell adulTs" (RESORT).

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients (n = 1505) of a tertiary teaching hospital in Melbourne, Australia.

METHODS

OH was defined as a drop in systolic blood pressure by ≥20 mm Hg and/or diastolic blood pressure by ≥10 mm Hg within three 3 of moving from supine to a standing or sitting position. Symptoms were recorded following the 3 minutes. Determinants included sociodemographics, reason for admission, cognitive health, nutritional status, physical performance, frailty, morbidity, medication use, length of stay (LOS), and number of geriatric conditions. Independent t-tests, Mann-Whitney U tests or χ² tests were used to analyze differences between inpatients with and without OH and symptoms. Logistic regression analyses were used to ascertain the determinants.

RESULTS

OH and orthostatic intolerance symptoms were prevalent in 19.8% (standing: 21.4%, sitting: 18.2%) and 22.6% (standing: 25.0%, sitting: 20.2%) of inpatients, respectively. Symptoms were reported by 32.8% of inpatients with OH and 20.1% without OH. Higher number of comorbidities and geriatric conditions, low functional independence, and longer LOS were determinants of OH. Female gender, higher number of morbidities and geriatric conditions, low functional independence, depression risk, poor physical performance, musculoskeletal and "other" reasons for admission, and long LOS during geriatric rehabilitation were determinants of symptoms.

CONCLUSIONS AND IMPLICATIONS

OH and orthostatic intolerance symptoms occur in one-fifth of geriatric rehabilitation inpatients, however, the co-occurrence is low and determinants differ. Poorer health in patients with orthostatic intolerance symptoms highlights the need to assess symptoms in clinical practice, independent of an OH diagnosis.

Orthostatic Hypotension is a Risk Factor for Falls Among Older Adults: 3-Year Follow-Up

OBJECTIVES

To assess the prevalence of orthostatic hypotension (OH) and the association of OH with the risk of falls among community-dwelling older adults with a previous fall.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

The subjects (n = 561) were participants in fall prevention conducted in western Finland.

METHODS

Blood pressure (BP) was measured in supine position and at 30 seconds and 3 minutes after standing. The participants were divided according to the consensus definition to an OH group (OHG) and a non-OH group (non-OHG). Falls were recorded by fall diaries during 12 months. Falls requiring treatment were gathered from health center and hospital registers during 12 and 36 months.

RESULTS

The prevalence of OH was 23.4% (30 seconds) and 7.3% (3 minutes). The 30-second measurement showed that the incidence of falls and that of falls requiring treatment were significantly higher in OHG compared with non-OHG during 12 months. After adjustments, the incidence of falls remained higher in all 5 adjusted models whereas that of falls requiring treatment remained higher only after adjustment for functional balance. The 3-minute measurement showed that the incidence of falls was higher in OHG compared with non-OHG during 12 months and remained higher after adjustments for functional balance and for age and functional balance. During the 36-month follow-up, OH measured at 30 seconds or 3 minutes after standing was not associated with the occurrence of falls leading to treatment.

CONCLUSIONS AND IMPLICATIONS

OH at 30 seconds or 3 minutes after standing is associated with a greater risk for falling within 12 months in older adults. The 30-second blood pressure measurement is more reliable to detect the risk than the 3-minute measurement. The results support the usability of 30-second measurement in determining OH and the risk for falling among older persons.

Orthostatic hypotension assessed by active standing is associated with worse cognition in geriatric rehabilitation inpatients, RESORT

PURPOSE

Geriatric rehabilitation inpatients who suffer from acute and chronic diseases that aggravate blood pressure (BP) dysregulation, may be particularly susceptible to orthostatic hypotension (OH). OH may increase the risk of cerebral small vessel disease and subsequent white matter hyperintensities inducing cognitive impairment (CI). This study investigates the association between OH and cognition in geriatric rehabilitation inpatients.

MATERIALS AND METHODS

Geriatric rehabilitation inpatients of the observational, longitudinal REStORing health of acutely unwell adulTs (RESORT) cohort in Melbourne, Australia, underwent intermittent BP measurements during active standing or partial postural change to sitting (when unable to stand). OH was defined as a systolic BP drop ≥20 mmHg and/or diastolic BP drop ≥10 mmHg within three minutes after postural change. CI included dementia diagnosis, Mini-Mental State Examination (MMSE) score <24 points (categorized as 18-23 (mild CI) and <18 points (severe CI)), Montreal Cognitive Assessment score <26 points or Rowland Universal Dementia Assessment Scale score <23 points.

RESULTS

In geriatric rehabilitation inpatients (n=1232, mean age 82.3 years (SD 8.2), 57.5% female), OH, CI and dementia prevalence was 20.0%, 61.0% and 20.4% respectively. MMSE was scored 18-23 in 32.6% and <18 points in 27.8% of patients (n=1033). In standing patients (51.7%), OH was associated with CI (p=0.045) and dementia (p=0.021), with a trend for MMSE scores <18 points (p=0.080), but not for MMSE scores 18-23 points (p=0.528). No association was found between seated OH and cognition.

CONCLUSION

OH assessed by active standing using intermittent BP measurements was associated with worse cognition in geriatric rehabilitation inpatients.

The effects of caffeine in adults with neurogenic orthostatic hypotension: a systematic review

Purpose

To systematically review the evidence base for the effectiveness and safety of caffeine for the treatment of neurogenic orthostatic hypotension in adults.

Methods

Eight electronic databases were searched in January 2021. Original research studies or case reports involving adults with neurogenic orthostatic hypotension were included if caffeine was an intervention and outcomes included symptoms, blood pressure or adverse effects. Relevant studies were screened and underwent qualitative analysis. Insufficient reporting precluded meta-analysis.

Results

Five studies were identified: four crossover studies and one case report summation. Study size ranged from 5 to 16 participants. Participants had neurogenic orthostatic hypotension, with a mean standing systolic blood pressure of 86 mmHg. Two studies evaluated caffeine alone. Three studies administered caffeine in combination with ergotamine. Caffeine dose ranged from 100 to 300 mg. Nature and timing of outcomes measured varied between studies, with measurements being recorded from 30 to 480 min after intervention. Caffeine/ergotamine improved symptoms in one study and reduced orthostatic blood pressure drop in two studies. Caffeine/ergotamine increased seated blood pressure in three studies, whilst the results for caffeine alone were inconsistent. No serious adverse events were reported. All studies demonstrated high risk of bias.

Conclusion

Caffeine should only be considered as a treatment for adults with neurogenic orthostatic hypotension when evidence-based treatments have been exhausted.

Systematic review registration

PROSPERO ID: CRD42020124589. Date of registration: 30/10/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s10286-021-00814-5.

Is Fall Risk Systematically Evaluated in Memory Clinics? A National Survey of Practice in France

BACKGROUND

Falls are a major health problem in older persons but are still under-diagnosed and challenging to prevent. Current guidelines do not target high-risk populations, especially people living with dementia. In France, people with neurocognitive disorders are mainly referred to memory clinics (MCs).

OBJECTIVE

We aimed to survey the routine practice of physicians working in MCs regarding fall risk assessment.

METHODS

We conducted a cross-sectional survey in France from January to May 2019 among physicians working in MCs, through an anonymous online questionnaire: twenty-seven questions about the physician's background and their practice of fall risk assessment, especially use of clinical and paraclinical tools. We compared the results according to the age and the specialty of the physician.

RESULTS

We obtained 171 responses with a majority of women (60%) and geriatricians (78%). All age classes and all French regions were represented. Most of respondents (98.8%) stated that they address gait and/or falls in outpatient clinic and 95.9%in day hospitals. When asked about how they assess fall risk, fall history (83%) and gait examination (68.4%) were the most widely used, while orthostatic hypotension (24%) and clinical standardized tests (25.7%) were less common. Among standardized tests, One-leg Balance, Timed Up and Go Test, and gait speed measurements were the most used. Geriatricians had more complete fall risk assessment than neurologists (e.g., 56%versus 13%for use of standardized tests, p < 0.0001).

CONCLUSION

Almost all physicians addressed the question of fall in MC, but practices are widely heterogeneous. Further investigations are needed to standardize fall risk assessment in MCs.