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McDonagh STJ, Mejzner N, Clark CE. Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:1. [PMID: 33388038 PMCID: PMC7777418 DOI: 10.1186/s12875-020-01313-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups. METHODS Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale. RESULTS One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2 = 99%) for 34 community cohorts, 19% (15-25%; I2 = 98%) for 23 primary care cohorts and 31% (15-50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16-23%; I2 = 98%) with hypertension (20 cohorts), 21% (16-26%; I2 = 92%) with diabetes (4 cohorts), 25% (18-33%; I2 = 88%) with Parkinson's disease (7 cohorts) and 29% (25-33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12-17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04). CONCLUSIONS PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH. PROSPERO CRD42017075423.
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Affiliation(s)
- Sinead T J McDonagh
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England.
| | - Natasha Mejzner
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England
| | - Christopher E Clark
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England
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Clark CE, Thomas D, Warren FC, Llewellyn DJ, Ferrucci L, Campbell JL. Detecting Risk Of Postural hypotension (DROP): derivation and validation of a prediction score for primary care. BMJ Open 2018; 8:e020740. [PMID: 29678986 PMCID: PMC5914723 DOI: 10.1136/bmjopen-2017-020740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Christopher Elles Clark
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Daniel Thomas
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Fiona C Warren
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - David J Llewellyn
- Mental Health Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Luigi Ferrucci
- Longitudinal Studies Section, National Institute on Aging, Baltimore, Maryland, USA
| | - John L Campbell
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
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McLean DL, Simpson SH, McAlister FA, Tsuyuki RT. Treatment and blood pressure control in 47,964 people with diabetes and hypertension: a systematic review of observational studies. Can J Cardiol 2006; 22:855-60. [PMID: 16957803 PMCID: PMC2569016 DOI: 10.1016/s0828-282x(06)70304-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes. OBJECTIVE To examine treatment and control of hypertension in people with diabetes. DATA SOURCES Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites. METHOD Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently. RESULTS A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control--160/90 mmHg or less--reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings. CONCLUSIONS Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.
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Affiliation(s)
- Donna L McLean
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Scot H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta
| | - Finlay A McAlister
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Ross T Tsuyuki
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta
- Correspondence and reprints: Dr Ross T Tsuyuki, Epidemiology Coordinating and Research Centre/Centre for Community Pharmacy Research and Interdisciplinary Strategies, Division of Cardiology, #220 College Plaza, University of Alberta, Edmonton, Alberta T6G 2C8. Telephone 780-492-8526, fax 780-492-6059, e-mail
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Maddens M, Imam K, Ashkar A. Hypertension in the Elderly. Prim Care 2005; 32:723-53. [PMID: 16140125 DOI: 10.1016/j.pop.2005.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertension is predictive of a wide variety of subsequent adverse events in elderly patients, at least up to the age of 80 years. Treatment can reduce these adverse outcomes, although the benefits in the very elderly remain somewhat unclear. In the very elderly, there appears to be a reduction in cardiovascular events, but this reduction is perhaps at the expense of an increase in overall mortality. Target BPs in the elderly remain controversial. Among patients who have not had previous stroke or significant cardiovascular or renal disease, the benefits of reducing the SBP below 159 mm Hg are well documented. There is some evidence to suggest, however, that if doing so increases the day-night difference in BP by more than 20% or is associated with a decline in DBP below 65 mm Hg, then the benefits of treatment may be attenuated or lost. In addition, there is some suggestion that reducing SBP consistently below 135 mm Hg may accelerate cognitive decline. There appears to be a role for sodium restriction in those who can comply without otherwise compromising nutrient intake. Likewise, exercise may be beneficial and have benefits beyond simply lowering BP. Weight loss in those who are overweight may also help in lowering the BP. For most patients, low-dose thiazides such as hydrochlorothiazide are likely to be the appropriate first-line therapy (even in patients who have diabetes) unless they exacerbate or precipitate urinary incontinence or gout or complicate concomitant drug therapy (eg, lithium treatment of bipolar disorder). In very elderly patients, the apparent beneficial effects on strokes, major cardiovascular events, and heart failure rates may justify treating despite lack of benefit on overall mortality.
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Affiliation(s)
- Michael Maddens
- Division of Geriatric Medicine, William Beaumont Hospital, 3535 West 13 Mile Road, Suite 108, Royal Oak, MI 48073, USA.
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Fisher AA, Davis MW, Le Couteur DG. The effect of meals at different mealtimes on blood pressure and symptoms in geriatric patients with postprandial hypotension. J Gerontol A Biol Sci Med Sci 2005; 60:184-5; author reply 185-6. [PMID: 15814859 DOI: 10.1093/gerona/60.2.184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lin JL, Armour D. Selected medical management of the older rehabilitative patient 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Arch Phys Med Rehabil 2004; 85:S76-82; quiz S83-4. [PMID: 15221737 DOI: 10.1016/j.apmr.2004.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
UNLABELLED This self-directed learning module highlights present practices of geriatric medicine that are commonly seen in an inpatient rehabilitation setting. It is a part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. In particular, attention is given to update physiatrists in the geriatric medical advances in pharmacotherapeutic considerations, the management of hypertension, diabetes mellitus, urinary tract infections, and sleep disorders. OVERALL ARTICLE OBJECTIVE To update the common present-day medical practices for older persons seen in a rehabilitation setting.
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Affiliation(s)
- John L Lin
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Hanon O, Rigaud AS, Seux ML, Forette F. Prévention du risque vasculaire cérébral. Faut-il traiter l’hypertension artérielle chez le sujet âgé ? Rev Neurol (Paris) 2004; 160:471-7. [PMID: 15103276 DOI: 10.1016/s0035-3787(04)70933-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- O Hanon
- Service de Gériatrie, Hôpital Broca, CHU Cochin Port-Royal/Université René Descartes, Paris V, 54-56, rue Pascal, 75013 Paris.
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Pham M, Pinganaud G, Richard-Harston S, Decamps A, Bourdel-Marchasson I. Prospective audit of diabetes care and outcomes in a group of geriatric French care homes. DIABETES & METABOLISM 2003; 29:251-8. [PMID: 12909813 DOI: 10.1016/s1262-3636(07)70034-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In geriatric institutions, diabetes prevalence varies from 10 to 20%. However, little is known about patterns of care and their outcomes. To assess both, an 18-month prospective audit was conducted in 240-bed nursing and 80-bed residential care homes. METHODS In diabetic subjects, items of care were compared to the corresponding French guideline end-points. Dependency in activities for daily living (ADL) was evaluated at inclusion and at the end of the survey for survivors. Diabetic residents were compared to others for age, sex, mortality and one-year change of iso-resource group ranging (IRG), a need-of-care scale. RESULTS The 73 diabetic patients among 494 residents (14.8%) were not different from the others for age and sex (respectively age: 76.0 y +/- 7.9 compared to 78.2 y +/- 9.4; M/F sex ratio: 0.59 compared to 0.31). Oral hypoglycemic agents were prescribed in 29 (39.7%) and insulin in 26 (35.6%). Control of diabetes with HbA(1C) was in keeping with guidelines in 23.3%, HbA(1C) was never performed in 26%, and > 8% in 20.5%. Rates of items of guidelines that were never addressed ranged from 2 to 80%. During the stay, ADL dependency worsened in diabetic patients, but their one-year change in GIR range was not different from that in the others. Mortality was 30.1% compared to 37.1% in the others (NS). This mortality rate and the evolution of functional dependency were not influenced by the quality of diabetes control. CONCLUSION In these disabled elderly patients, diabetes management needs to be improved. However, mortality and the evolution of functional dependency were similar in diabetic people than in others. Interventional studies for controlling with reference to geriatric evaluation, i.e. function, nutrition and mental health, are needed in order to establish specific guidelines based on benefit-burden analysis.
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Affiliation(s)
- M Pham
- Département de Gériatrie, CHU de Bordeaux, France
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Hossain M, Ooi WL, Lipsitz LA. Intra-individual postural blood pressure variability and stroke in elderly nursing home residents. J Clin Epidemiol 2001; 54:488-94. [PMID: 11337212 DOI: 10.1016/s0895-4356(00)00322-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Orthostatic hypotension (OH) is a potential risk factor for adverse cardiovascular events, but OH is highly variable and may not be detected on a single occasion. To assess the relation between intra-individual variability of systolic orthostatic blood pressure change (DeltaSBP) and cardiovascular outcomes, an algorithm was developed to identify DeltaSBP instability using repeated supine and standing BP measurements. A cohort of 673 nursing home residents underwent baseline postural BP measurements (supine to 1 minute of standing, four times in a single day) and were followed for up to 2 years. Two groups (stable vs. unstable) were identified based on an analysis of DeltaSBP variance components. Differences in outcomes were compared via Cox survival analysis. At baseline 12.6% were unstable, defined as a one standard deviation difference of at least 20.2 mmHg between DeltaSBP readings. Unstable subjects were more likely to have OH on at least one measurement (systolic BP drop of 20 mmHg or more; 85% vs. 36%, respectively) and to be on psychotropic medication at baseline (47% vs 35%) (P-values <0.001). Other characteristics (including previous stroke) did not differ. During a mean follow-up of 10.3 months, stroke incidence was higher in unstable subjects (13.1% vs. 4.9%; P = 0.012), but ischemic heart disease and mortality rates were not significantly different (respectively, 13.5% vs. 7.4%, P = 0.115; 14.8% vs. 10.7%, P = 0.178). Survival analyses (adjusted for age, sex, psychotropic medications, body mass index, ischemic heart disease, and supine systolic pressure) confirmed a higher risk of stroke in unstable subjects (relative risk = 3.7, 95% CI: 1.6-8.4). Highly variable orthostatic BP measures may reflect impaired BP regulatory mechanisms in elders with occult cerebrovascular disease, or may directly affect cerebral blood flow. Orthostatic BP variability may be a better indicator of future stroke than a single supine or orthostatic change measure.
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Affiliation(s)
- M Hossain
- West Roxbury Veterans Administration Medical Center, Massachusetts Veterans Epidemiology Research & Information Center, West Roxbury, MA 02132, USA
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Cushman WC. Measuring blood pressure and treating hypertension in (frail) older people. J Am Geriatr Soc 1999; 47:373-4. [PMID: 10078905 DOI: 10.1111/j.1532-5415.1999.tb03007.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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