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Vallelonga F, Valente M, Tangari MM, Covolo A, Milazzo V, Di Stefano C, Sobrero G, Giudici M, Milan A, Veglio F, Lopiano L, Maule S, Romagnolo A. Hypotensive episodes at 24-h ambulatory blood pressure monitoring predict adverse outcomes in Parkinson's disease. Clin Auton Res 2024; 34:281-291. [PMID: 38662269 DOI: 10.1007/s10286-024-01030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Neurogenic orthostatic hypotension (nOH) is a frequent nonmotor feature of Parkinson's disease (PD), associated with adverse outcomes. Recently, 24-h ambulatory blood pressure monitoring (ABPM) showed good accuracy in diagnosing nOH. This study aims at evaluating the prognostic role of ABPM-hypotensive episodes in predicting PD disability milestones and mortality and comparing it to the well-defined prognostic role of bedside nOH. METHODS Patients with PD who underwent ABPM from January 2012 to December 2014 were retrospectively enrolled and assessed for the development of falls, fractures, dementia, bed/wheelchair confinement, hospitalization, and mortality, during an up-to-10-year follow-up. Significant ABPM-hypotensive episodes were identified when greater than or equal to two episodes of systolic BP drop ≥ 15 mmHg (compared with the average 24 h) were recorded during the awakening-to-lunch period. RESULTS A total of 99 patients (74% male, age 64.0 ± 10.1 years, and PD duration 6.4 ± 4.0 years) were enrolled. At baseline, 38.4% of patients had ABPM-hypotensive episodes and 46.5% had bedside nOH. On Kaplan-Meier analysis, patients with ABPM-hypotensive episodes showed earlier onset of falls (p = 0.001), fractures (p = 0.004), hospitalizations (p = 0.009), bed/wheelchair confinement (p = 0.032), dementia (p = 0.001), and shorter survival (8.0 versus 9.5 years; p = 0.009). At Cox regression analysis (adjusted for age, disease duration, Charlson Comorbidity Index, and Hoehn and Yahr stage) a significant association was confirmed between ABPM-hypotensive episodes and falls [odds ratio (OR) 3.626; p = 0.001), hospitalizations (OR 2.016; p = 0.038), and dementia (OR 2.926; p = 0.008), while bedside nOH was only associated with falls (OR 2.022; p = 0.039) and dementia (OR 1.908; p = 0.048). CONCLUSIONS The presence of at least two ABPM-hypotensive episodes independently predicted the development of falls, dementia, and hospitalization, showing a stronger prognostic value than the simple bedside assessment.
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Affiliation(s)
- Fabrizio Vallelonga
- Division of Internal Medicine, Candiolo Cancer Institute FPO-IRCCS, Strada Provinciale 142, Km 3,95, Candiolo, 10060, Turin, Italy.
- Department of Medical Science, University of Turin, Turin, Italy.
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Matteo Valente
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marta Maria Tangari
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Anna Covolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Valeria Milazzo
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristina Di Stefano
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gabriele Sobrero
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marta Giudici
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Milan
- Division of Internal Medicine, Candiolo Cancer Institute FPO-IRCCS, Strada Provinciale 142, Km 3,95, Candiolo, 10060, Turin, Italy
- Department of Medical Science, University of Turin, Turin, Italy
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Franco Veglio
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Simona Maule
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
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Kissell CE, Young BE, Jarrard CP, Huang M, Allen DR, Okuda DT, Smith SA, Fadel PJ, Davis SL. Reduced resting beat-to-beat blood pressure variability in females with relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2024; 83:105416. [PMID: 38244526 DOI: 10.1016/j.msard.2023.105416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) is a demyelinating disease of the central nervous system and cardiovascular autonomic dysfunction has been well documented in this population. The sympathetic nervous system contributes to beat-to-beat blood pressure regulation primarily by baroreflex control of the peripheral vasculature which may be impaired in females with RRMS. Even at rest, attenuated sympathetic control of vasomotor tone may result in large and frequent blood pressure excursions (i.e., greater blood pressure variability). Therefore, the primary purpose of this investigation was to test the following hypotheses; (1) females with RRMS have augmented beat-to-beat blood pressure variability compared to healthy controls and (2) reduced sympathetic baroreflex sensitivity in females with RRMS is related to augmented blood pressure variability. METHODS Electrocardiogram and beat-to-beat blood pressure were continuously recorded during 8-10 min of supine rest in 26 females with clinically definite RRMS and 24 sex-, age- and BMI- matched healthy controls. Muscle sympathetic nerve activity (MSNA) was recorded in a subset of participants (MS, n = 15; CON, n = 14). Traditional statistical measurements of dispersions were used to index beat-to-beat blood pressure variability. Spontaneous sympathetic baroreflex sensitivity was quantified by sorting diastolic blood pressures into 3 mmHg bins and calculating MSNA burst incidence within each bin. Weighted linear regression was then used to account for the number of cardiac cycles in each bin and calculate slopes. Spontaneous cardiac baroreflex sensitivity was determined using the sequence method. RESULTS Groups had similar resting mean arterial pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), MSNA burst frequency and MSNA burst incidence (All P > 0.05). The standard deviation and interquartile range of MAP, SBP and DBP were less in females with RRMS compared to healthy controls (All P < 0.05). There were no between groups differences in sympathetic baroreflex sensitivity or cardiac baroreflex sensitivity (Both P > 0.05) and baroreflex sensitivity measures were not related to any indices of blood pressure variability (Both P > 0.05). CONCLUSION These data suggest that females with RRMS have reduced beat-to-beat blood pressure variability. However, this does not appear to be related to changes in sympathetic or cardiac baroreflex sensitivity.
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Affiliation(s)
- Claire E Kissell
- Department of Applied Physiology and Sport Management, Southern Methodist University, Dallas, TX, USA
| | - Benjamin E Young
- Department of Applied Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caitlin P Jarrard
- Department of Applied Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mu Huang
- Office of Science, Medicine, and Health, American Heart Association, Dallas, TX, USA
| | - Dustin R Allen
- Department of Health Sciences, Boston University, Boston, Massachusetts, USA
| | - Darin T Okuda
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott A Smith
- Department of Applied Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Fadel
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - Scott L Davis
- Department of Applied Physiology and Sport Management, Southern Methodist University, Dallas, TX, USA; Department of Applied Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
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A. Shirsath M, O'Connor JD, Boyle R, Newman L, Knight SP, Hernandez B, Whelan R, Meaney JF, Kenny RA. Slower speed of blood pressure recovery after standing is associated with accelerated brain aging: Evidence from The Irish Longitudinal Study on Ageing (TILDA). CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2024; 6:100212. [PMID: 38445293 PMCID: PMC10912350 DOI: 10.1016/j.cccb.2024.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/17/2024] [Accepted: 02/02/2024] [Indexed: 03/07/2024]
Abstract
Background Impaired recovery of blood pressure (BP) in response to standing up is a prevalent condition in older individuals. We evaluated the relationship between the early recovery of hemodynamic responses to standing and brain health in adults over 50. Methods Participants from The Irish Longitudinal Study on Ageing (TILDA) (n=411; age 67.6 ± 7.3 years; 53.4 % women) performed an active stand challenge while blood pressure and heart rate were continuously monitored. The recovery of these parameters was determined as the slope of the BP and HR response, following the initial drop/rise after standing. We have previously reported a novel and validated measure of brain ageing using MRI data, which measures the difference between biological brain age and chronological age, providing a brain-predicted age difference (brainPAD) score. Results Slower recovery of systolic and diastolic BP was found to be significantly associated with higher brainPAD scores (i.e., biologically older brains), where a one-year increase in brainPAD was associated with a decrease of 0.02 mmHg/s and 0.01 mmHg/s in systolic and diastolic BP recovery, respectively, after standing. Heart rate (HR) recovery was not significantly associated with brainPAD score. Conclusion These results demonstrate that slower systolic and diastolic BP recovery in the early phase after standing is associated with accelerated brain aging in older individuals. This suggests that the BP response to standing, measured using beat-to-beat monitoring, has the potential to be used as a marker of accelerated brain aging, relying on a simple procedure and devices that are easily accessible.
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Affiliation(s)
- Morgana A. Shirsath
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
| | - John D. O'Connor
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
- School of Engineering, Ulster University, Northern Ireland, UK
| | - Rory Boyle
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Louise Newman
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
| | - Silvin P. Knight
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
| | - Belinda Hernandez
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
| | - Robert Whelan
- Trinity College Institute of Neuroscience, Trinity College, University of Dublin, Ireland
- Global Brain Health Institute, Trinity College, Trinity College Dublin, Ireland
| | - James F. Meaney
- National Centre for Advanced Medical Imaging (CAMI), St. James's Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College, University of, Ireland
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Vallelonga F, Valente M, Tangari MM, Covolo A, Milazzo V, Di Stefano C, Sobrero G, Giudici M, Milan A, Veglio F, Lopiano L, Maule S, Romagnolo A. Hypotensive episodes at 24-h Ambulatory Blood Pressure Monitoring predict adverse outcomes in Parkinson's Disease. RESEARCH SQUARE 2024:rs.3.rs-3904996. [PMID: 38405860 PMCID: PMC10889044 DOI: 10.21203/rs.3.rs-3904996/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Purpose Neurogenic orthostatic hypotension (nOH) is a frequent non-motor feature of Parkinson's disease (PD), associated with adverse outcomes. Recently, 24-hour ambulatory BP monitoring (ABPM) has been shown to diagnose nOH with good accuracy (in the presence of at least 2 episodes of systolic BP drop ≥ 15 mmHg compared to the average 24-h). This study aims at evaluating the prognostic role of ABPM-hypotensive episodes in predicting PD disability milestones and mortality and comparing it to well-defined prognostic role of nOH. Methods PD patients who underwent ABPM from January 2012 to December 2014 were retrospectively enrolled and assessed for the development of falls, fractures, dementia, bed/wheelchair confinement, hospitalization, mortality, during an up-to-10-year follow-up. Results Ninety-nine patients (male 74%; age: 64.0 ± 10.1 years; PD duration: 6.4 ± 4.0 years) were enrolled. At baseline, 38.4% of patients had ABPM-hypotensive episodes and 46.5% had bedside nOH.At Kaplan-Meier analysis patients with ABPM-hypotensive episodes had an earlier onset of falls (p = 0.001), fractures (p = 0.004), hospitalizations (p = 0.009), bed/wheelchair confinement (p = 0.032), dementia (p = 0.001), and showed a shorter survival (8.0vs9.5 years; p = 0.009). At Cox regression analysis (adjusted for age, disease duration, Charlson Comorbidity Index, and H&Y stage at baseline) a significant association was confirmed between ABPM-hypotensive episodes and falls (OR:3.626; p = 0.001), hospitalizations (OR:2.016; p = 0.038), and dementia (OR:2.926; p = 0.008), while bedside nOH was only associated with falls (OR 2.022; p = 0.039) and dementia (OR:1.908; p = 0.048). Conclusion The presence of at least two ABPM-hypotensive episodes independently predicted the development of falls, dementia, and hospitalization, showing a stronger prognostic value than the simple bedside assessment.
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Affiliation(s)
| | - Matteo Valente
- Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Marta Maria Tangari
- Università degli Studi di Torino Dipartimento di Neuroscienze 'Rita Levi Montalcini': Universita degli Studi di Torino Dipartimento di Neuroscienze Rita Levi Montalcini
| | - Anna Covolo
- Universita degli Studi di Torino Dipartimento di Neuroscienze Rita Levi Montalcini
| | - Valeria Milazzo
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Cristina Di Stefano
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Gabriele Sobrero
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Marta Giudici
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Alberto Milan
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Franco Veglio
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Leonardo Lopiano
- University of Turin Department of Neurosciences Rita Levi Montalcini: Universita degli Studi di Torino Dipartimento di Neuroscienze Rita Levi Montalcini
| | - Simona Maule
- Università degli Studi di Torino Dipartimento di Scienze Mediche: Universita degli Studi di Torino Dipartimento di Scienze Mediche
| | - Alberto Romagnolo
- University of Turin Department of Neurosciences Rita Levi Montalcini: Universita degli Studi di Torino Dipartimento di Neuroscienze Rita Levi Montalcini
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Pronk AC, Wang L, van Poelgeest EP, Leeflang MMG, Daams JG, Hoekstra AG, van der Velde N. The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map. GeroScience 2024; 46:153-169. [PMID: 37864713 PMCID: PMC10828261 DOI: 10.1007/s11357-023-00974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults. METHODS Design: scoping review and evidence map. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis. RESULTS Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning). CONCLUSION Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.
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Affiliation(s)
- Anouschka C Pronk
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Liping Wang
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - Mariska M G Leeflang
- Department of Epidemiology and Data Science Section of Methodology, Amsterdam University Medical Centres, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Joost G Daams
- Medical Library, University of Amsterdam, Amsterdam, The Netherlands
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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O'Halloran AM, Cremers J, Vrangbæk K, Roe L, Bourke R, Mortensen LH, Westendorp RGJ, Kenny RA. Cardiovascular disease and the risk of incident falls and mortality among adults aged ≥ 65 years presenting to the emergency department: a cohort study from national registry data in Denmark. BMC Geriatr 2024; 24:93. [PMID: 38267873 PMCID: PMC10809657 DOI: 10.1186/s12877-023-04618-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality. METHODS A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined. RESULTS Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history. CONCLUSION In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall.
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Affiliation(s)
- Aisling M O'Halloran
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland.
| | - Jolien Cremers
- Data Science Lab, Statistics Denmark, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Karsten Vrangbæk
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Centre for Health Economics and Policy, University of Copenhagen, Copenhagen, Denmark
- Department of Political Science, University of Copenhagen, Copenhagen, Denmark
| | - Lorna Roe
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Global Brain Health Institute (GBHI), Trinity College Dublin, Dublin, Ireland
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Robert Bourke
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Laust H Mortensen
- Data Science Lab, Statistics Denmark, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Rudi G J Westendorp
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Rose Anne Kenny
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
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Duggan E, Knight SP, Xue F, Romero-Ortuno R. Haemodynamic Parameters Underlying the Relationship between Sarcopenia and Blood Pressure Recovery on Standing. J Clin Med 2023; 13:18. [PMID: 38202023 PMCID: PMC10779883 DOI: 10.3390/jcm13010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Sarcopenia, delayed blood pressure (BP) recovery following standing, and orthostatic hypotension (OH) pose significant clinical challenges associated with ageing. While prior studies have established a link between sarcopenia and impaired BP recovery and OH, the underlying haemodynamic mechanisms remain unclear. METHODS We enrolled 107 participants aged 50 and above from a falls and syncope clinic, conducting an active stand test with continuous non-invasive haemodynamic measurements. Hand grip strength and five-chair stand time were evaluated, and muscle mass was estimated using bioelectrical impedance analysis. Participants were categorised as non-sarcopenic or sarcopenic. Employing mixed-effects linear regression, we modelled the effect of sarcopenia on mean arterial pressure and heart rate after standing, as well as Modelflow®-derived parameters such as cardiac output, total peripheral resistance, and stroke volume, while adjusting for potential confounders. RESULTS Sarcopenia was associated with diminished recovery of mean arterial pressure during the 10-20 s period post-standing (β -0.67, p < 0.001). It also resulted in a reduced ascent to peak (0-10 s) and recovery from peak (10-20 s) of cardiac output (β -0.05, p < 0.001; β 0.06, p < 0.001). Furthermore, sarcopenia was associated with attenuated recovery (10-20 s) of total peripheral resistance from nadir (β -0.02, p < 0.001) and diminished recovery from peak (10-20 s) of stroke volume (β 0.54, p < 0.001). Notably, heart rate did not exhibit a significant association with sarcopenia status at any time interval post-standing. CONCLUSION The compromised BP recovery observed in sarcopenia appears to be driven by an initial reduction in the peak of cardiac output, followed by attenuated recovery of cardiac output from its peak and total peripheral resistance from its nadir. This cardiac output finding seems to be influenced by stroke volume rather than heart rate. Possible mechanisms for these findings include cardio-sarcopenia, the impact of sarcopenia on the autonomic nervous system, and/or the skeletal muscle pump.
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Affiliation(s)
- Eoin Duggan
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer’s Institute for Successful Ageing, St James’s Hospital, D08 KC95 Dublin, Ireland
| | - Silvin P. Knight
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Feng Xue
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer’s Institute for Successful Ageing, St James’s Hospital, D08 KC95 Dublin, Ireland
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Fernando CV, Osborn S, Horne M. At-Home Blood Pressure Measurements Provide Better Assessments of Orthostatic Hypotension in Parkinson's Disease. J Pers Med 2023; 13:1324. [PMID: 37763091 PMCID: PMC10532916 DOI: 10.3390/jpm13091324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Orthostatic hypotension (OH) is common in Parkinson's Disease (PD). It is intermittent, exacerbated by stressors including meals, medications, and dehydration, and frequently is unrecognized. Although intermittent, assessment is usually by a single "in clinic" BP measurement. This study examines whether 10 home measurements are more sensitive in detecting OH than a single "in clinic" measurement. Participants (44 people with PD and 16 controls) were instructed to measure lying and standing BP at home. BP was measured on five consecutive days upon waking and before bedtime. Symptoms were also assessed using the Movement Disorder Society United Parkinson's Disease Rating Scale and the Non-Motor Questionnaire. While a postural drop in systolic BP (≥20 mmHg) was recorded "in clinic" in thirteen of the forty-four PD participants, a postural drop was found in at least one of the ten home measurements in twenty-eight of the forty-four participants. Morning hypertension and variability in lying systolic BP was more common in these subjects than in those without a postural drop or the controls. A greater number of measurements of lying and standing BP are more likely to reveal orthostatic hypotension, variation in systolic BP, and hypertension than a single office measurement in people with PD.
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Affiliation(s)
| | - Sarah Osborn
- The Bionics Institute, East Melbourne, VIC 3002, Australia;
| | - Malcolm Horne
- The Bionics Institute, East Melbourne, VIC 3002, Australia;
- Department of Medicine, University of Melbourne, St Vincent’s Hospital, Fitzroy, VIC 3065, Australia
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10
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Duggan E, Murphy CH, Knight SP, Davis JRC, O'Halloran AM, Kenny RA, Romero-Ortuno R. Differential Associations Between Two Markers of Probable Sarcopenia and Continuous Orthostatic Hemodynamics in The Irish Longitudinal Study on Ageing. J Gerontol A Biol Sci Med Sci 2023; 78:1376-1382. [PMID: 36480700 PMCID: PMC10395558 DOI: 10.1093/gerona/glac243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Sarcopenia and orthostatic hypotension are growing age-related health burdens associated with adverse outcomes, including falls. Despite a possible pathophysiological link, the association between the 2 disorders is not well elucidated. We sought to investigate this relationship in The Irish Longitudinal Study on Ageing (TILDA). METHODS Data from 2 858 participants at wave 3 of TILDA were analyzed. Probable sarcopenia was defined as per the European Working Group on Sarcopenia in Older People revised definition cutoffs (hand grip strength [HGS] <27 kg in men, <16 kg in women, and/or 5-chair stand test [5CST] time >15 seconds). Participants underwent an active stand orthostatic test with continuous blood pressure (BP) monitoring. Multilevel mixed-effects models, controlling for possible confounders, were used to assess the effect of probable sarcopenia by HGS and 5CST criteria on the change in BP after standing. RESULTS HGS- and 5CST-defined probable sarcopenia were independently associated with an attenuated BP recovery at 10-20 seconds poststand (systolic BP: β -0.54, p < .001; β -0.25, p < .001). On average, those meeting HGS probable sarcopenia criteria had a significantly lower BP at 20, 30, and 40 seconds (differences in systolic BP: -5.01 mmHg, -3.68 mmHg, -2.32 mmHg, p < .05 for all). Those meeting 5CST probable sarcopenia criteria had a significant difference in systolic BP at 20 seconds (-1.94 mmHg, p = .002) but not at 30 or 40 seconds. CONCLUSION Probable sarcopenia had a significant association with delayed orthostatic BP recovery, with HGS-defined probable sarcopenia having a stronger association than 5CST-defined probable sarcopenia. Results support a modest but significant pathophysiological link between probable sarcopenia and orthostatic hypotension.
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Affiliation(s)
- Eoin Duggan
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Caoileann H Murphy
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Teagasc, Food Research Centre, Ashtown, Dublin, Ireland
| | - Silvin P Knight
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - James R C Davis
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Aisling M O'Halloran
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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11
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Mastrandrea CJ, Hedge ET, Robertson AD, Heckman GA, Ho J, Granados Unger F, Hughson RL. High-intensity exercise does not protect against orthostatic intolerance following bedrest in 55- to 65-yr-old men and women. Am J Physiol Regul Integr Comp Physiol 2023; 325:R107-R119. [PMID: 37184226 DOI: 10.1152/ajpregu.00315.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/20/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
Prolonged bedrest provokes orthostatic hypotension and intolerance of upright posture. Limited data are available on the cardiovascular responses of older adults to head-up tilt following bedrest, with no studies examining the potential benefits of exercise to mitigate intolerance in this age group. This randomized controlled trial of head-down bedrest (HDBR) in 55- to 65-yr-old men and women investigated if exercise could avert post-HDBR orthostatic intolerance. Twenty-two healthy older adults (11 female) underwent a strict 14-day HDBR and were assigned to either an exercise (EX) or control (CON) group. The exercise intervention included high-intensity, aerobic, and resistance exercises. Head-up tilt-testing to a maximum of 15 minutes was performed at baseline (Pre-Bedrest) and immediately after HDBR (R1), as well as 6 days (R6) and 4 weeks (R4wk) later. At Pre-Bedrest, three participants did not complete the full 15 minutes of tilt. At R1, 18 did not finish, with no difference in tilt end time between CON (422 ± 287 s) and EX (409 ± 346 s). No differences between CON and EX were observed at R6 or R4wk. At R1, just 1 participant self-terminated the test with symptoms, while 12 others reported symptoms only after physiological test termination criteria were reached. Finishers on R1 protected arterial pressure with higher total peripheral resistance relative to Pre-Bedrest. Cerebral blood velocity decreased linearly with reductions in arterial pressure, end-tidal CO2, and cardiac output. High-intensity interval exercise did not benefit post-HDBR orthostatic tolerance in older adults. Multiple factors were associated with the reduction in cerebral blood velocity leading to intolerance.
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Affiliation(s)
| | - Eric T Hedge
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- Department of Kinesiology and Health Studies, University of Waterloo, Waterloo, Ontario, Canada
| | - Andrew D Robertson
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- Department of Kinesiology and Health Studies, University of Waterloo, Waterloo, Ontario, Canada
| | - George A Heckman
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Joanne Ho
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Federico Granados Unger
- Department of Kinesiology and Health Studies, University of Waterloo, Waterloo, Ontario, Canada
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12
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Duggan E, Knight SP, Romero-Ortuno R. Relationship between sarcopenia and orthostatic blood pressure recovery in older falls clinic attendees. Eur Geriatr Med 2023:10.1007/s41999-023-00775-0. [PMID: 37029293 DOI: 10.1007/s41999-023-00775-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Sarcopenia and delayed orthostatic blood pressure (BP) recovery are two disorders increasingly associated with adverse clinical outcomes in older adults. There may exist a pathophysiological link between the two via the skeletal muscle pump of the lower limbs. Previously in a large population-based study, we found an association between probable sarcopenia and orthostatic BP recovery. Here, we sought to determine the association between confirmed sarcopenia and orthostatic BP recovery in falls clinic attendees aged 50 years or over. METHODS One hundred and nine recruited patients (mean age 70 years, 58% women) underwent an active stand with non-invasive beat-to-beat haemodynamic monitoring. Hand grip strength and five-chair stands time were measured, and bioelectrical impedance analysis was performed. They were then classified as robust, probable sarcopenic or sarcopenic as per the European Working Group on Sarcopenia in Older People guidelines. Mixed effects models with linear splines were used to model the effect of sarcopenia status on orthostatic BP recovery, whilst controlling for potential confounders. RESULTS Probable sarcopenia was identified in 32% of the sample and sarcopenia in 15%. Both probable and confirmed sarcopenia were independently associated with an attenuated rate of recovery of both systolic and diastolic BP in the 10-20 s period after standing. Attenuation was larger for confirmed than probable sarcopenia (systolic BP β - 0.85 and - 0.59, respectively, P < 0.01; diastolic BP β - 0.65, - 0.45, P < 0.001). CONCLUSION Sarcopenia was independently associated with slower BP recovery during the early post-stand period. The potentially modifiable effect of the skeletal muscle pump in orthostatic haemodynamics requires further study.
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Affiliation(s)
- Eoin Duggan
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
- Falls and Syncope Unit (FASU), Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland.
| | - Silvin P Knight
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
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13
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Chao CT, Hung KY. Vascular frailty, a proposal for new frailty type: A narrative review. Kaohsiung J Med Sci 2023; 39:318-325. [PMID: 36866657 DOI: 10.1002/kjm2.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 03/04/2023] Open
Abstract
Frailty is the incremental accumulation of minute defects that progressively impair health and performance. Frailty is commonly observed in older adults; however, secondary frailty may also occur in patients with metabolic disorders or major organ failure. In addition to physical frailty, several distinct types of frailty have been identified, including oral, cognitive, and social frailty, each of which is of practical importance. This nomenclature suggests that detailed descriptions of frailty can potentially advance relevant researches. In this narrative review, we first summarize the clinical value and plausible biological origin of frailty, as well as how to appropriately assess it using physical frailty phenotypes and frailty indexes. In the second part, we discuss the issue of vascular tissue as a relatively underappreciated organ whose pathologies contribute to the development of physical frailty. Moreover, when vascular tissue undergoes degeneration, it exhibits vulnerability to subtle injuries and manifests a unique phenotype amenable to clinical assessment prior to or accompanying physical frailty development. Finally, we propose that vascular frailty, based on an extensive set of experimental and clinical evidence, can be considered a new frailty type that requires our attention. We also outline potential methods for the operationalization of vascular frailty. Further studies are required to validate our claim and sharpen the spectrum of this degenerative phenotype.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yu Hung
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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14
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Donnell DO, Romero-Ortuno R, Kennelly SP, O’Neill D, Donoghue PO, Lavan A, Cunningham C, McElwaine P, Kenny RA, Briggs R. The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing. Age Ageing 2023; 52:7024511. [PMID: 36735845 PMCID: PMC9897301 DOI: 10.1093/ageing/afad005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Desmond O Donnell
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Roman Romero-Ortuno
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Sean P Kennelly
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Desmond O’Neill
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Patrick O Donoghue
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Amanda Lavan
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Conal Cunningham
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Paul McElwaine
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Robert Briggs
- Address correspondence to: Robert Briggs. Tel: (+35) 314284105.
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15
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Baker JR, Raj SR. Comment on: Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms. J Am Geriatr Soc 2023; 71:673-674. [PMID: 36356261 DOI: 10.1111/jgs.18112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Jacquie R Baker
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Paschen S, Hansen C, Welzel J, Albrecht J, Atrsaei A, Aminian K, Zeuner KE, Romijnders R, Warmerdam E, Urban PP, Berg D, Maetzler W. Effect of Lower Limb vs. Abdominal Compression on Mobility in Orthostatic Hypotension: A Single-Blinded, Randomized, Controlled, Cross-Over Pilot Study in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2531-2541. [PMID: 36278359 DOI: 10.3233/jpd-223406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) in Parkinson's disease (PD) is frequent and associated with impairments in quality of life and reduced activities of daily living. Abdominal binders (AB) and compression stockings (CS) have been shown to be effective non-pharmacological treatment options. OBJECTIVE Here, we investigate the effect of AB versus CS on physical activity using a digital mobility outcome (sit to stand [STS] frequency) collected in the usual environment as a primary endpoint. METHODS We enrolled 16 PD patients with at least moderate symptomatic OH. In a randomized, single-blinded, controlled, crossover design, participants were assessed without OH treatment over 1 week (baseline), then were given AB or CS for 1 week and subsequently switched to the other treatment arm. The primary outcome was the number of real-life STS movements per hour as assessed with a lower back sensor. Secondary outcomes included real-life STS duration, mean/systolic/diastolic blood pressure drop (BPD), orthostatic hypotension questionnaire (OHQ), PD quality of life (PDQ-39), autonomic symptoms (SCOPA-AUT), non-motor symptoms (NMSS), MDS-UPDRS, and activities of daily living (ADL/iADL). RESULTS Real-life STS frequency on CS was 4.4±4.1 per hour compared with 3.6±2.2 on AB and 3.6±1.8 without treatment (p = 1.0). Concerning the secondary outcomes, NMSS showed significant improvement with CS and AB. OHQ and SCOPA-AUT improved significantly with AB but not CS, and mean BPD drop worsened with CS but not AB. Mean STS duration, PDQ-39, MDS-UPDRS, ADL, and iADL did not significantly change. CONCLUSION Both AB and CS therapies do not lead to a significant change of physical activity in PD patients with at least moderate symptomatic OH. Secondary results speak for an effect of both therapies concerning non-motor symptoms, with superiority of AB therapy over CS therapy.
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Affiliation(s)
| | - Clint Hansen
- Department of Neurology, Kiel University, Kiel, Germany
| | - Julius Welzel
- Department of Neurology, Kiel University, Kiel, Germany
| | | | - Arash Atrsaei
- Laboratory of Movement Analysis and Measurement, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Kamiar Aminian
- Laboratory of Movement Analysis and Measurement, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | | | | | | | - Paul Peter Urban
- Department of Neurology, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Daniela Berg
- Department of Neurology, Kiel University, Kiel, Germany
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17
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Hui G, Xiahuan C, Yanjun W, Wenyi L, Meilin L. Influencing factors and hemodynamic study of initial and sustained orthostatic hypotension in middle-aged and elderly patients. J Clin Hypertens (Greenwich) 2022; 24:1491-1497. [PMID: 36263516 DOI: 10.1111/jch.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 12/01/2022]
Abstract
Orthostatic hypotension (OH) is a common autonomic disorder. This study aimed to investigate the influencing factors and hemodynamic mechanisms of initial and sustained OH in middle-aged and elderly patients. The authors analyzed the clinical characteristics and hemodynamic variables of patients aged ≥ 50 years according to the various forms of OH, diagnosed by an active orthostatic test using the CNAP monitor. The study included 473 participants; 119 (25.2%) patients had initial (54, 45.4%) or sustained (65, 54.6%) OH. Age, comorbidities, or medications did not differ significantly between the initial OH and non-OH groups. Sustained OH was associated with age and diabetes (p = .003 and p = .015, respectively). Hemodynamic analysis revealed higher cardiac output (CO) in the sustained OH group within 15 s than in the non-OH and initial OH groups (both p < .001); no difference in CO was observed between the initial OH and non-OH groups. The systemic vascular resistance (SVR) in both initial OH and sustained OH groups within 15 s was lower than that in the non-OH group (both p < .001). No differences in SVR at 3 min were observed between the initial OH and non-OH groups. The SVR at 3 min in the sustained OH group was significantly lower than in non-OH and initial OH groups (both p < .001). Age and diabetes emerged as the independent risk factors associated with sustained OH. Initial OH is associated with a mismatch of increase in CO and decrease in SVR. Sustained OH is mainly associated with sustained inadequate adjustment in SVR.
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Affiliation(s)
- Geng Hui
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Chen Xiahuan
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Wang Yanjun
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liang Wenyi
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liu Meilin
- Department of Geriatrics, Peking University First Hospital, Beijing, China
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18
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Williams EL, Khan FM, Claydon VE. Counter pressure maneuvers for syncope prevention: A semi-systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:1016420. [PMID: 36312294 PMCID: PMC9606335 DOI: 10.3389/fcvm.2022.1016420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/20/2022] [Indexed: 11/24/2022] Open
Abstract
Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment cardiovascular control. However, these recommendations are largely based on theoretical benefit, with limited data evaluating the efficacy of CPM to prevent syncope in the real-world setting. We conducted a semi-systematic literature review and meta-analysis to assess CPM efficacy, identify literature gaps, and highlight future research needs. Articles were identified through a literature search (PubMed, April 2022) of peer-reviewed publications evaluating the use of counter pressure or other lower body maneuvers to prevent syncope. Two team members independently screened records for inclusion and extracted data. From 476 unique records identified by the search, 45 met inclusion criteria. Articles considered various syncopal conditions (vasovagal = 12, orthostatic hypotension = 8, postural orthostatic tachycardia syndrome = 1, familial dysautonomia = 2, spinal cord injury = 1, blood donation = 10, healthy controls = 11). Maneuvers assessed included hand gripping, leg fidgeting, stepping, tiptoeing, marching, calf raises, postural sway, tensing (upper, lower, whole body), leg crossing, squatting, “crash” position, and bending foreword. CPM were assessed in laboratory-based studies (N = 28), the community setting (N = 4), both laboratory and community settings (N = 3), and during blood donation (N = 10). CPM improved standing systolic blood pressure (+ 14.8 ± 0.6 mmHg, p < 0.001) and heart rate (+ 1.4 ± 0.5 bpm, p = 0.006), however, responses of total peripheral resistance, stroke volume, or cerebral blood flow were not widely documented. Most patients experienced symptom improvement following CPM use (laboratory: 60 ± 4%, community: 72 ± 9%). The most prominent barrier to employing CPM in daily living was the inability to recognize an impending faint. Patterns of postural sway may also recruit the skeletal muscle pump to enhance cardiovascular control, and its potential as a discrete, proactive CPM needs further evaluation. Physical CPM were successful in improving syncopal symptoms and producing cardiovascular responses that may bolster against syncope; however, practical limitations may restrict applicability for use in daily living.
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19
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Hedge ET, Patterson CA, Mastrandrea CJ, Sonjak V, Hajj-Boutros G, Faust A, Morais JA, Hughson RL. Implementation of exercise countermeasures during spaceflight and microgravity analogue studies: Developing countermeasure protocols for bedrest in older adults (BROA). Front Physiol 2022; 13:928313. [PMID: 36017336 PMCID: PMC9395735 DOI: 10.3389/fphys.2022.928313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/27/2022] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Eric T. Hedge
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, Canada
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | | | - Vita Sonjak
- Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Guy Hajj-Boutros
- Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Andréa Faust
- Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - José A. Morais
- Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
- Division of Geriatric Medicine, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Richard L. Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, Canada
- *Correspondence: Richard L. Hughson,
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20
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Quinn C, Monaghan A, Foran T, Kenny RA, Gormley J. A Review of Heart Rate and Blood Pressure Responses to Active Standing in Healthy Adults. Curr Aging Sci 2022; 15:198-208. [PMID: 35440341 DOI: 10.2174/1874609815666220419102648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/16/2022] [Accepted: 03/06/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This review outlines the normal heart rate and blood pressure response to active standing, the physiological mechanisms governing these, and the effect of ageing on the responses. METHODS A literature search was conducted to identify articles investigating the normal heart rate and/or blood pressure response to standing. RESULTS Heart rate when standing increases and then decreases and recovers to baseline. Blood pressure responses are inverse. Skeletal muscle contraction and the baroreceptor reflex drive this. With ageing, heart rate response attenuates and the initial blood pressure response increases. DISCUSSION Normal heart rate and blood pressure responses are attributed to the baroreceptor reflex and skeletal muscle contraction. Decreased muscle strength and baroreceptor sensitivity are associated with ageing, suggesting a possible benefit in improving skeletal muscle strength to maintain an efficient response. Understanding these responses and their variation with ageing is clinically relevant and may be beneficial in improving rehabilitation outcomes.
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Affiliation(s)
- Caitríona Quinn
- Discipline of Physiotherapy, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin Ireland
| | - Ann Monaghan
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Tim Foran
- Medical Physics and Bioengineering Department of Discipline of Physiotherapy, Trinity Centre for Health Sciences, St. James's Hospital, TRIL Centre, St James's Hospital, Dublin 8, Dublin, Ireland
| | - Rose Anne Kenny
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - John Gormley
- Discipline of Physiotherapy, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin Ireland
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21
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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22
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Newman L, O'Connor JD, Nolan H, Reilly RB, Kenny RA. Age and sex related differences in orthostatic cerebral oxygenation: Findings from 2764 older adults in the Irish Longitudinal Study on Ageing (TILDA). Exp Gerontol 2022; 167:111903. [PMID: 35902001 DOI: 10.1016/j.exger.2022.111903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/29/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
AIMS Cerebral hypoperfusion is implicated in the pathogenesis of associations between orthostatic hypotension and adverse outcome such as falls, cognitive impairment, depression, and mortality. Although the blood pressure response to orthostasis has been well studied there is a lack of information on orthostatic cerebrovascular responses in older populations. METHODS AND RESULTS We measured cerebral hemodynamics, utilizing near infrared spectroscopy, coupled with peripheral blood pressure during an active stand in a large population of well-phenotyped older adults (N = 2764). Multi-level mixed effect models were utilized to investigate associations with age and sex, as well as confounders including anti-hypertensive medications. Normative cerebral oxygenation responses were also modelled utilizing generalized additive models for location, scale, and shape (GAMLSS). Older age groups experienced larger initial drops in oxygenation and a slower recovery, and responses also differed by sex. The drop after standing ranged from -1.85 % (CI: -2.02 to -1.68) in the males aged 54-59 years vs -1.15 % (CI: -1.31 to -1.00 %) in females aged 54-59 years, to -2.67 % (CI: -3.01 to -2.33) in males aged ≥ 80 years vs -1.97 % (CI: -2.32 to -1.62) females aged ≥ 80 years. Reduced oxygenation levels were also evident in those taking anti-hypertensive medications. CONCLUSION Cerebral autoregulation is impaired with age, particularly in older women and those taking anti-hypertensives. SBP during the stand explained some of the age gradient in the late recovery stage of the stand for the oldest age group. Reported orthostatic symptoms did not correlate with hypoperfusion. Therefore, measures of orthostatic cerebral flow should be assessed in addition to peripheral BP in older patients irrespective of symptoms. Further studies are required to investigate the relationship between NIRS measurements and clinical outcomes such as falls, cognitive impairment and depression.
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Affiliation(s)
- Louise Newman
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 2, Ireland.
| | - John D O'Connor
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 2, Ireland
| | - Hugh Nolan
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 2, Ireland
| | - Richard B Reilly
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin 2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin 2, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
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23
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Spies PE, Beune TNN, Heesakkers J, van Munster BC, Claassen JAHR. Orthostatic blood pressure recovery in older males using alpha-blockers for lower urinary tract symptoms, an explorative study in a urology outpatient clinic. J Clin Pharm Ther 2022; 47:1698-1703. [PMID: 35777069 DOI: 10.1111/jcpt.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/31/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Alpha-blockers have been associated with orthostatic hypotension (OH). We aimed to assess the prevalence of OH measured with beat-to-beat blood pressure monitoring in older male outpatients who used alpha-blockers for lower urinary tract symptoms (LUTS). In addition, we investigated associations of OH with duration of alpha-blocker use, concomitant medication use and comorbidity. METHODS Cross-sectional explorative study in a urology outpatient clinic. Older white males ≥65 years using alpha-blockers for LUTS were included. Blood pressure responses to standing up from supine were recorded using a validated beat-to-beat blood pressure device (Finapres). Prevalence rates were derived from the beat-to-beat data to include OH measured between 60-110 s (OH), impaired recovery OH at 40 s (OH[40]), initial OH (IOH) and normal orthostatic response. Subgroups were defined based on duration of alpha-blocker use, polypharmacy, and Charlson comorbidity index (CCI), to obtain relative risks. RESULTS AND DISCUSSION Sixty-five patients were included. Median age was 75 years (range 65-92). The prevalence of OH was 7.7% (n = 5). The prevalence of OH(40) was 16.9% (n = 11) and of IOH 38.5% (n = 25). Thirty-six patients (55.4%) had a normal orthostatic response. The relative risk of OH for the subgroup using ≥ $$ \ge $$ 10 medications (n = 13) was 6.0 (95%CI 1.1-32.3). For the subgroup with multimorbidity (CCI ≥3, n = 11) this was 7.4 (95%CI 1.4-39.0). Recent initiation of alpha-blocker use (<3 months) did not increase OH risk (RR 0.6 [95%CI 0.1-5.1]). WHAT IS NEW AND CONCLUSION The overall prevalence of OH was low and comparable to age-matched population prevalence, suggesting that the relative contribution of alpha-blockers to OH was small. However, OH risk significantly increased in patients with multimorbidity or polypharmacy. For these patients, the benefits of starting alpha-blockers for LUTS should be weighed against the increased risk of OH.
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Affiliation(s)
- Petra E Spies
- Dept. of Geriatric Medicine, Gelre Ziekenhuizen, Apeldoorn & Zutphen, Zutphen, The Netherlands.,Centre of Excellence for Old Age Medicine, Gelre ziekenhuizen, Apeldoorn & Zutphen, Zutphen, The Netherlands
| | - Thimpe N N Beune
- Dept. of Geriatric Medicine, Gelre Ziekenhuizen, Apeldoorn & Zutphen, Zutphen, The Netherlands.,Centre of Excellence for Old Age Medicine, Gelre ziekenhuizen, Apeldoorn & Zutphen, Zutphen, The Netherlands
| | - John Heesakkers
- Dept. of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Barbara C van Munster
- Centre of Excellence for Old Age Medicine, Gelre ziekenhuizen, Apeldoorn & Zutphen, Zutphen, The Netherlands.,Department of Internal Medicine and Geriatrics, Groningen, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jurgen A H R Claassen
- Dept. of Geriatric Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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24
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Rodrigues GD, Gurgel JL, da Nobrega ACL, Soares PPDS. Orthostatic intolerance: a handicap of aging or physical deconditioning? Eur J Appl Physiol 2022; 122:2005-2018. [PMID: 35716190 DOI: 10.1007/s00421-022-04978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
Despite several studies that have been investigated physical inactivity and age-related effects on orthostatic tolerance, impaired hemodynamics and postural balance responses to orthostatic stress are incorrectly attributed to aging or sedentarism alone. The isolated effects from aging and sedentarism should be investigated through comparative studies between senior athletes and age-matched controls, and physical activity assessments on aging follow-up studies. On the other hand, bed rest and space flight studies mimic accelerated physical inactivity or disuse, which is not the same physiological decline provoked by aging alone. Thus, the elementary question is: could orthostatic intolerance be attributed to aging or physical inactivity? The main purpose of this review is to provide an overview of possible mechanisms underlying orthostatic tolerance contrasting the paradigm of aging and/or physical inactivity. The key points of this review are the following: (1) to counterpoint all relevant literature on physiological aspects of orthostatic tolerance; (2) to explore the mechanistic aspects underneath the cerebrovascular, cardiorespiratory, and postural determinants of orthostatic tolerance; and (3) examine non-pharmacological interventions with the potential to counterbalance the physical inactivity and aging effects. To date, the orthostatic intolerance cannot be attributed exclusively with aging since physical inactivity plays an important role in postural balance, neurovascular and cardiorespiratory responses to orthostatic stress. These physiological determinates should be interpreted within an integrative approach of orthostatic tolerance, that considers the interdependence between physiological systems in a closed-loop model. Based on this multisystem approach, acute and chronic countermeasures may combat aging and sedentarism effects on orthostatic tolerance.
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Affiliation(s)
- Gabriel Dias Rodrigues
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Brazil.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,National Institute for Science & Technology - INCT, (In)activity & Exercise, CNPq-Niterói (RJ), Rio de Janeiro, Brazil
| | - Jonas Lírio Gurgel
- Department of Physical Education and Sports, Fluminense Federal University, Niterói, Brazil
| | - Antonio Claudio Lucas da Nobrega
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Brazil.,National Institute for Science & Technology - INCT, (In)activity & Exercise, CNPq-Niterói (RJ), Rio de Janeiro, Brazil
| | - Pedro Paulo da Silva Soares
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Brazil. .,National Institute for Science & Technology - INCT, (In)activity & Exercise, CNPq-Niterói (RJ), Rio de Janeiro, Brazil.
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25
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Pérez-Denia L, Claffey P, Byrne L, Rice C, Kenny RA, Finucane C. Increased multimorbidity is associated with impaired cerebral and peripheral hemodynamic stabilization during active standing. J Am Geriatr Soc 2022; 70:1973-1986. [PMID: 35535653 PMCID: PMC9545463 DOI: 10.1111/jgs.17810] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Abstract
Background Age‐related morbidities and frailty are associated with impaired blood pressure (BP) and heart rate (HR) recovery after standing. Here we investigate how multimorbidity affects cerebral and peripheral hemodynamics during standing in a large sample of older patients. Methods Patients were recruited from a national Falls and Syncope Unit. They underwent an active stand test (5–10 min lying +3 min standing) with monitoring of continuous BP, HR, total peripheral resistance (TPR), stroke volume (SV), and a near‐infrared spectroscopy (NIRS) derived cerebral tissue saturation index (TSI). A multimorbidity count was derived from a 26‐item list of conditions. Features derived from the signals included: nadir, overshoot, value at 30 s, steady‐state and recovery rate. Robust linear regression was used to assess the association between multimorbidity, TSI and peripheral hemodynamics while correcting for covariates. A p‐value <0.05 was considered statistically significant. Results Multimorbidity was associated with poorer recovery of TSI at 30 s after standing (β: −0.15, CI:[−0.25–0.06], p = 0.009) independent of all peripheral hemodynamics. Impaired diastolic BP (DBP) recovery at 30s (β:−1.34, CI:[−2.29–0.40], p = 0.032), DBP steady‐state (β:−1.18, CI:[−2.04–0.32], p = 0.032), TPR overshoot‐to‐nadir difference (β:−0.041, CI:[−0.070–0.013], p = 0.045), and SV at 30s (β:1.30, CI:[0.45 2.15], p = 0.027) were also associated with increasing multimorbidity. After sex stratification, only females demonstrated impaired TSI with multimorbidity at overshoot (β: −0.19, CI: [−0.32 ‐0.07], p = 0.009), 30 s (β: −0.22 [−0.35–0.10], p = 0.005) and steady‐state (β: −0.20, CI:[−0.35–0.04], p = 0.023), independent of peripheral hemodynamics. Conclusions Transient cerebral oxygenation and peripheral hemodynamic responses are impaired with multimorbidity (frailty) in older patients, particularly in females. This study demonstrates the feasibility of using NIRS in this clinical context and may inform the development of clinical management strategies targeting both cerebral oxygenation and blood pressure impairments in patients with faints and falls.
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Affiliation(s)
- Laura Pérez-Denia
- School of Medicine, Trinity College Dublin, Dublin, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland.,Department of Medical Physics, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
| | - Paul Claffey
- School of Medicine, Trinity College Dublin, Dublin, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
| | - Lisa Byrne
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
| | - Ciara Rice
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- School of Medicine, Trinity College Dublin, Dublin, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
| | - Ciarán Finucane
- School of Medicine, Trinity College Dublin, Dublin, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland.,Department of Medical Physics, Mercer's Institute for Successful Ageing, St. James's Hospital Dublin, Dublin, Ireland
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26
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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27
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Diagnostic criteria for initial orthostatic hypotension: a narrative review. Clin Auton Res 2021; 31:685-698. [PMID: 34677720 DOI: 10.1007/s10286-021-00833-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
Abnormalities in orthostatic blood pressure changes upon active standing are associated with morbidity, mortality, and reduced quality of life. However, over the last decade, several population-based cohort studies have reported a remarkably high prevalence (between 25 and 70%) of initial orthostatic hypotension (IOH) among elderly individuals. This has raised the question as to whether the orthostatic blood pressure patterns in these community-dwelling elderly should truly be considered as pathological. If not, redefining of the systolic cutoff values for IOH (i.e., a value ≥ 40 mmHg in systolic blood pressure in the first 15 s after standing up) might be necessary to differ between normal aging and true pathology. Therefore, in this narrative review, we provide a critical analysis of the current reference values for the changes in systolic BP in the first 60 s after standing up and discuss how these values should be applied to large population studies. We will address factors that influence the magnitude of the systolic blood pressure changes following active standing and the importance of standardization of the stand-up test, which is a prerequisite for quantitative, between-subject comparisons of the postural hemodynamic response.
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28
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Johansson M, Rogmark C, Sutton R, Fedorowski A, Hamrefors V. Risk of incident fractures in individuals hospitalised due to unexplained syncope and orthostatic hypotension. BMC Med 2021; 19:188. [PMID: 34446019 PMCID: PMC8394111 DOI: 10.1186/s12916-021-02065-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Impaired orthostatic blood pressure response and syncope confer a high risk of falls and trauma. The relationship between a history of unexplained syncope and orthostatic hypotension (OH) with subsequent fractures, however, has not been thoroughly examined. In this study, we aimed to investigate the relationship between previous hospital admissions due to unexplained syncope and OH and incident fractures in a middle-aged population. METHODS We analysed a large population-based prospective cohort of 30,399 middle-aged individuals (age, 57.5 ± 7.6; women, 60.2%). We included individuals hospitalised due to unexplained syncope or OH as the main diagnosis. Multivariable-adjusted Cox regression analysis was applied to assess the impact of unexplained syncope and OH hospitalisations on subsequent incident fractures. RESULTS During a follow-up period of 17.8 + 6.5 years, 8201 (27%) subjects suffered incident fractures. The mean time from baseline and first admission for syncope (n = 493) or OH (n = 406) was 12.6 ± 4.2 years, and the mean age of the first hospitalisation was 74.6 ± 7.4 years. Individuals with incident fractures were older, more likely to be women, and had lower BMI, higher prevalence of prevalent fractures, and family history of fractures. Multivariable-adjusted Cox regression showed an increased risk of incident fractures following hospitalisations due to unexplained syncope (HR 1.20; 95% CI 1.02-1.40; p = 0.025) and OH (HR 1.42; 95% CI 1.21-1.66; p < 0.001) compared with unaffected individuals. CONCLUSIONS Individuals hospitalised due to unexplained syncope and orthostatic hypotension have an increased risk of subsequent fractures. Our findings suggest that such individuals should be clinically assessed for their syncope aetiology, with preventative measures aimed at fall and fracture risk assessment and management.
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Affiliation(s)
- Madeleine Johansson
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | - Cecilia Rogmark
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden.,Department of Orthopaedics, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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29
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Older Adults with Hypertension: Prevalence of Falls and Their Associated Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168257. [PMID: 34444005 PMCID: PMC8392439 DOI: 10.3390/ijerph18168257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 01/04/2023]
Abstract
Falls are prominent health issues among older adults. Among hypertensive older adults, falls may have a detrimental effect on their health and wellbeing. The purpose of this study is to determine the prevalence of falls among hypertensive older adults and to identify the associated factors that contribute to their falls. This was a cross-sectional study conducted among two hundred and sixty-nine hypertensive older adults who were selected via systematic random sampling in two primary health clinics in Kuala Terengganu, Malaysia. Data on their socio-demographic details, their history of falls, medication history and clinical characteristics were collected. Balance and gait were assessed using the Performance Oriented Mobility Assessment (POMA). It was found that 32.2% of participants reported falls within a year. Polypharmacy (adjusted OR 2.513, 95% CI 1.339, 4.718) and diuretics (adjusted OR 2.803, 95% CI 1.418, 5.544) were associated with an increased risk of falls. Meanwhile, a higher POMA score (adjusted OR 0.940, 95% CI 0.886, 0.996) and the number of antihypertensives (adjusted OR 0.473, 95% CI 0.319, 0.700) were associated with a low incidence of falling among hypertensive older adults. Falls are common among hypertensive older adults. Older adults who are taking diuretics and have a polypharmacy treatment plan have a higher incidence of falls. However, older adults taking a higher number of anti-hypertensive medications specifically were not associated with an increased prevalence of falls.
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30
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Federici C, Pecchia L. Early health technology assessment using the MAFEIP tool. A case study on a wearable device for fall prediction in elderly patients. HEALTH AND TECHNOLOGY 2021. [DOI: 10.1007/s12553-021-00580-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractBy using a case-study on a fall-prediction device for elderly patients with orthostatic hypotension we aim to demonstrate how the MAFEIP tool, developed as part of the European Innovation Programme on Active and Healthy Ageing (EIP on AHA), can be used to inform manufacturers on their product development based on a cost-effectiveness criterion. Secondly, we critically appraise the tool and suggest further improvements that may be needed for a larger-scale adoption of MAFEIP within and beside the EIP on AHA initiative. The model was implemented using the MAFEIP tool. Within the tool one way sensitivity analyses were performed to assess the robustness of the model against the relative effectiveness of the fall-prevention device at different price levels. The MAFEIP tool was applied to a novel fall-prediction device and used to estimate the expected cost-effectiveness and perform threshold analysis. In our case study, the device produced estimated gains of 0.035 QALYs per patient and incremental costs of £ 518 (incremental cost-effectiveness ratio £14,719). Based on the one-way sensitivity analysis, the maximum achievable price at a willingness to pay threshold of £20,000 per QALY is estimated close to £900. The MAFEIP allows to quickly create early economic models, and to explore model uncertainty by performing deterministic sensitivity analysis for single parameters. However, the integration within the MAFEIP of common analytical tools such as probabilistic sensitivity analysis and Value of information would greatly contribute to its relevance for evaluating innovative technologies within and beside the EIP on AHA initiative.
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31
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O'Connor JD, O'Connell MDL, Knight SP, Newman L, Donoghue OA, Kenny RA. Impaired Stabilisation of Orthostatic Cerebral Oxygenation is Associated with Slower Gait Speed: Evidence from The Irish Longitudinal Study on Ageing. J Gerontol A Biol Sci Med Sci 2021; 77:1216-1221. [PMID: 34331759 PMCID: PMC9159662 DOI: 10.1093/gerona/glab219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cerebral autoregulation (CAR) systems maintain blood flow to the brain across a wide range of blood pressures. Deficits in CAR have been linked to gait speed (GS) but previous studies had small sample sizes and used specialized equipment which impede clinical translation. The purpose of this work was to assess the association between GS and orthostatic cerebral oxygenation in a large, community-dwelling sample of older adults. Method Data for this study came from the Irish Longitudinal Study on Ageing. A near-infrared spectroscopy (NIRS) device attached to the forehead of each participant (n = 2 708) was used to track tissue saturation index (TSI; the ratio of oxygenated to total hemoglobin) during standing. GS was assessed using a portable walkway. Results Recovery was impaired in slower GS participants with a TSI value at 20 seconds (after standing) of −0.55% (95% CI: −0.67, −0.42) below baseline in the slowest GS quartile versus −0.14% (95% CI: −0.25, −0.04) in the fastest quartile. Slower GS predicted a lower TSI throughout the 3-minute monitoring period. Results were not substantially altered by adjusting for orthostatic hypotension. Adjustment for clinical and demographic covariates attenuated the association between but differences remained between GS quartiles from 20 seconds to 3 minutes after standing. Conclusion This study reported evidence for impaired recovery of orthostatic cerebral oxygenation depending on GS in community-dwelling older adults. Future work assessing NIRS as a clinical tool for monitoring the relationship between GS and cerebral regulation is warranted.
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Affiliation(s)
- John D O'Connor
- The Irish Longitudinal Study on Ageing, University of Dublin, Trinity College, Ireland.,The Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, UK
| | - Matthew D L O'Connell
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, UK
| | - Silvin P Knight
- The Irish Longitudinal Study on Ageing, University of Dublin, Trinity College, Ireland
| | - Louise Newman
- The Irish Longitudinal Study on Ageing, University of Dublin, Trinity College, Ireland
| | - Orna A Donoghue
- The Irish Longitudinal Study on Ageing, University of Dublin, Trinity College, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, University of Dublin, Trinity College, Ireland
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Spectrum of Hemodynamic Responses in the First 60 Seconds after Active Standing Up: Importance of Time Course of Blood Pressure Changes and Definitions. J Am Med Dir Assoc 2021; 22:2401-2403. [PMID: 34126059 DOI: 10.1016/j.jamda.2021.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 12/21/2022]
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Newman L, O'Connor JD, Romero-Ortuno R, Reilly RB, Kenny RA. Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing. Hypertension 2021; 78:210-219. [PMID: 34058851 DOI: 10.1161/hypertensionaha.121.17111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Louise Newman
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland
| | - John D O'Connor
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland.,Mercer's Institute for Successful Ageing, St. James' Hospital, Dublin, Ireland (R.R.-O., R.A.K.)
| | - Richard B Reilly
- Trinity Centre for Biomedical Engineering (R.B.R.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland.,Mercer's Institute for Successful Ageing, St. James' Hospital, Dublin, Ireland (R.R.-O., R.A.K.)
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Donoghue OA, O’Connell MDL, Bourke R, Kenny RA. Is orthostatic hypotension and co-existing supine and seated hypertension associated with future falls in community-dwelling older adults? Results from The Irish Longitudinal Study on Ageing (TILDA). PLoS One 2021; 16:e0252212. [PMID: 34043698 PMCID: PMC8158994 DOI: 10.1371/journal.pone.0252212] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Orthostatic hypotension (OH) often co-exists with hypertension. As increasing age affects baroreflex sensitivity, it loses its ability to reduce blood pressure when lying down. Therefore, supine hypertension may be an important indicator of baroreflex function. This study examines (i) the association between OH and future falls in community-dwelling older adults and (ii) if these associations persist in those with co-existing OH and baseline hypertension, measured supine and seated. Data from 1500 community-dwelling adults aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) were used. Continuous beat-to-beat blood pressure was measured using digital photoplethysmography during an active stand procedure with OH defined as a drop in systolic blood pressure (SBP) ≥20 mmHg and/or ≥10 mm Hg in diastolic blood pressure (DBP) within 3 minutes of standing. OH at 40 seconds (OH40) was used as a marker of impaired early stabilisation and OH sustained over the second minute (sustained OH) was used to indicate a more persistent deficit, similar to traditional OH definitions. Seated and supine hypertension were defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg. Modified Poisson models were used to estimate relative risk of falls (recurrent, injurious, unexplained) and syncope occurring over four year follow-up. OH40 was independently associated with recurrent (RR = 1.30, 95% CI = 1.02,1.65), injurious (RR = 1.43, 95% CI = 1.13,1.79) and unexplained falls (RR = 1.55, 95% CI = 1.13,2.13). Sustained OH was associated with injurious (RR = 1.55, 95% CI = 1.18,2.05) and unexplained falls (RR = 1.63, 95% CI = 1.06,2.50). OH and co-existing hypertension was associated with all falls outcomes but effect sizes were consistently larger with seated versus supine hypertension. OH, particularly when co-existing with hypertension, was independently associated with increased risk of future falls. Stronger effect sizes were observed with seated versus supine hypertension. This supports previous findings and highlights the importance of assessing orthostatic blood pressure behaviour in older adults at risk of falls and with hypertension. Observed associations may reflect underlying comorbidities, reduced cerebral perfusion or presence of white matter hyperintensities.
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Affiliation(s)
- Orna A. Donoghue
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
- * E-mail:
| | - Matthew D. L. O’Connell
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Robert Bourke
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, Dublin, Ireland
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35
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Fitzgibbon-Collins LK, Heckman GA, Bains I, Noguchi M, McIlroy WE, Hughson RL. Older Adults' Drop in Cerebral Oxygenation on Standing Correlates With Postural Instability and May Improve With Sitting Prior to Standing. J Gerontol A Biol Sci Med Sci 2021; 76:1124-1133. [PMID: 32766776 DOI: 10.1093/gerona/glaa194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Impaired blood pressure (BP) recovery with orthostatic hypotension on standing occurs in 20% of older adults. Low BP is associated with low cerebral blood flow but mechanistic links to postural instability and falls are not established. We investigated whether posture-related reductions in cerebral tissue oxygenation (tSO2) in older adults impaired stability upon standing, if a brief sit before standing improved tSO2 and stability, and if Low-tSO2 predicted future falls. METHOD Seventy-seven older adults (87 ± 7 years) completed (i) supine-stand, (ii) supine-sit-stand, and (iii) sit-stand transitions with continuous measurements of tSO2 (near-infrared spectroscopy). Total path length (TPL) of the center of pressure sway quantified stability. K-cluster analysis grouped participants into High-tSO2 (n = 62) and Low-tSO2 (n = 15). Fall history was followed up for 6 months. RESULTS Change in tSO2 during supine-stand was associated with increased TPL (R = -.356, p = .001). When separated into groups and across all transitions, the Low-tSO2 group had significantly lower tSO2 (all p < .01) and poorer postural stability (p < .04) through 3 minutes of standing compared to the High-tSO2 group. There were no effects of transition type on tSO2 or TPL for the High-tSO2 group, but a 10-second sitting pause improved tSO2 and enhanced postural stability in the Low-tSO2 group (all p < .05). During 6-month follow-up, the Low-tSO2 group had a trend (p < .1) for increased fall risk. CONCLUSIONS This is the first study to show an association between posture-related cerebral hypoperfusion and quantitatively assessed instability. Importantly, we found differences among older adults suggesting those with lower tSO2 and greater instability might be at increased risk of a future fall.
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Affiliation(s)
- Laura K Fitzgibbon-Collins
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | - George A Heckman
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Ikdip Bains
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Mamiko Noguchi
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | | | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
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Moloney D, O’Connor J, Newman L, Scarlett S, Hernandez B, Kenny RA, Romero-Ortuno R. Clinical clustering of eight orthostatic haemodynamic patterns in The Irish Longitudinal Study on Ageing (TILDA). Age Ageing 2021; 50:854-860. [PMID: 32894746 PMCID: PMC8098799 DOI: 10.1093/ageing/afaa174] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) can be assessed with non-invasive continuous beat-to-beat haemodynamic monitoring during active stand (AS) testing; this yields large volumes of data outside the scope of the traditional OH definition. We explored clinical associations of different AS patterns in participants from Wave 1 of the Irish Longitudinal Study on Ageing. METHODS AS patterns were generated based on three sequential binary systolic blood pressure features: drop ≥40 mmHg within 10 sec post-stand ("immediate deficit"), failure to return to within 20 mmHg of supine level at 40 sec after standing ("stabilisation deficit") and drop ≥20 mmHg between >40 and 120 sec post-stand ("late deficit"). Eight AS groups resulted from combining the presence/absence of these three features. The groups were cross-sectionally characterised, and their ability to independently predict orthostatic intolerance (OI) during AS, and falls or syncope in the past year, was evaluated using multivariate logistic regression models. RESULTS A total of 4,899 participants were included (mean age 61), of which 3,312 (68%) had no deficits. Older age was associated with stabilisation deficit and late deficits were seen in groups with higher proportions of beta blockers and psychotropic medications. Regression models identified independent associations between OI and three immediate-deficit groups; associations seemed stronger as more deficits were present. There was a significant association between falls history and the three-deficit group (odds ratio 1.54, 95% confidence interval: 1.15-2.07, P = 0.004). CONCLUSIONS More deficits seemed associated with the higher risk of OI and falls history. Observations are not causal but the recognition of these patterns may help clinicians focus on careful prescribing.
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Affiliation(s)
- David Moloney
- Address correspondence to: Dr David Moloney, The Irish Longitudinal Study on Ageing (TILDA), Trinity Central, 152-160 Pearse Street, Dublin D02 R590, Republic of Ireland. Tel: (+353) 1 896 2509; Fax: (+353) 1 896 3407.
| | - John O’Connor
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
| | - Louise Newman
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
| | - Siobhan Scarlett
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
| | - Belinda Hernandez
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
- Falls and Syncope Unit, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
- Falls and Syncope Unit, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
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37
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Mol A, Blom MEC, van den Bosch DJ, Van Wezel RJA, Meskers CGM, Maier AB. Orthostatic Blood Pressure Recovery Measured Using a Sphygmomanometer Is Not Associated with Physical Performance or Number of Falls in Geriatric Outpatients. Gerontology 2021; 68:75-79. [PMID: 33902032 DOI: 10.1159/000515658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) and impaired OH recovery derived from beat-to-beat blood pressure (BP) measurements are associated with detrimental clinical outcome, but the clinical relevance of OH recovery assessed using the widely available sphygmomanometer is still unclear. METHOD 635 geriatric outpatients underwent comprehensive geriatric assessment, including orthostatic BP measurements using a sphygmomanometer, during supine rest and 1 and 3 min after standing up and assessment of physical performance (i.e., the timed up and go test and the Short Physical Performance Battery) and the number of falls in the past year. The association between BP recovery, defined as BP at 3 min minus BP at 1 min after standing up, with physical performance and falls was assessed using regression analyses, adjusting for age and sex, both in the entire cohort and after stratifying for the presence of OH at 1 min after standing up. RESULTS BP recovery was not associated with physical performance or number of falls, neither in the entire cohort, nor in subpopulations with or without OH. CONCLUSION The clinical relevance of BP recovery between 1 and 3 min after standing up could not be demonstrated. The results suggest that sphygmomanometer measurements have an inadequate time resolution to record the clinically relevant dynamics of orthostatic BP recovery.
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Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Marieke Esmé Charlotte Blom
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Danique Johanna van den Bosch
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard Jack Anton Van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.,Biomedical Signals and Systems, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
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38
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Kocyigit SE, Ates Bulut E, Aydin AE, Isik AT. Improvement of nutritional status enhances cognitive and physical functions in older adults with orthostatic hypotension. Nutrition 2021; 90:111261. [PMID: 33975062 DOI: 10.1016/j.nut.2021.111261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/23/2021] [Accepted: 03/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Malnutrition may be an important risk factor for orthostatic hypotension (OH). The aim of this study was to investigate the relationship between malnutrition and OH, and the effect of nutritional improvement on cognitive functions and gait-balance parameters in patients with OH. METHODS A total of 692 patients were included in the study. The Head-up Tilt Table Test and Mini Nutritional Assessment (MNA) were implemented for participants. Patients underwent a comprehensive geriatric assessment, including a neurocognitive evaluation and physical performance. After 6 mo, the participants who had OH were reevaluated. RESULTS Women comprised 64.8% of the patients and the mean age was 74.98 ± 7.68 y. The frequencies of OH, malnutrition, and risk of malnutrition were 31.9%, 7.4%, and 13.3%, respectively. The rates of dementia, hypertension, sarcopenia, frailty, and a history of falls in the past year were higher in the OH-positive group. OH was associated with malnutrition (odds ratio: 2.48; confidence interval, 1.35‒4.54; P = 0.003) and risk of malnutrition (odds ratio: 1.64; CI, 1.03‒2.62; P = 0.035) in contrast with normal nutritional status. A higher MNA score during the follow-up period resulted in improved cognitive and gait-balance scores when confounding factors were adjusted (P < 0.05). Patients with OH whose MNA score improved during the follow up also had a significant decrease in the number of falls (P = 0.034). CONCLUSIONS Optimization of nutritional status may improve global cognition and gait-balance functions, and prevent falls in older people with OH.
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Affiliation(s)
| | - Esra Ates Bulut
- Department of Geriatric Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Ali Ekrem Aydin
- Department of Geriatric Medicine, Sivas Numune State Hospital, Sivas, Turkey
| | - Ahmet Turan Isik
- Unit for Aging Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
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Lieten S, Debain A, Bravenboer B, Mets T. Inverted circadian variation of arterial pressure in a geriatric patient: an indicator of autonomic dysfunction. BMC Geriatr 2021; 21:148. [PMID: 33648443 PMCID: PMC7919995 DOI: 10.1186/s12877-021-02059-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/01/2021] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) in geriatric patients frequently involves a component of autonomic failure (AF). The combination of OH with nocturnal hypertension (NHT) is indicative of AF, which is described as pure (PAF), when neurologic symptoms are absent, or as multisystem atrophy (MSA), when combined with motor disturbance (Parkinsonism or Parkinson disease). CASE PRESENTATION An 87-year-old man presented with long-lasting OH. He frequently fell, causing several fractures, and he developed heart failure. Blood pressure (BP) registration revealed a reversal of the day-night rhythm with NHT. An 18-FDG PET brain CT scan showed cerebellar hypometabolism, indicating MSA. CONCLUSIONS This case demonstrates the use of continuous BP registration in geriatric patients with OH for diagnosing NHT. It illustrates the usefulness of 18-FDG PET brain CT scan to specify the nature of the AF. The case also illustrates the difficulty of managing the combination of OH and NHT.
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Affiliation(s)
- Siddhartha Lieten
- Department of Geriatrics, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium. .,Frailty in Aging (FRIA) investigation group, Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium.
| | - Aziz Debain
- Department of Geriatrics, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium.,Frailty in Aging (FRIA) investigation group, Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium
| | - Bert Bravenboer
- Department of Geriatrics, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium.,Frailty in Aging (FRIA) investigation group, Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium.,Departments of Endocrinology & Clinical Pharmacology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium
| | - Tony Mets
- Department of Geriatrics, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium.,Frailty in Aging (FRIA) investigation group, Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium
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Harms MPM, Finucane C, Pérez-Denia L, Juraschek SP, van Wijnen VK, Lipsitz LA, van Lieshout JJ, Wieling W. Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view. Auton Neurosci 2021; 231:102756. [PMID: 33385733 PMCID: PMC8103784 DOI: 10.1016/j.autneu.2020.102756] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls. This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2-3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging. It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.
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Affiliation(s)
- Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ciáran Finucane
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Laura Pérez-Denia
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Johannes J van Lieshout
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; School of Life Sciences, The Medical School, MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, Nottingham, United Kingdom
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Doyle K, Lavan A, Kenny RA, Briggs R. Delayed Blood Pressure Recovery After Standing Independently Predicts Fracture in Community-Dwelling Older People. J Am Med Dir Assoc 2021; 22:1235-1241.e1. [PMID: 33516675 DOI: 10.1016/j.jamda.2020.12.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Orthostatic hypotension, characterized by delayed blood pressure (BP) recovery after standing, is a risk factor for falls but the longitudinal relationship with fracture is not yet known. The aim of this study was to examine the prospective risk of fracture associated with delayed BP recovery. DESIGN Longitudinal study with 8-year follow-up. SETTING AND PARTICIPANTS More than 3000 (54% female) community-dwelling people aged ≥50 years from a large longitudinal study on ageing. METHODS Orthostatic BP was measured using a finometer when standing from lying. Delayed BP recovery was defined as systolic BP ≥20 mm Hg lower and/or diastolic BP ≥10 mm Hg from the baseline value at 30, 60, and 90 seconds after standing. Participants with a fracture reported at any of waves 2 to 5 were defined as having incident fracture. Logistic regression models were used to estimate odds ratios (ORs) for the association between delayed BP recovery and incident fracture. RESULTS Seven percent (212/3117) of participants sustained a fracture during follow-up. Delayed BP recovery at 30 seconds was a significant predictor of any fracture [OR 1.80, 95% confidence interval (CI) 1.28-2.53] and hip fracture (OR 4.44, 95% CI 2.03-9.71) in fully adjusted models. Delayed BP recovery at 30 seconds did not predict wrist or vertebral fracture. Delayed BP recovery at 60 seconds also predicted any fracture (OR 1.74, 95% CI 1.19-2.54) and hip fracture (OR 4.66, 95% CI 2.12-10.26) whereas delayed BP recovery at 90 seconds predicted any (OR 1.99, 95% CI 1.38-2.87), wrist (OR 1.87, 95% CI 1.19-2.95), and hip fracture (OR 3.39, 95% CI 1.45-7.93) in fully adjusted models. CONCLUSION and Implications: Delayed BP recovery independently predicts fracture in community-dwelling older people, is potentially modifiable, and can be measured in an ambulatory setting. Because of the morbidity and mortality associated with fractures, identification of such risk factors is crucial in order to inform preventative strategies.
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Affiliation(s)
- Kate Doyle
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Amanda Lavan
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Rose-Anne Kenny
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland.
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Zuj KA, Hedge ET, Milligan JD, Peterson SD, Hughson RL. Intermittent compression of the calf muscle as a countermeasure to protect blood pressure and brain blood flow in upright posture in older adults. Eur J Appl Physiol 2021; 121:839-848. [PMID: 33386985 DOI: 10.1007/s00421-020-04547-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Orthostatic hypotension, leading to cerebral hypoperfusion, can result in postural instability and falls in older adults. We determined the efficacy of a novel, intermittent pneumatic compression system, applying pressure around the lower legs, as a countermeasure against orthostatic stress in older adults. METHODS Data were collected from 13 adults (4 male) over 65 years of age. Non-invasive ultrasound measured middle cerebral artery blood velocity (MCAv) and finger photoplethysmography measured mean arterial blood pressure (MAP). Intermittent lower leg compression was applied in a peristaltic manner in the local diastolic phase of each cardiac cycle to optimize venous return during 1-min of seated rest and during a sit-to-stand transition to 1-min of quiet standing with compression initiated 15 s before transition. RESULTS During seated rest, compression resulted in a 4.5 ± 6.5 mmHg increase in MAP, and 2.3 ± 2.1 cm/s increase in MCAv (p < 0.05). MAP and MCAv increased during the 15 s of applied compression before the posture transition (2.3 ± 7.2 mmHg and 2.1 ± 4.0 cm/s, respectively, p < 0.05) with main effects for both variables confirming continued benefit during the transition and quiet stand periods. CONCLUSIONS Application of carefully timed, intermittent compression to the lower legs of older adults increased MAP and MCAv during seated rest and maintained an elevated MAP and MCAv during a transition to standing posture. Future research could assess the benefits of this technology for persons at risk for orthostatic hypotension on standing and while walking in an effort to reduce injurious, unexplained falls in older adults.
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Affiliation(s)
- K A Zuj
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.,Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada
| | - E T Hedge
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.,Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada
| | - J D Milligan
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada.,Centre for Family Medicine, Kitchener, ON, Canada
| | - S D Peterson
- Department of Mechanical Engineering, University of Waterloo, Waterloo, ON, Canada
| | - R L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada.
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43
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Zanotto T, Hernandez ME, Medrano CN, Wilund KR, Sosnoff JJ. Cardiovascular Autonomic Dysfunction and Falls in People With Multiple Sclerosis: Is There a Link? An Opinion Article. Front Neurosci 2020; 14:610917. [PMID: 33364920 PMCID: PMC7750464 DOI: 10.3389/fnins.2020.610917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/18/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Tobia Zanotto
- Motor Control Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Manuel E Hernandez
- Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Mobility and Fall Prevention Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Cristina N Medrano
- McKinley Health Center, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Kenneth R Wilund
- Renal and Cardiovascular Disease Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Jacob J Sosnoff
- Motor Control Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States
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44
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Dyer AH, Murphy C, Briggs R, Lawlor B, Kennelly SP. Antidepressant use and orthostatic hypotension in older adults living with mild-to-moderate Alzheimer disease. Int J Geriatr Psychiatry 2020; 35:1367-1375. [PMID: 32668020 DOI: 10.1002/gps.5377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/05/2020] [Accepted: 07/06/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Antidepressant use is often reported as a risk factor for Orthostatic Hypotension (OH), however this relationship has never been explored in those with mild/moderate Alzheimer Disease (AD), who may represent a particularly vulnerable cohort. METHODS We performed a cross-sectional analysis of baseline data from the NILVAD study. Participants with mild-moderate AD were recruited from 23 centres in nine countries. Systolic and Diastolic Blood Pressure (SBP/DBP) was recorded in the seated position and after both 1 and 5 minutes of standing. OH was defined as a drop of ≥20 mmHg SBP/≥10 mmHg DBP. We examined the relationship between antidepressant use, orthostatic BP drop and the presence of OH, controlling for important covariates. RESULTS Of 509 participants (72.9 ± 8.3 years, 61.9% female), two-fifths (39.1%; 199/509) were prescribed a regular antidepressant. Antidepressant use was associated with a significantly greater SBP and DBP drop at 5 minutes (β: 1.83, 0.16-3.50, P = .03 for SBP; β: 1.13, 0.02-2.25, P < .05 for DBP). Selective Serotonin Reuptake Inhibitor (SSRI) use was associated with a significantly greater likelihood of OH (OR 2.0, 1.1-3.6, P = .02). Both findings persisted following robust covariate adjustment. CONCLUSIONS In older adults with AD, antidepressants were associated with a significantly greater SBP/DBP drop at 5 minutes. SSRI use in particular may be a risk factor for OH. This emphasises the need to screen older antidepressant users, and particularly those with AD, for ongoing orthostatic symptoms in order to reduce the risk of falls in this vulnerable cohort.
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Affiliation(s)
- Adam H Dyer
- Department of Age-Related Healthcare, Tallaght University Hospital, Tallaght, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Claire Murphy
- Department of Age-Related Healthcare, Tallaght University Hospital, Tallaght, Ireland
| | - Robert Briggs
- Department of Age-Related Healthcare, Tallaght University Hospital, Tallaght, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Mercer's Institute for Research on Ageing, St James's Hospital, Dublin, Ireland
| | - Brian Lawlor
- Mercer's Institute for Research on Ageing, St James's Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Healthcare, Tallaght University Hospital, Tallaght, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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45
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Laird E, O'halloran AM, Fedorowski A, Melander O, Hever A, Sjögren M, Carey D, Kenny RA. Orthostatic Hypotension and Novel Blood Pressure Associated Gene Variants in Older Adults: Data From the TILDA Study. J Gerontol A Biol Sci Med Sci 2020; 75:2074-2080. [PMID: 31821404 DOI: 10.1093/gerona/glz286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Indexed: 11/14/2022] Open
Abstract
Orthostatic hypotension (OH) is associated with increased risk of trauma and cardiovascular events. Recent studies have identified new genetic variants that influence orthostatic blood pressure (BP). The aim of this study was to investigate the associations of candidate gene loci with orthostatic BP responses in older adults. A total of 3,430 participants aged ≥50 years from The Irish Longitudinal Study on Ageing (TILDA) with BP measures and genetic data from 12 single-nucleotide polymorphism (SNP) linked to BP responses were analyzed. Orthostatic BP responses were recorded at each 10 s interval and were defined as OH (SBP drop ≥20 mmHg or DBP drop ≥10 mmHg) at the time-points 40, 90, and 110 s. We defined sustained OH (SOH) as a drop that exceeded consensus BP thresholds for OH at 40, 90, and 110 s after standing. Logistic regression analyses modeled associations between the candidate SNP alleles and OH. We report no significant associations between OH and measured SNPs after correction for multiple comparisons apart from the SNP rs5068 where proportion of the minor allele was significantly different between cases and controls for SOH 40 (p = .002). After adjustment for covariates in a logistic regression, those with the minor G allele (compared to the A allele) had a decreased incidence rate ratio (IRR) for SOH 40 (IRR 0.45, p = .001, 95% CI 0.29-0.72). Only one SNP linked with increased natriuretic peptide concentrations was associated with OH. These results suggest that genetic variants may have a weak impact on OH but needs verification in other population studies.
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Affiliation(s)
- Eamon Laird
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland
| | | | - Artur Fedorowski
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö, Sweden
| | - Ann Hever
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland
| | - Marketa Sjögren
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö, Sweden
| | - Daniel Carey
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland.,Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
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Fanciulli A, Campese N, Goebel G, Ndayisaba JP, Eschlboeck S, Kaindlstorfer C, Raccagni C, Granata R, Bonuccelli U, Ceravolo R, Seppi K, Poewe W, Wenning GK. Association of transient orthostatic hypotension with falls and syncope in patients with Parkinson disease. Neurology 2020; 95:e2854-e2865. [PMID: 32938788 DOI: 10.1212/wnl.0000000000010749] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/25/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To assess the frequency of transient orthostatic hypotension (tOH) and its clinical impact in Parkinson disease (PD), we retrospectively studied 173 patients with PD and 173 age- and sex-matched controls with orthostatic intolerance, who underwent cardiovascular autonomic function testing under continuous noninvasive blood pressure (BP) monitoring. METHODS We screened for tOH (systolic BP fall ≥20 mm Hg or diastolic ≥10 mm Hg resolving within the first minute upon standing) and classic OH (cOH, sustained systolic BP fall ≥20 mm Hg or diastolic ≥10 mm Hg within 3 minutes upon standing). In patients with PD, we reviewed the medical records of the 6 months preceding and following autonomic testing for history of falls, syncope, and orthostatic intolerance. RESULTS tOH occurred in 24% of patients with PD and 21% of controls, cOH in 19% of patients with PD and in none of the controls, independently of any clinical-demographic or PD-specific characteristic. Forty percent of patients with PD had a history of falls, in 29% of cases due to syncope. Patients with PD with history of orthostatic intolerance and syncope had a more severe systolic BP fall and lower diastolic BP rise upon standing, most pronounced in the first 30-60 seconds. CONCLUSIONS tOH is an age-dependent phenomenon, which is at least as common as cOH in PD. Transient BP falls when changing to the upright position may be overlooked with bedside BP measurements, but contribute to orthostatic intolerance and syncope in PD. Continuous noninvasive BP monitoring upon standing may help identify a modifiable risk factor for syncope-related falls in parkinsonian patients.
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Affiliation(s)
- Alessandra Fanciulli
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - Nicole Campese
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Georg Goebel
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Jean Pierre Ndayisaba
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Sabine Eschlboeck
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Christine Kaindlstorfer
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Cecilia Raccagni
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Roberta Granata
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Ubaldo Bonuccelli
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Roberto Ceravolo
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Klaus Seppi
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Werner Poewe
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gregor K Wenning
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
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Farrell MC, Shibao CA. Morbidity and mortality in orthostatic hypotension. Auton Neurosci 2020; 229:102717. [PMID: 32896712 DOI: 10.1016/j.autneu.2020.102717] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/27/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.
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Affiliation(s)
- Maureen C Farrell
- Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Cyndya A Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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48
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Buckley A, Carey D, Meaney JM, Kenny R, Harbison J. Is there an association between orthostatic hypotension and cerebral white matter hyperintensities in older people? The Irish longitudinal study on ageing. JRSM Cardiovasc Dis 2020; 9:2048004020954628. [PMID: 32953093 PMCID: PMC7476335 DOI: 10.1177/2048004020954628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Orthostatic Hypotension (OH) is an abnormal drop in blood pressure (BP) that occurs following orthostatic challenge. OH is associated with increased risk of falls, cognitive impairment and death. White Matter Hyperintensities (WMH) on MR Brain are associated with vascular risk factors such as hypertension, diabetes and age. We examined whether extent White matter intensities were associated with presence of OH detected in a community dwelling population of older people. Methods Individuals from the MR sub-study of the Irish Longitudinal Study of Ageing underwent a 3 Tesla MR Brain scan to assess WMH severity (Schelten’s Score). The scans were performed during the Wave 3 TILDA health assessment phase when the subjects also underwent assessment for OH with an active stand protocol. Data was analysed for association between WMH and vascular risks and orthostatic change in BP 10 second intervals during the OH evaluation. Results 440 subjects were investigated; median age 72 years (65–92 years) and 228 (51.5%) female. Range of Scheltens’ Scores was 0–32. Mean score was 9.72 (SD 5.87). OH was detected in 68.4% (301). On linear regression, positive associations were found between Scheltens’ Score and age, hypertension, prior history of stroke and TIA, and with OH at 30, 70, 90 and 100 seconds following standing (p < 0.05, O.R. 1.9–2.5). Conclusion WMD is associated with OH detected at multiple time points using active stand in community dwelling older subjects. Further research is necessary to evaluate the direction of this association.
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Affiliation(s)
- Anne Buckley
- The Irish Longitudinal Study of Ageing and Department of Medical Gerontology, Trinity College Dublin, University of Dublin, Dublin, Ireland.,Centre for Advanced Medical Imaging, St James's Hospital, Dublin, Ireland
| | - Daniel Carey
- The Irish Longitudinal Study of Ageing and Department of Medical Gerontology, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - James M Meaney
- Centre for Advanced Medical Imaging, St James's Hospital, Dublin, Ireland
| | - RoseAnne Kenny
- The Irish Longitudinal Study of Ageing and Department of Medical Gerontology, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Joseph Harbison
- The Irish Longitudinal Study of Ageing and Department of Medical Gerontology, Trinity College Dublin, University of Dublin, Dublin, Ireland
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Stewart JM, Kota A, O'Donnell-Smith MB, Visintainer P, Terilli C, Medow MS. The preponderance of initial orthostatic hypotension in postural tachycardia syndrome. J Appl Physiol (1985) 2020; 129:459-466. [PMID: 32702262 DOI: 10.1152/japplphysiol.00540.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Reduced systolic/diastolic blood pressure (BP) by >40/20 mmHg defines initial orthostatic hypotension (IOH). Rapid resolution of hypotension and lightheadedness follows, but tachycardia may be prolonged. We aimed to examine IOH in controls and patients with postural tachycardia syndrome (POTS) using indices of spontaneous fluctuations of heart rate (HR) and systolic BP as measures of cardiac baroreflex differences. We recruited otherwise healthy IOH patients without POTS (n = 20, 16 ± 3 yr), healthy volunteers (n = 32, 17 ± 3 yr), and POTS patients (n = 39, 17 ± 4 yr). Subjects were instrumented for electrocardiography and beat-to-beat BP. After 10 min supine, subjects stood for 5 min. Following supine recovery, subjects underwent 70° head-up tilt for 10 min to test for POTS. BP, HR, and time, referenced to standing, were measured at events during standing: minimum BP, BP recovery, peak HR, HR minimum, and steady state. Baseline HR and BP were higher in POTS compared with healthy groups. IOH occurred in 13% of controls and 51% of POTS patients. The BP minimum was lower in POTS. Parasympathetic modulation of cardiac baroreflex was decreased in all POTS and control-IOH subjects. Sympathetic indices were increased. Events following BP minimum occurred progressively later in all POTS and control-IOH subjects compared with non-IOH controls. IOH is more frequent in POTS than in controls with a lower minimum BP. POTS has markedly reduced heart rate variability and baroreflex, indicating reduced HR buffering of BP. POTS-IOH and control-IOH subjects had similar peak HR despite decreased minimum BP in POTS. IOH data indicate modest parasympathetic and cardiovagal baroreflex deficits in control-IOH subjects. Parasympathetic deficits are more severe in all POTS patients.NEW & NOTEWORTHY Significant initial orthostatic hypotension (IOH) occurs in ~50% of postural tachycardia syndrome (POTS) patients and 13% of controls. Heart rate and blood pressure recovery are prolonged in IOH sustaining lightheadedness; IOH is more prevalent and severe in POTS. Altered cerebral blood flow and cardiorespiratory regulation are more prevalent in POTS. Altered heart rate variability and baroreflex gain may cause nearly instantaneous lightheadedness in POTS. IOH alone fails to confer a strong probability of POTS.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| | - Archana Kota
- Department of Pediatric, New York Medical College, Valhalla, New York
| | | | - Paul Visintainer
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts
| | - Courtney Terilli
- Department of Pediatric, New York Medical College, Valhalla, New York
| | - Marvin S Medow
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
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50
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Orthostatic blood pressure recovery associates with physical performance, frailty and number of falls in geriatric outpatients. J Hypertens 2020; 39:101-106. [PMID: 32773650 PMCID: PMC7752240 DOI: 10.1097/hjh.0000000000002617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Blood pressure (BP) recovery after orthostatic hypotension might be important to prevent cerebral hypoperfusion episodes in older adults, and be related to better clinical outcome. The objective was to study the relationship between BP recovery and clinical outcome, that is physical and cognitive performance, frailty and falls, in geriatric outpatients.
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