Impairments in Hemodynamic Responses to Orthostasis Associated with Frailty: Results from The Irish Longitudinal Study on Ageing (TILDA)

Which Components of the Haemodynamic Response to Active Stand Predict Cardiovascular Disease and Mortality? Data From The Irish Longitudinal Study on Ageing

Background

An integrated haemodynamic response during standing may serve as an integrative marker of neuro-cardiovascular function. Individual components of both heart rate (HR) and blood pressure (BP) responses to active stand (AS) have been linked with cardiovascular disease (CVD) and mortality. We assessed longitudinal associations between entire HR/BP response curves during AS, incident CVD and mortality over 12 years.

Methods

Beat-to-beat measurements of dynamic HR/BP responses to AS were conducted in 4,336 individuals (61.5±8.2 years; 53.7% female). Functional Principal Components Analysis was applied to HR/BP response curves and their association with CVD and mortality assessed. We hypothesised that integrating BP/HR information from the entire haemodynamic response curve may uncover novel associations with both CVD and mortality.

Results

Higher systolic BP (SBP) before AS and blunted recovery of SBP during AS was associated with all-cause mortality over 12-years (Hazard Ratio [HR]: 1.14; 1.04, 1.26; p=0.007). Higher baseline/peak HR and lower HR from 30 seconds post stand onwards were associated with lower mortality due to circulatory causes (HR: 0.78; 0.64, 0.95; p = 0.013). Higher HR throughout AS was associated with mortality from other causes (HR: 1.48; 1.22, 1.80; p<0.001). Findings persisted on robust covariate adjustment.

Conclusions

We observed distinct relationships between HR/BP responses to AS and 12-year incident CVD and mortality. Integrating the entire haemodynamic response may reveal more nuanced relationships between HR/BP responses to AS, CVD and mortality - serving as an integrative marker of neuro-cardiovascular health in midlife and beyond.

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

Background

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

Methods

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

Results

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

Conclusion

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

Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study

Background

Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRRexercise), is an independent predictor of cardiorespiratory capacity and mortality (particularly when HRR ≤12 beats min-1). Heart rate also often declines after orthostatic challenge (HRRorthostatic), but the mechanism remains unclear. We tested whether HRRorthostatic reflects similar vagal autonomic characteristics as HRRexercise.

Methods

Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise testing (CPET) as part of routine care. Before undergoing CPET, heart rate was measured with participants seated for 3 min, before standing for 3 min (HRRorthostatic). HRRexercise 1 min after the end of CPET was recorded. The primary outcome was the correlation between mean heart rate change every 10 s for 1 min after peak heart rate was attained on standing and after exercise for each participant. Secondary outcomes were HRRorthostatic and peak VO2 compared between individuals with HRRexercise <12 beats min-1.

Results

A total of 87 participants (mean age: 64 yr [95%CI: 61-66]; 48 (55%) females) completed both tests. Mean heart rate change every 10 s for 1 min after peak heart rate after standing and exercise was significantly correlated (R2=0.81; P<0.0001). HRRorthostatic was unchanged in individuals with HRRexercise ≤12 beats min-1 (n=27), but was lower when HRRexercise >12 beats min-1 (n=60; mean difference: 3 beats min-1 [95% confidence interval 1-5 beats min-1]; P<0.0001). Slower HRRorthostatic was associated with lower peak VO2 (mean difference: 3.7 ml kg-1 min-1 [95% confidence interval 0.7-6.8 ml kg-1 min-1]; P=0.039).

Conclusion

Prognostically significant heart rate recovery after exhaustive exercise is characterised by quantitative differences in heart rate recovery after orthostatic challenge. These data suggest that orthostatic challenge is a valid, simple test indicating vagal impairment.

Clinical trial registration

researchregistry6550.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intrinsic capacity and resilience: Taking frailty to the next level

In addition to frailty, two novel concepts have been introduced in the field of geriatrics to capture the heterogeneous ageing process: the first is intrinsic capacity, which uses a community-based, holistic approach and is propagated by the World Health Organization (WHO); and the second is resilience, which provides a more dynamic perspective on the individual's reserves, injury and recovery. While both concepts are linked to frailty, with all three focusing on reserves in relation to ageing, each approaches this issue from a different point of view. In this paper, we will compare and contrast these three concepts - frailty, intrinsic capacity and resilience - and assess their relevance to future geriatric oncology research as well as daily clinical practice.

Blood Pressure Signal Entropy as a Novel Marker of Physical Frailty: Results from the FRAILMatics Clinical Cohort

In this study we investigated the association between information entropy in short length blood pressure signals and physical frailty status, in a group of patients aged 50+ recruited from the Falls and Syncope Unit at the Mercer's Institute for Successful Ageing in St James's Hospital, Dublin, Ireland. This work is an external clinical validation of findings previously derived in a population-based cohort from The Irish Longitudinal Study on Ageing (TILDA). The hypothesis under investigation was that dysregulation (as quantified by entropy) in continuous non-invasive blood pressure signals could provide a clinically useful marker of physical frailty status. We found that in the 100 patients investigated, higher entropy in continuously measured resting state diastolic blood pressure was associated with worse physical frailty score, as measured by the Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI). Since physical frailty is defined as a pre-disability state and hence it can be difficult for clinicians to identify at an early stage, the quantification of entropy in short length cardiovascular signals could provide a clinically useful marker of the physiological dysregulations that underlie physical frailty, potentially aiding in identifying individuals at higher risk of adverse health outcomes.

Age and sex related differences in orthostatic cerebral oxygenation: Findings from 2764 older adults in the Irish Longitudinal Study on Ageing (TILDA)

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.

Increased multimorbidity is associated with impaired cerebral and peripheral hemodynamic stabilization during active standing

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.

Orthostatic Hypotension and Concurrent Autonomic Dysfunction: A Novel Complication of Lung Transplantation

Background

Persistent orthostatic hypotension (OH) is a lesser-known complication of lung transplantation (LTx). In this retrospective case series, we describe the clinical manifestations, complications, and treatment of persistent OH in 13 LTx recipients.

Methods

We identified LTx recipients who underwent transplantation between March 1, 2018, and March 31, 2020, with persistent symptomatic OH and retrospectively queried the records for clinical information.

Results

Thirteen patients were included in the analysis, 9 (69%) had underlying pulmonary fibrosis, and 12 (92%) were male. The median age, height, and body mass index at LTx were 68 years, 70 inches, and 27 kg/m², respectively. Six (46%) patients were deceased at the time of chart abstraction with a median (IQR) posttransplant survival of 12.6 months (6, 21); the 7 remaining living patients were a median of 19.6 months (18, 32) posttransplant. Signs and symptoms of OH developed a median of 60 (7, 75) days after transplant. Patients were treated with pharmacological agents and underwent extensive physical therapy. Most patients required inpatient rehabilitation (n = 10, 77%), and patients commonly developed comorbid conditions including weight loss, renal insufficiency with eGFR <50 (n = 13, 100%), gastroparesis (n = 7, 54%), and tachycardia-bradycardia syndrome (n = 2, 15%). Falls were common (n = 10, 77%). The incidence of OH in LTx recipients at our center during the study period was 5.6% (13/234).

Conclusions

Persistent OH is a lesser-known complication of LTx that impacts posttransplant rehabilitation and may lead to comorbidities and shortened survival. In addition, most LTx recipients with OH at our center were tall, thin men with underlying pulmonary fibrosis, which may offer an opportunity to instate pretransplant OH screening of at-risk patients.

Autonomic symptoms and associated factors in patients with chronic heart failure

OBJECTIVE

Autonomic disorders are common in chronic illness, and their symptoms may restrict the daily functioning of patients. However, in chronic heart failure, extensive knowledge about autonomic symptoms is still lacking. This study aims to explore self-perceived autonomic symptoms, associated factors, and their relationship with health-related quality of life in chronic heart failure.

METHODS

One hundred and twenty-four patients with documented chronic heart failure (men and women; 50-86 years) and 124 sex and age-matched controls participated in this study. The participants filled validated questionnaires about autonomic symptom profile (COMPASS 31), fatigue (CIS, Checklist for individual strength), anxiety and depression (HADS, Hospital Anxiety and Depression), and health-related quality of life (SF36). Non-parametric statistics were performed to analyse the data.

RESULTS

Total score for autonomic symptoms was higher in chronic heart failure compared to controls [Median: 14.9; IQR: 6.2-25.1 vs. 7.3; 0-18; p < 0.001], especially for orthostatic hypotension [Median: 8; IQR: 0-16 vs. 0; 0-12; p < 0.001], vasomotor [Median: 0; IQR: 0-0 vs. 0; 0-0; p < 0.001] and secretomotor function [Median: 0; IQR: 0-4.2 vs. 0; 0-2.1; p = 0.013]. High scores for autonomic symptoms were moderate correlated with higher scores of fatigue, anxiety and depression (0.343 ≤ rs ≥ 0.420; p < 0.001) and with decreased health-related quality of life (-0.454; p < 0.01).

CONCLUSION

Autonomic symptoms, especially for orthostatic intolerance, vasomotor and secretomotor subdomains, are prevalent and are associated with fatigue complaints and poor health-related quality of life in CHF.

Impaired Stabilisation of Orthostatic Cerebral Oxygenation is Associated with Slower Gait Speed: Evidence from The Irish Longitudinal Study on Ageing

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.

One-Dimensional Statistical Parametric Mapping Identifies Impaired Orthostatic Cerebrovascular and Cardiovascular Response in Frailty Index

Background

Orthostasis is a potent physiological stressor which adapts with age. The age-related accumulation of health deficits in multiple physiological systems may impair the physiological response to orthostasis and lead to negative health outcomes such as falls, depression, and cognitive decline. Research to date has focused on changes with orthostasis at prespecified intervals of time, without consideration for whole signal approaches.

Methods

One-dimensional statistical parametric mapping identified regions in time of significant association between variables of interest using a general linear model. Frailty index operationalized accumulated health and social deficits using 32-items from a computer-assisted interview. This study examined the association of frailty index on blood pressure, heart rate, and cerebral oxygenation during an orthostatic test in a sample of 2742 adults aged 50 or older from The Irish Longitudinal Study on Ageing.

Results

Frailty index was seen to be negatively associated with cerebral oxygenation changes from baseline over a period of 7 seconds (p = .036). Heart rate and systolic blood pressure were positively and negatively associated with frailty index over periods of 17 seconds (p = .001) and 10 seconds (p = .015), respectively.

Conclusions

Statistical parametric mapping demonstrated these significant regions of cerebral oxygenation during orthostasis provide indirect evidence of impaired autoregulation associated with frailty. Statistical parametric mapping also replicated prior relationships in heart rate and systolic blood pressure associated with a higher frailty index. These findings highlight the utility of 1-dimensional statistical parametric modeling in identifying significant regions of interest in physiological recordings.

Hypertension, hypotension and syncope

Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.

Associations between Neurocardiovascular Signal Entropy and Physical Frailty

In this cross-sectional study, the relationship between noninvasively measured neurocardiovascular signal entropy and physical frailty was explored in a sample of community-dwelling older adults from The Irish Longitudinal Study on Ageing (TILDA). The hypothesis under investigation was that dysfunction in the neurovascular and cardiovascular systems, as quantified by short-length signal complexity during a lying-to-stand test (active stand), could provide a marker for frailty. Frailty status (i.e., "non-frail", "pre-frail", and "frail") was based on Fried's criteria (i.e., exhaustion, unexplained weight loss, weakness, slowness, and low physical activity). Approximate entropy (ApEn) and sample entropy (SampEn) were calculated during resting (lying down), active standing, and recovery phases. There was continuously measured blood pressure/heart rate data from 2645 individuals (53.0% female) and frontal lobe tissue oxygenation data from 2225 participants (52.3% female); both samples had a mean (SD) age of 64.3 (7.7) years. Results revealed statistically significant associations between neurocardiovascular signal entropy and frailty status. Entropy differences between non-frail and pre-frail/frail were greater during resting state compared with standing and recovery phases. Compared with ApEn, SampEn seemed to have better discriminating power between non-frail and pre-frail/frail individuals. The quantification of entropy in short length neurocardiovascular signals could provide a clinically useful marker of the multiple physiological dysregulations that underlie physical frailty.

Hypertension management in frail older adults: a gap in evidence

Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.

Functional Analysis of Continuous, High-Resolution Measures in Aging Research: A Demonstration Using Cerebral Oxygenation Data From the Irish Longitudinal Study on Aging

Background: A shift towards the dynamic measurement of physiologic resilience and improved technology incorporated into experimental paradigms in aging research is producing high-resolution data. Identifying the most appropriate analysis method for this type of data is a challenge. In this work, the functional principal component analysis (fPCA) was employed to demonstrate a data-driven approach to the analysis of high-resolution data in aging research. Methods: Cerebral oxygenation during standing was measured in a large cohort [The Irish Longitudinal Study on Aging (TILDA)]. FPCA was performed on tissue saturation index (TSI) data. A regression analysis was then conducted with the functional principal component (fPC) scores as the explanatory variables and transition time as the response. Results: The mean ± SD age of the analysis sample was 64 ± 8 years. Females made up 54% of the sample and overall, 43% had tertiary education. The first PC explained 96% of the variance in cerebral oxygenation upon standing and was related to a baseline shift. Subsequent components described the recovery to before-stand levels (fPC2), drop magnitude and initial recovery (fPC3 and fPC4) as well as a temporal shift in the location of the minimum TSI value (fPC5). Transition time was associated with components describing the magnitude and timing of the nadir. Conclusions: Application of fPCA showed utility in reducing a large amount of data to a small number of parameters which summarize the inter-participant variation in TSI upon standing. A demonstration of principal component regression was provided to allow for continued use and development of data-driven approaches to high-resolution data analysis in aging research.

Translating Frailty Assessment Methodologies and Research-based Evidence to Clinical Education and Practice

Frailty is a common clinical syndrome that predisposes older adults to an increased risk of adverse health outcomes. With population aging, this will become an increasing challenge for the healthcare services; therefore, different models of healthcare training and provision are required to address these increasing demands. In Ireland, the National Clinical Programme for Older People (NCPOP) has partnered with The Irish Longitudinal Study on Ageing (TILDA) to deliver the National Frailty Education Programme. This demonstrates an innovative way in which evidence-based longitudinal research can be translated into clinical education and practice to improve patient care, following a Knowledge to Action (KTA) process. To the authors' knowledge, it is the first time that a longitudinal research study such as TILDA has employed such methods of translation and therefore, this collaboration could serve as an international model of translation and implementation for frailty and other areas of clinical priority.

Association of Antidepressants With Recurrent, Injurious and Unexplained Falls is Not Explained by Reduced Gait Speed

OBJECTIVE

To examine if antidepressants at baseline are associated with falls and syncope over 4 years follow-up and if any observed associations are explained by baseline gait speed.

DESIGN

Longitudinal study (three waves).

SETTING

The Irish Longitudinal Study on Ageing (TILDA), a nationally representative cohort study.

PARTICIPANTS

Two thousand ninety-three community-dwelling adults aged ≥60 years.

MEASUREMENTS

Antidepressants (ATC code "N06A") were identified. Recurrent falls (≥2 falls), injurious falls (requiring medical attention), unexplained falls, and syncope were reported at either Wave 2 or 3. Usual gait speed was the mean of two walks on a 4.88 m GAITRite walkway. Poisson regression analysis was used to examine associations between baseline antidepressant use and future falls adjusting for sociodemographics, physical, cognitive and mental health, and finally, gait speed.

RESULTS

Compared to non-antidepressant users, those on antidepressants at baseline were more likely to report all types of falls (24.8-40.7% versus 9.8-18%) at follow-up. Antidepressants at baseline were independently associated with injurious falls (incidence risk ratio: 1.58, 95% confidence interval: 1.21, 2.06, z = 3.38, p = 0.001, df = 32) and unexplained falls (incidence risk ratio: 1.49, 95% confidence interval: 1.04, 2.15, z = 2.17, p = 0.030, df = 32) independent of all covariates including gait speed.

CONCLUSION

There was little evidence to support the hypothesis that gait would (partly) explain any observed associations between baseline use of antidepressants and future falls. The underlying mechanisms of the observed relationships may be related to depression, vascular pathology, or direct effects of antidepressants. Clinicians should identify the best treatment option for an individual based on existing risk factors for outcomes such as falls.

Impact of Standing Speed on the Peripheral and Central Hemodynamic Response to Orthostasis: Evidence From the Irish Longitudinal Study on Ageing

Assessment of the cerebrovascular and cardiovascular response to standing has prognostic value for a range of outcomes in the older adult population. Studies generally attempt to control for standing speed differences by asking participants to stand in a specified time but little is known about the range of transition times observed. This study aimed to characterize how standing speed associates with cardiovascular and cerebrovascular measures following transition from supine to standing. Continuous cerebral oxygenation, heart rate, systolic and diastolic blood pressure were monitored for 3 minutes after transitioning from supine to standing. An algorithm was used to calculate the time taken to transition from existing Finometer data (from the height correction unit). Linear mixed-effects models were used to assess the influence of transition time on each of the signals while adjusting for covariates. Transition time ranged from 2 to 27 s with 17% of participants taking >10 s to stand. Faster transition was associated with a more extreme decrease 10 s after standing but improved recovery at 20 s for cerebral oxygenation and blood pressure. Standing faster was associated with an elevated heart rate on initiation of stand and a quicker recovery 10 to 20 s after standing. The speed of transitioning from supine to standing position is associated with cardiovascular and cerebrovascular response in the early period after standing (<40 s). Care should be taken in the interpretation of findings which may be confounded by standing speed and statistical adjustment for standing time should be applied where appropriate.

Resilience in Clinical Care: Getting a Grip on the Recovery Potential of Older Adults

Background

Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct.

Methods

Based on an outline of the state‐of‐the‐art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon.

Results

An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response.

Conclusion

A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650–2657, 2019