Oscillometric measure of blood pressure detects association between orthostatic hypotension and depression in population based study of older adults

Orthostatic intolerance: a frailty marker for older adults

PURPOSE

Frailty, orthostatic blood pressure changes (OBPC), and orthostatic intolerance syndrome (OIS) are common in geriatric patients. However, the results of the studies evaluating the relationship between these entities are discordant. We aimed to investigate the association between frailty and OIS with or without OBPC.

METHODS

Comprehensive geriatric assessment (CGA), frailty assessment, OBPC evaluations in the active-standing test (1st, 3rd, 5th, and 10th min), OIS investigation both in history before the test (self-reported OIS) and emerged during the active-standing test, and sarcopenia assessment via BIA and handgrip strength (HGS) were performed in 102 geriatric outpatients.

RESULTS

Patients were divided into three categories according to their frailty status (non-frail, prefrail, and frail) by Modified Fried Frailty Index (FFI) and Clinical Frailty Scale (CFS). Prevalence of self-reported OIS and OIS during the test were statistically higher in the frail group assessed by both frailty scales (P value: 0.001 for CFS, P value < 0.0001 for FFI, and P value: 0.001 for CFS, P value: 0.007 for FFI, respectively). Logistic regression analysis showed that OIS significantly increased frailty assessed both by FFI and CFS, when adjusted for age, sex, comorbidities, CGA, and sarcopenia (For FFI, OR: 19.37; 95% CI: 2.38-157.14; P value: 0.006 and for CFS OR: 4.32; 95% CI: 1.184-11.47; P value: 0.003, respectively).

CONCLUSION

To the best of our knowledge, this is the first study defining OIS as symptoms both self-reported and provoked during the test, and showed a strong correlation between OIS and frailty. OIS may be defined as a multifactorial and independent marker for frailty, regardless of OBPC. Further prospective investigations are warranted to support the relationships between OIS and frailty.

Is there an association between orthostatic hypotension and cerebral white matter hyperintensities in older people? The Irish longitudinal study on ageing

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.

Efficacy of atomoxetine versus midodrine for neurogenic orthostatic hypotension

Objective

The efficacy and safety of 1‐month atomoxetine and midodrine therapies were compared. Three‐month atomoxetine and combination therapies were investigated for additional benefits.

Methods

This prospective open‐label randomized trial included 50 patients with symptomatic neurogenic orthostatic hypotension (nOH). The patients received either atomoxetine 18 mg daily or midodrine 5 mg twice daily and were evaluated 1 and 3 months later. Those who still met the criteria for nOH at 1 month received both midodrine and atomoxetine for an additional 2 months, and if not, they continued their initial medication. The primary outcome was an improvement in orthostatic blood pressure (BP) drop (maximum BP change from supine to 3 min after standing) at 1 month. The secondary endpoints were symptom scores, percentage of patients with nOH at 1 and 3 months.

Results

Patients with midodrine or atomoxetine treatment showed comparative improvement in the orthostatic BP drop, and overall only 26.2% of the patients had nOH at 1 month, which was similar between the treatment groups. Only atomoxetine resulted in significant symptomatic improvements at 1 month. For those without nOH at 1 month, there was additional symptomatic improvement at 3 months with their initial medication. For those with nOH at 1 month, the combination treatment resulted in no additional improvement. Mild‐to‐moderate adverse events were reported by 11.6% of the patients.

Interpretation

One‐month atomoxetine treatment was effective and safe in nOH patients. Atomoxetine improved orthostatic BP changes as much as midodrine and was better in terms of ameliorating nOH symptoms.

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

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

Orthostatic hypotension in patients with late-life depression: Prevalence and validation of a new screening tool

OBJECTIVES

The objective of this study was to assess the prevalence of orthostatic hypotension (OH) in a sample of late life depression (LLD) patients and to determine the validity of a standardized questionnaire, the Orthostatic Hypotension Questionnaire (OHQ). Secondarily, we wished to assess variables associated with OH.

METHODS

We conducted a cross-sectional study on 82 consecutive geriatric outpatients presenting with LLD. OH was defined as a fall in systolic blood pressure of greater than 20 mm Hg and/or 10 mm Hg on diastolic blood pressure on an orthostatic stress test from sitting to standing. Logistic regressions were used to identify factors associated with OH.

RESULTS

The prevalence of OH as measured on the orthostatic stress test and on the OHQ was 28% and 57%, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the OHQ were 69.6% (95% CI 47%-87%), 47.5% (95%CI 34%-61%), 0.54 (95% CI: 0.43-0.64), 34% (95%CI 21%-49%), and 80% (95%CI 63%-92%), respectively. Females were more likely to have OH (OR: 3.96, 95%CI 1.06-14.89, P = .041), and those married or in a common-law relationship were less likely to have OH (OR: 0.25, 95% CI 0.08-0.72, P = .011).

CONCLUSIONS

OH is common in patients with LLD conferring them a risk of gait instability and falls. Females had a higher risk of having OH while participants who were married or in a common-law relationship were less likely to have OH. Although the OHQ is a quick to administer paper-based screening test, it did not show adequate diagnostic accuracy in patients with LLD seen in a routine psychiatry clinic.

Does baseline hypotension predict incident depression in a cohort of community-dwelling older people? Data from The Irish Longitudinal Study on Ageing (TILDA)

Background

hypotension is now recognised as a risk factor for syncope, cardiovascular events and mortality, but it may also represent a risk factor for late life depression (LLD). The aim of this study was to clarify the longitudinal relationship between hypotension and incident LLD.

Methods

this is a longitudinal study involving community-dwelling participants aged ≥50 years, using data from The Irish Longitudinal Study on Ageing. The Centre for Epidemiological Studies Depression Scale (CES-D) was administered at baseline and at follow-up 2 years later. Blood pressure (BP) was measured at baseline. Participants with a CES-D score ≥16 at baseline and those taking antidepressants were excluded and considered to have a current diagnosis of depression. A score of ≥16 at follow-up was used to define incident depression.

Results

about 4,525 participants were included and 200 participants had diagnosis of incident LLD. The incident depression group had lower systolic BP at baseline than the non-depressed group (132.8 ± 1.43 mm Hg vs. 136.0 ± 0.30 mm HG, P = 0.025). Logistic regression showed those with systolic BP <130 mm HG had an unadjusted odds ratio of 1.31 (1.01-1.68) for incident depression. This persisted after adjustment for confounding factors.

Conclusion

systolic BP <130 mm Hg increased the likelihood of incident depression in a cohort of community-dwelling older adults. These findings are important because systolic hypotension may represent a potentially modifiable risk factor for LLD. They are also relevant in the context of BP treatment targets for older people.

Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study

BACKGROUND

Orthostatic hypotension (OH) is commonly reported among older adults and is associated with an increased risk of mortality. This study aimed to describe the prevalence and investigate the possible associations between OH with sociodemographic variables, chronic medical conditions, health service utilisation, dementia and cognitive status among older adults residing in Singapore.

METHODS

Data was collected from 2266 participants aged 60 years and older who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013. Face-to-face interviews were conducted and data collected includes sociodemographic information, blood pressure measurements, medical history, health services utilisation, and cognitive status.

RESULTS

The prevalence of OH among older adults in Singapore was 7.8%. OH was highest in participants aged 85 years and above (OR: 2.33; 1.26-4.30; p=0.007) compared to those aged 75-84 years (OR: 1.76; 1.08-2.85; p=0.023). Participants with hypertension were more likely to have OH (OR: 3.03; 1.56-5.88, p=0.001) than those without hypertension. Those with dementia were also more likely to have OH than those with normal cognitive status (p=0.007).

CONCLUSIONS

Older age, hypertension, and dementia were independently associated with OH in the older adult population in Singapore. Interventions such as home safety assessment and preventive measures should be implemented to improve older adult's functional capacity and quality of life to prevent injury.

Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism

BACKGROUND AND PURPOSE

Recent studies have shown that several nonmotor symptoms differ between Parkinson's disease (PD) and drug-induced parkinsonism (DIP). However, there have been no reports on cardiovascular autonomic function in DIP, and so this study investigated whether cardiovascular autonomic function differs between PD and DIP patients.

METHODS

This study consecutively enrolled 20 DIP patients, 99 drug-naïve PD patients, and 25 age-matched healthy controls who underwent head-up tilt-table testing and 24-h ambulatory blood pressure monitoring.

RESULTS

Orthostatic hypotension was more frequent in patients with PD or DIP than in healthy controls. In DIP, orthostatic hypotension was associated with the underlying psychiatric diseases and neuroleptics use, whereas prokinetics were not related to orthostatic hypotension. The supine blood pressure, nighttime blood pressure, and nocturnal blood pressure dipping did not differ significantly between the DIP and control groups. Supine hypertension and nocturnal hypertension were more frequent in PD patients than in controls.

CONCLUSIONS

The included DIP patients frequently exhibited orthostatic hypotension that was associated with the underlying diseases as well as the nature of and exposure time to the offending drugs. Clinicians should individualize the manifestations of DIP according to underlying diseases as well as the action mechanism of and exposure time to each offending drug.

The association between orthostatic hypertension and all-cause mortality in hospitalized elderly persons

Background

Little is known about the prevalence of orthostatic hypertension (OHT) and its effect on long-term mortality in the elderly. We evaluated the prevalence of OHT and its effect on mortality in hospitalized elderly patients.

Methods

Out of 1852 patients admitted between 31/12/1999 and 31/12/2000 to an acute geriatric ward, 474 patients (48% males) with a mean age of 81.5 ± 6.8 years were enrolled in this study. Blood pressure (BP) was measured three times during the day in a supine and standing position. Patients with at least one increase in systolic or diastolic BP levels upon standing were diagnosed with OHT. Medical history, physical examination and laboratory parameters were retrieved from the medical records. Mortality data until 18^th June 2014 were retrieved from the computerized system of the Ministry of the Interior.

Results

Four hundred and seven patients (86%) were diagnosed with OHT. Those without OHT had a lower body mass index and were more likely males, smokers, had a higher rate of Parkinson's disease and less congestive heart failure compared with those with OHT. Patients with OHT had a better survival rate than those without OHT (P = 0.024). Hazard ratios (HRs) for mortality in those with OHT adjusted to age and multiple risk factors were: 0.67 [95% confidence interval (CI): 0.51−0.87] and 0.73 (95% CI: 0.55−0.97), respectively; a similar tendency was noticed in a sensitivity analysis by gender.

Conclusion

Hospitalized elderly patients with OHT had a better survival rate than those without OHT.

Autonomic Nervous System Dysfunction in Patients With Parkinson Disease Having Depression

BACKGROUND AND AIM

Both depression and cardiovascular autonomic dysfunctions, such as orthostatic hypotension, supine hypertension, and the absence of normal nocturnal blood pressure (BP) fall ("nondipping"), occur relatively commonly in Parkinson disease (PD); however, the relationship between depression and cardiovascular autonomic abnormalities has not been established. In this study, we sought to determine whether the cardiovascular autonomic abnormalities found in PD are associated with depression.

METHODS

Among 129 nondemented, levodopa-naive patients with mild PD, 44 had depression. Orthostatic vital signs and ambulatory 24-hour BP monitoring were recorded, and geriatric depressive scales were obtained in all patients. Associations between orthostatic hypotension, supine hypertension, nocturnal hypertension, nondipping, and depression were analyzed. The ratio of the standard deviation of 24-hour heart rate to that of systolic BP (SBP) was utilized as an index of baroreflex-cardiovagal function.

RESULTS

Depression was associated with orthostatic hypotension, and patients with depression had higher SBP change during orthostasis and attenuated cardiovagal dysfunction as observed during ambulatory BP monitoring. Across individuals, values for orthostatic changes in BP were correlated with values for geriatric depressive scale.

CONCLUSION

Depression is associated with neurocirculatory abnormalities-especially orthostatic hypotension-in early PD. Although the association does not imply causation, this result suggests that depression in PD might be associated with functional impairment of the autonomic nervous system and its pathologic substrate.