Blood pressure associates with standing balance in elderly outpatients

Low muscle strength and physical function contribute to falls in hemodialysis patients, but not muscle mass

INTRODUCTION

Patients on hemodialysis (HD) have a higher incidence of fractures than the general population. Sarcopenia is frequently observed in patients on HD; however, the association of falls with sarcopenia and its diagnostic factors, including muscle mass, muscle strength, and physical function, are incompletely understood.

METHODS

This prospective cohort study was conducted at a single center. Sarcopenia was assessed according to the 2019 Asian Working Group for Sarcopenia diagnostic criteria. Muscle mass was measured the bioelectrical impedance method. Grip strength was evaluated to assess muscle strength, while the Short Physical Performance Battery (SPPB) was used to assess physical function. Falls and their detailed information were surveyed every other week.

RESULTS

This study analyzed 65 HD patients (median age, 74.5 [67.5-80.0] years; 33 women [49.2%]). Sarcopenia was diagnosed in 36 (55.4%) patients. During the 1-year observation period, 31 (47.7%) patients experienced accidental falls. The falls group had lower median grip strength than the non-falls group (14.7 [11.4-21.8] kg vs. 22.2 [17.9-27.6] kg; p < 0.001). The median SPPB score was also lower in the falls versus non-falls group (7.0 [5.0-11.0] vs. 11.0 [8.0-12.0]; p = 0.009). In adjusted multiple regression analysis, diagnostic factors, including grip strength (B = 0.96, p = 0.04, R2 = 0.19) and SPPB (B = 1.11, p = 0.006, R2 = 0.23), but not muscle mass, were independently associated with fall frequency.

CONCLUSIONS

The frequency of falls in HD patients was related to muscle strength and physical function, but not muscle mass.

Association of blood pressure and postural control in older adults with hypertension: an observational study

The study investigated the association of orthostatic hypotension (OH) with functional position change and balance in older adults with hypertension. The presence of OH was assessed with intermittent (OH intermittent) and continuous blood pressure (OH continuous) monitoring. The change in functional position was tested with sitting to standing assessment, balance performance using activity specific balance confidence scale (ABC), and timed up and go test (TUG). Testing unilateral and bilateral standing with and without altered sensory inputs was tested using the Humac balance system. ABC, TUG, and standing up time showed no significant association with OH intermittent and OH continuous. A significant association was found between bilateral standing with eyes closed on foam surface for overall stability index and OH intermittent. Older people with hypertension may be routinely examined for OH and appropriate intervention strategies should be included for comprehensive care.

The underlying mechanisms of improved balance after one and ten sessions of balance training in older adults

Training improves balance control in older adults, but the time course and neural mechanisms underlying these improvements are unclear. We studied balance robustness and performance, H-reflex gains, paired reflex depression, and co-contraction duration in ankle muscles after one and ten training sessions in 22 older adults (+65 yrs). Mediolateral balance robustness, time to balance loss in unipedal standing on a platform with decreasing rotational stiffness, improved (33%) after one session, with no further improvement after ten sessions. Balance performance, absolute mediolateral center of mass velocity, improved (18.75%) after one session in perturbed unipedal standing and (18.18%) after ten sessions in unperturbed unipedal standing. Co-contraction duration of soleus/tibialis anterior increased (16%) after ten sessions. H-reflex gain and paired reflex depression excitability did not change. H-reflex gains were lower, and soleus/tibialis anterior co-contraction duration was higher in participants with more robust balance after ten sessions, and co-contraction duration was higher in participants with better balance performance at several time-points. Changes in robustness and performance were uncorrelated with changes in co-contraction duration, H-reflex gain, or paired reflex depression. In older adults, balance robustness improved over a single session, while performance improved gradually over multiple sessions. Changes in co-contraction and excitability of ankle muscles were not exclusive causes of improved balance.

Management of Hypertension and Blood Pressure Dysregulation in Patients with Parkinson's Disease-a Systematic Review

PURPOSE OF REVIEW

The aim of this review article was to summarize the cardiovascular and blood pressure profile regarding Parkinson disease patients and to provide an update on the recent advancements in the field of the diagnosis and management of blood pressure abnormalities in these patients. Our goal was to guide physicians to avoid pitfalls in current practice while treating patients with Parkinson disease and blood pressure abnormalities. For this purpose, we searched bibliographic databases (PubMed, Google Scholar) for all publications published on blood pressure effects in Parkinson disease until May 2020. Furthermore, we highlight some thoughts and potential perspectives for the next possible steps in the field.

RECENT FINDINGS

Blood pressure dysregulation in patients with Parkinson's disease has several implications in clinical practice and presents an ongoing concern. Compared with chronic essential hypertension, the syndrome of combined neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease has received little attention. If left untreated, hypertension may lead to cardiovascular disease whereas hypotension may lead to fall-related complications, with tremendous impact on the quality of life of affected individuals. The effect of blood Epressure control and the risk of death from cardiovascular disease in Parkinson disease are largely unexplored. Blood pressure abnormalities in Parkinson disease present bidirectional relationship and the rationale for treating and controlling hypertension in persons with Parkinson disease and concurrent neurogenic orthostatic hypotension and/or supine hypertension is compelling. Further research is warranted in order to clarify the mechanisms, clinical implications, and potential reversibility of compromised cardiovascular function, in persons with Parkinson disease.

Short-term balance training and acute effects on postural sway in balance-deficient older adults: a randomized controlled trial

BACKGROUND

We aimed to determine the effectiveness of 4 weeks of balance exercise compared with no intervention on objectively measured postural sway.

METHODS

This was a single-center parallel randomized controlled, open label, trial. A six-sided dice was used for allocation at a 1:1-ratio between exercise and control. The trial was performed at a university hospital clinic in Sweden and recruited community-dwelling older adults with documented postural instability. The intervention consisted of progressively challenging balance exercise three times per week, during 4 weeks, with follow-up at week five. Main outcome measures were objective postural sway length during eyes open and eyes closed conditions.

RESULTS

Sixty-five participants aged 70 years (balance exercise n = 32; no intervention n = 33) were randomized. 14 participants were excluded from analysis because of early dropout before follow-up at week five, leaving 51 (n = 22; n = 29) participants for analysis. No significant differences were detected between the groups in any of the postural sway outcomes. Within-group analyses showed significant improvements in hand grip strength for the intervention group, while Timed Up & Go improvements were comparable between groups but only statistically significant in the control group.

CONCLUSIONS

Performing balance exercise over a four-week intervention period did not acutely improve postural sway in balance-deficient older adults. The lower limit in duration and frequency to achieve positive effects remains unclear.

TRIAL REGISTRATION

Clinical trials NCT03227666 , July 24, 2017, retrospectively registered.

Malnutrition is associated with dynamic physical performance

BACKGROUND

Malnutrition and poor physical performance are both conditions that increase in prevalence with age; however, their interrelation in a clinically relevant population has not been thoroughly studied.

AIMS

This study aimed to determine the strength of the association between malnutrition and measures of both static and dynamic physical performance in a cohort of geriatric outpatients.

METHODS

This cross-sectional study included 286 older adults (mean age 81.8, SD 7.2 years, and 40.6% male) who were referred to geriatric outpatient mobility clinics. The presence of malnutrition was determined using the Short Nutritional Assessment Questionnaire (SNAQ, cut-off ≥ 2 points). Measures of dynamic physical performance included timed up and go (TUG), 4-m walk test, and chair stand test (CST). Static performance encompassed balance tests and hand grip strength (HGS). Physical performance was standardized into sex-specific Z-scores. The association between malnutrition and each individual measure of physical performance was assessed using linear regression analysis.

RESULTS

19.9% of the cohort was identified as malnourished. Malnutrition was most strongly associated with CST and gait speed; less strong but significant associations were found between malnutrition and TUG. There was no significant association between malnutrition and HGS or balance.

DISCUSSION

Physical performance was associated with malnutrition, specifically, dynamic rather than static measures. This may reflect muscle power being more impacted by nutritional status than muscle strength; however, this needs to be further addressed.

CONCLUSIONS

Malnutrition is associated with dynamic physical performance in geriatric outpatients, which should inform diagnosis and treatment/prevention strategies.

Diminished Dynamic Physical Performance Is Associated With Orthostatic Hypotension in Geriatric Outpatients

BACKGROUND AND PURPOSE

Orthostatic hypotension (OH), a blood pressure drop after postural change, is a highly prevalent and disabling syndrome in older adults. Yet, the association between physical performance and OH is not clearly established. The aim of this study was to determine whether different types of physical performance are associated with OH in a clinically relevant population of geriatric outpatients.

METHODS

This cross-sectional study included 280 geriatric outpatients (mean age: 82.2 years, standard deviation: 7.1). Orthostatic hypotension was determined using intermittently measured blood pressure and continuously measured blood pressure in a random subgroup of 58 patients. Physical performance was classified into a dynamic type (4-m Walk Test, Chair Stand Test, and Timed Up and Go test) and a static type (standing balance tests, handgrip strength). Associations were analyzed using logistic regression models with adjustments for age, sex, weight, and height.

RESULTS

Diminished physical performance on the Chair Stand Test was associated with OH measured intermittently. Diminished physical performance on all dynamic physical domains (4-m Walk Test, Chair Stand Test, and Timed Up and Go test) was associated with OH measured continuously. Static physical performance was not significantly associated with OH.

CONCLUSION

Dynamic physical performance tests with a substantial postural change and center of mass displacement were significantly associated with OH. The influence of physical performance on OH in daily routine activities should be further explored to establish counteracting interventions.

Blood Pressure Drop Rate After Standing Up Is Associated With Frailty and Number of Falls in Geriatric Outpatients

Background

The relationship between orthostatic hypotension and clinical outcome in older adults is poorly understood. Blood pressure drop rate (ie, speed of blood pressure drop) may particularly reflect the imposed challenge to the baroreflex and the associated clinical outcome (ie, frailty and number of falls). This study aimed to compare orthostatic blood pressure drop rate and drop magnitude with regard to their association with frailty and number of falls.

Methods and Results

Blood pressure was measured continuously during a standardized active stand task in 168 patients (mean age 81.4±7.0; 55.4% female) who visited a geriatric outpatient clinic for cognitive or mobility problems. The association of orthostatic blood pressure drop rate, blood pressure drop magnitude, and baroreflex sensitivity (ie, increase in heart rate divided by systolic blood pressure drop magnitude) with frailty (Fried criteria and 4 frailty markers) and self‐reported number of falls was assessed using linear regression models, adjusting for age and sex. Systolic blood pressure drop rate had the strongest association with frailty according to the 4 frailty markers (β 0.30; 95% CI, 0.11–0.49; P=0.003) and number of falls (β 1.09; 95% CI, 0.19–1.20; P=0.018); diastolic blood pressure drop magnitude was most strongly associated with frailty according to the Fried criteria (β 0.37; 95% CI, 0.15–0.60; P<0.001). Baroreflex sensitivity was associated with neither frailty nor number of falls.

Conclusions

Orthostatic blood pressure drop rate was associated with frailty and falls and may reflect the challenge to the baroreflex rather than drop magnitude.

Multimodal Monitoring of Cardiovascular Responses to Postural Changes

Background

In the poorly understood relationship between orthostatic hypotension and falls, next to blood pressure (BP), baroreflex sensitivity (BRS) and cerebral autoregulation (CAR) may be key measures. The posture- and movement dependency of orthostatic hypotension requires continuous and unobtrusive monitoring. This may be possible using simultaneous photoplethysmography (PPG), electrocardiography (ECG), and near-infrared spectroscopy (NIRS) signal recordings, from which pulse wave velocity (PWV; potentially useful for BP estimation), BRS and CAR can be derived. The PPG, NIRS and PWV signal correlation with BP and BRS/CAR reliability and validity need to be addressed.

Methods

In 34 healthy adults (mean age 25 years, inter quartile range 22–45; 10 female), wrist and finger PPG, ECG, bifrontal NIRS (oxygenated and deoxygenated hemoglobin) and continuous BP were recorded during sit to stand and supine to stand movements. Sixteen participants performed slow and rapid supine to stand movements; eighteen other participants performed a 1-min squat movement. Pulse wave velocity (PWV) was defined as the inverse of the ECG R-peak to PPG pulse delay; PPG, NIRS and PWV signal correlation with BP as their Pearson correlations with mean arterial pressure (MAP) within 30 s after the postural changes; BRS as inter beat interval drop divided by systolic BP (SBP) drop during the postural changes; CAR as oxygenated hemoglobin drop divided by MAP drop. BRS and CAR were separately computed using measured and estimated (linear regression) BP. BRS/CAR reliability was defined by the intra class correlation between repeats of the same postural change; validity as the Pearson correlation between BRS/CAR values based on measured and estimated BP.

Results

The highest correlation with MAP was found for finger PPG and oxygenated hemoglobin, ranging from 0.75–0.79 (sit to stand), 0.66–0.88 (supine to stand), and 0.82–0.94 (1-min squat). BRS and CAR reliability was highest during the different supine to stand movements, ranging from 0.17 – 0.49 (BRS) and 0.42-0.75 (CAR); validity was highest during rapid supine to stand movements, 0.54 and 0.79 respectively.

Conclusion

PPG-ECG-NIRS recordings showed high correlation with BP and enabled computation of reliable and valid BRS and CAR estimates, suggesting their potential for continuous unobtrusive monitoring of orthostatic hypotension key measures.

Rapid Systolic Blood Pressure Changes After Standing Up Associate With Impaired Physical Performance in Geriatric Outpatients

Background

Orthostatic hypotension is a prevalent condition in older adults and is associated with impaired physical performance and falls. The ability of older adults to compensate for rapid changes in systolic blood pressure (SBP; ie, SBP decline rate and SBP variability) may be important for physical performance. This study investigates the association of rapid SBP changes after standing up with physical performance.

Methods and Results

Consecutive patients who visited the Center of Geriatrics Amsterdam in 2014 and 2015 were included. The following SBP parameters were computed in 2 intervals (0–15 and 15–180 seconds) after standing up: steepness of steepest SBP decline; ratio of standing/supine SBP variability; and magnitude of largest SBP decline. Physical performance was assessed using the following measures: chair stand time, timed up and go time, walking speed, handgrip strength, and tandem stance performance. A total of 109 patients (45% men; age, mean, 81.7 years [standard deviation, 7.0 years]) were included. Steepness of steepest SBP decline (0–15 seconds) was associated with slower chair stand time (P<0.001), timed up and go time (P=0.022), and walking speed (P=0.024). Ratio of standing/supine SBP variability (0–15 seconds) was associated with slower chair stand time (P=0.005). Magnitude of largest SBP decline was not associated with physical performance.

Conclusions

SBP parameters reflecting rapid SBP changes were more strongly associated with physical performance compared with SBP decline magnitude in geriatric outpatients. These results support the hypothesis of an inadequate cerebral autoregulation during rapid SBP changes and advocate the use of continuous blood pressure measurements.

[Prevalence and relations of orthostatic hypotension in patients 80 years old and over from a primary care unit]

OBJECTIVE

To estimate the prevalence of orthostatic hypotension (OH) in patients 80 years old and over attending a primary care unit. To relate OH to the most prevalent pathologies and to the most used drugs.

DESIGN

Transversal observational study.

LOCATION

Primary care unit, Santiago de Compostela.

PARTICIPANTS

Eighty one patients 80 years old or over representative of a primary care unit were recruited. Ten patients were excluded.

MAIN MEASUREMENTS

Blood pressure was measured in decubitus and later in erect position first immediately after standing and then after 3 minutes. Diagnoses and active treatments were reviewed in the electronic clinical history and through an interview with the patient and caregiver.

RESULTS

In 26.76% of patients the systolic blood pressure fell by 20mmHg or more and/or the diastolic blood pressure fell by 10mmHg in the instant following the postural shift. In 16.90% of patients the drop persisted after 3 minutes of standing from decubitus position. None of the patients was diagnosed with OH. The highest prevalence ratio was observed for diabetes mellitus (1.6; P=.412), not existing differences for arterial hypertension (P=.881). OH related in a statistically meaningful way to the use of renin angiotensin aldosterone system inhibitors (OR: 8.174, CI95%: 1.182-56.536); P=.033] and benzodiazepines (OR: 5.938, CI95%: 1.242-28.397; P=.026)].

CONCLUSION

OH had a prevalence of 16.90% among the elderly patients who had a consultation. Its connection with some drugs (renin angiotensin aldosterone system inhibitors and benzodiazepines) must be considered.

Orthostatic Hypotension and Falls in Older Adults: A Systematic Review and Meta-analysis

OBJECTIVES

Orthostatic hypotension is a potential risk factor for falls in older adults, but existing evidence on this relationship is inconclusive. This study addresses the association between orthostatic hypotension and falls.

DESIGN

Systematic review and meta-analysis of the cross-sectional and longitudinal studies assessing the association between orthostatic hypotension and falls, as preregistered in the PROSPERO database (CRD42017060134).

SETTING AND PARTICIPANTS

A literature search was performed on February 20, 2017, in MEDLINE (from 1946), PubMed (from 1966), and EMBASE (from 1947) using the terms orthostatic hypotension, postural hypotension, and falls. References of included studies were screened for other eligible studies. Study selection was performed independently by 2 reviewers using the following inclusion criteria: published in English; mean/median age of the population ≥65 years; blood pressure measurement before and after postural change; and assessment of the association of orthostatic hypotension with falls. The following studies were excluded: conference abstracts, case reports, reviews, and editorials. Data extraction was performed independently by 2 reviewers.

MEASURES

Unadjusted odds ratios of the association between orthostatic hypotension and falls were used for pooling using a random effects model. Studies were rated as high, moderate, or low quality using the Newcastle-Ottawa Scale.

RESULTS

Out of 5646 studies, 63 studies (51,800 individuals) were included in the systematic review and 50 studies (49,164 individuals) in the meta-analysis. Out of 63 studies, 39 were cross-sectional and 24 were longitudinal. Orthostatic hypotension was positively associated with falls (odds ratio 1.73, 95% confidence interval 1.50-1.99). The result was independent of study population, study design, study quality, orthostatic hypotension definition, and blood pressure measurement method.

CONCLUSIONS AND IMPLICATIONS

Orthostatic hypotension is significantly positively associated with falls in older adults, underpinning the clinical relevance to test for an orthostatic blood pressure drop and highlighting the need to investigate orthostatic hypotension treatment to potentially reduce falls.

Relationships between orthostatic hypotension, frailty, falling and mortality in elderly care home residents

BACKGROUND

Orthostatic hypotension (OH; profound falls in blood pressure when upright) is a common deficit that increases in incidence with age, and may be associated with falling risk. Deficit accumulation results in frailty, regarded as enhanced vulnerability to adverse outcomes. We aimed to evaluate the relationships between OH, frailty, falling and mortality in elderly care home residents.

METHODS

From the Minimum Data Set (MDS) document, a frailty index (FI-MDS) was generated from a list of 58 deficits, ranging from 0 (no deficits) to 1.0 (58 deficits). OH was evaluated from beat-to-beat blood pressure and heart rate (finger plethysmography) collected during a 15-min supine-seated orthostatic stress test. Retrospective and prospective falling rates (falls/year) were extracted from facility falls incident reports. All-cause 3-year mortality was determined. Data are reported as mean ± standard error.

RESULTS

Data were obtained from 116 older adults (aged 84.2 ± 0.9 years; 44% males) living in two long term care facilities. The mean FI-MDS was 0.36 ± 0.01; FI-MDS was correlated with age (r = 0.277; p = 0.003). Those who were frail (FI ≥ 0.27) had larger Initial (- 17.8 ± 4.2 vs - 6.1 ± 3.3 mmHg, p = 0.03) and Consensus (- 22.7 ± 4.3 vs - 11.5 ± 3.3 mmHg, p = 0.04) orthostatic reductions in systolic arterial pressure. Frail individuals had higher prospective and retrospective falling rates and higher 3-year mortality. Receiver operating characteristic curves evaluated the ability of FI-MDS alone to predict prospective falls (sensitivity 72%, specificity 36%), Consensus OH (sensitivity 68%, specificity 60%) and 3-year mortality (sensitivity 77%, specificity 49%). Kaplan Meier survival analyses showed significantly higher 3-year mortality in those who were frail compared to the non-frail (p = 0.005).

CONCLUSIONS

Frailty can be captured using a frailty index based on MDS data in elderly individuals living in long term care, and is related to susceptibility to orthostatic hypotension, falling risk and 3-year mortality. Use of the MDS to generate a frailty index may represent a simple and convenient risk assessment tool for older adults living in long term care. Older adults who are both frail and have impaired orthostatic blood pressure control have a particularly high risk of falling and should receive tailored management to mitigate this risk.

Baroreflex function, haemodynamic responses to an orthostatic challenge, and falls in haemodialysis patients

BACKGROUND

Stage 5 chronic kidney disease patients on haemodialysis (HD) often present with dizziness and pre-syncopal events as a result of the combined effect of HD therapy and cardiovascular disease. The dysregulation of blood pressure (BP) during orthostasis may be implicated in the aetiology of falls in these patients. Therefore, we explored the relationship between baroreflex function, the haemodynamic responses to a passive orthostatic challenge, and falls in HD patients.

METHODS

Seventy-six HD patients were enrolled in this cross-sectional study. Participants were classified as "fallers" and "non-fallers" and completed a passive head up tilting to 60o (HUT-60°) test on an automated tilt table. ECG signals, continuous and oscillometric BP measurements and impedance cardiography were recorded. The following variables were derived from these measurements: heart rate (HR) stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR), number of baroreceptor events, and baroreceptor effectiveness index (BEI).

RESULTS

The forty-four participants who were classified as fallers (57.9%) had a lower number of baroreceptor events (6.5±8.5 vs 14±16.7, p = .027) and BEI (20.8±24.2% vs 33.4±23.3%, p = .025). In addition, fallers experienced a significantly larger drop in systolic (-6.4±10.9 vs -0.4±7.7 mmHg, p = .011) and diastolic (-2.7±7.3 vs 1.8±6 mmHg, p = .027) oscillometric BP from supine to HUT-60° compared with non-fallers. None of the variables taken for the analysis were significantly associated with falls in multivariate logistic regression analysis.

CONCLUSIONS

This cross-sectional comparison indicates that, at rest, HD patients with a positive history of falls present with a lower count of baroreceptor sequences and BEI. Short-term BP regulation warrants further investigation as BP drops during a passive orthostatic challenge may be implicated in the aetiology of falls in HD.

Proprioceptive activities to postural balance of the elderly - systematic review

Abstract Introduction: Proprioceptive activities are commonly described for control of the postural balance of the elderly in order to avoid falls. But, there is no consensus on which ones can significantly improve balance or on intervention and assessment protocols. Objective: To investigate which proprioceptive activities are specific to static and dynamic postural balance of the elderly through a systematic review. Method: This is a systematic review based on PRISMA recommendation, by surveying PubMed, Medline, LILACS, Scielo and EBSCO databases. The period considered for the search was from 2006 to 2016, using the following descriptors - aged, proprioception, exercise therapy, and postural balance for articles in English, Portuguese or Spanish. Randomized and non-randomized clinical trials were included using the PEDro scale to analyze the methodological quality of the studies. Results: Eight articles were included with different protocols, without standardization of evaluation and intervention, but, which demonstrated improvement of functional abilities. Different kinds of walk, muscular strengthening exercises, stretching, postural oscillations and Yoga patterns for the improvement of functional abilities. Conclusion: The association of static and dynamic activities can contribute to the improvement of functional abilities, but it cannot be affirmed that they are specific for postural control, given the lack of standardization of exercise protocols and evaluation tools.

Diagnosing orthostatic hypotension with continuous and interval blood pressure measurement devices

Orthostatic hypotension (OH) is defined as a drop in systolic blood pressure (SBP) of ≥20 mm Hg and/or a drop in diastolic blood pressure (DBP) of ≥10 mm Hg within 3 min of standing. The international guidelines recommend ideally diagnosing OH with a continuous blood pressure (BP) measurement device, although in daily practice interval BP measurement devices are used more often. We aimed to investigate the difference in observed prevalence of OH between an interval and a continuous BP measurement device. A total of 104 patients with a mean age of 69 years were included. The prevalence of OH was 35.6% (95% CI: 26.4-44.8) with the interval BP measurement and 45.2% (95% CI: 35.6-54.8) with the continuous BP measurement device (P = .121). Lin's coefficient of concordance ranged from 0.47 to 0.59 for the drop in systolic blood pressure and from 0.33 to 0.42 for the drop in diastolic blood pressure. The positive proportion of agreement in diagnosis of OH between the interval and continuous measure was 59.5% and the negative proportion of agreement was 72.5%. Although the prevalence of OH was not significantly different between the continuous and the interval BP measurement devices using a similar amount of measurement, the concordance between interval and continuous measure is low resulting in low positive and negative proportions of agreement in the diagnosis of OH. We conclude that continuous BP measurement cannot be substituted by an interval BP measurement to diagnose OH.

Influence of breathing patterns and orthostatic stress on postural control in older adults

AIM

To investigate the influence of breathing patterns and blood pressure behavior postural control in older adults.

METHODS

A total of 20 older adults carried out spontaneous, controlled (15 cycles/min) and deep (6 cycles/min) breathing trials, in random order. In this session, the heart rate was recorded continuously and blood pressure measured every 3 min. In addition, the challenge from sitting to an active standing position was carried out with eyes closed during 6 min on a baropodometer plate with electromyography recording. The root mean square (RMS) of electromyography was calculated.

RESULTS

There were significant differences in the postural control with spontaneous breathing from the first minute (center of pressure [COP]-area 216.40 ± 116.70 mm² ) in comparison with the third minute (COP-area 79.35 ± 68.11 mm² ; d = 0.89; P < 0.01) and the sixth minute (COP-area 70.24 ± 41.26 mm² ; d = 0.60; P < 0.05) of active standing. Furthermore, deep breathing significantly increases the COP-area (158.50 ± 126.2 mm² ) at the sixth minute of active standing in comparison with spontaneous breathing (70.24 ± 41.26 mm² ; d = 0.80; P < 0.01). There were also significant differences in systolic blood pressure during spontaneous breathing between the baseline measures (sitting position 123 ± 11 mmHg) and the first minute of active standing (117 ± 13 mmHg; d = 0.24; P < 0.05). Furthermore, electromyography activity of the tibialis anterior increased during the deep (17.52 ± 9.21 RMS) and controlled breathing (16.75 ± 5.26 RMS) compared with the spontaneous condition (14.93 ± 5.56 RMS; d = 0.17; P < 0.05).

CONCLUSIONS

The present data provide important insight into the respiratory and hemodynamics effects of postural control in older adults. The current data confirm that deep breathing causes periodic perturbation in the neuromuscular compensation of the lower limbs. Geriatr Gerontol Int 2018; 18: 692-697.

Blood pressure change does not associate with Center of Pressure movement after postural transition in geriatric outpatients

BACKGROUND

Orthostatic hypotension (OH), a blood pressure drop after postural change, is associated with impaired standing balance and falls in older adults. This study aimed to assess the association between blood pressure (BP) and a measure of quality of standing balance, i.e. Center of Pressure (CoP) movement, after postural change from supine to standing position in geriatric outpatients, and to compare CoP movement between patients with and without OH.

METHODS

In a random subgroup of 75 consecutive patients who were referred to a geriatric outpatient clinic, intermittent BP measurements were obtained simultaneously with CoP measurements in mediolateral and anterior-posterior direction directly after postural change during 3 min of quiet stance with eyes open on a force plate. Additional measurements of continuous BP were available in n = 38 patients. Associations between BP change during postural change and CoP movement were analyzed using Spearman correlation. Mann-Whitney-U tests were used to compare CoP movement between patients with OH and without OH, in which OH was defined as a BP drop exceeding 20 mmHg of systolic BP (SBP) and/or 10 mmHg of diastolic BP (DBP) within 3 min after postural change.

RESULTS

OH measured intermittently was found in 8 out of 75 (11%) and OH measured continuously in 22 out of 38 patients (57.9%). BP change did not associate with CoP movement. CoP movement did not differ significantly between patients with and without OH.

CONCLUSIONS

Results do not underpin the added value of CoP movement measurements in diagnosing OH in a clinical setting. Neither could we identify the role of CoP measurements in the understanding of the relation between OH and impaired standing balance.

Cardiovascular responses to orthostasis and their association with falls in older adults

Background

Orthostatic hypotension (OH) refers to a marked decline in blood pressure when upright. OH has a high incidence and prevalence in older adults and represents a potential intrinsic risk factor for falls in these individuals. Previous studies have not included more recent definitions for blood pressure responses to orthostasis, including initial, delayed, and recovery blood pressure responses. Furthermore, there is little research examining the relationships between cerebrovascular functioning and falling risk. Therefore, we aimed to: (i) test the association between different blood pressure responses to orthostatic stress and retrospective falling history and; (ii) test the association between cerebrovascular responses to orthostatic stress and falling history.

Methods

We tested 59 elderly residents in long term care facilities who underwent a passive seated orthostatic stress test. Beat-to-beat blood pressure and cerebral blood flow velocity (CBFV) responses were assessed throughout testing. Risk factors for falls and falling history were collected from facility records. Cardiovascular responses to orthostasis were compared between retrospective fallers (≥1 fall in the previous year) and non-fallers.

Results

Retrospective fallers had larger delayed declines in systolic arterial pressure (SAP) compared to non-fallers (p = 0.015). Fallers also showed poorer early (2 min) and late (15 min) recovery of SAP. Fallers had a greater decline in systolic CBFV.

Conclusions

Older adults with a positive falling history have impaired orthostatic control of blood pressure and CBFV. With better identification and understanding of orthostatic blood pressure impairments earlier intervention and management can be implemented, potentially reducing the associated risk of morbidity and mortality. Future studies should utilize the updated OH definitions using beat-to-beat technology, rather than conventional methods that may offer less accurate detection.

Uncontrolled hypertension and orthostatic hypotension in relation to standing balance in elderly hypertensive patients

Objective

To investigate the associations among uncontrolled hypertension, orthostatic hypotension (OH), and standing balance impairment in the elderly hypertensive patients referred to comprehensive geriatric assessment (CGA).

Methods

In a cross-sectional study, a total of 176 elderly hypertensive patients who underwent CGA were divided into OH group (n=36) and non-OH group (n=140) according to blood pressure measurement in the supine position, after immediate standing up, and after 1 minute and 3 minutes of standing position. Uncontrolled hypertension was defined as blood pressure of ≥140/90 mmHg if accompanied by diabetes mellitus (DM) or chronic kidney disease (CKD), or ≥150/90 mmHg if no DM and no CKD. Standing balance, including immediate standing balance and prolonged standing balance, was assessed in side-by-side and tandem stance.

Results

Neither uncontrolled hypertension nor OH was associated with prolonged standing balance impairment in elderly hypertensive patients (P>0.05). Blood pressure decrease after postural change was significantly associated with immediate standing balance impairment in side-by-side and tandem stance (P<0.05). Patients with OH were at greater risk of immediate standing balance impairment in both side-by-side and tandem stance than those without OH (odds ratio [OR] 3.44, 95% confidence interval [CI] 1.26–9.33, P<0.05; OR 3.14, 95% CI 1.14–8.64, P<0.01). Furthermore, uncontrolled hypertension was associated with immediate standing balance impairment in side-by-side stance (OR 2.96, 95% CI 1.31–6.68, P<0.05).

Conclusion

Uncontrolled hypertension, OH, and blood pressure decrease after postural change were associated with immediate standing balance impairment, and therefore, a better understanding of the underlying associations might have major clinical value.

The association between orthostatic hypotension, falling and successful rehabilitation in a nursing home population

PURPOSE OF THE STUDY

Our objectives were to identify the prevalence of orthostatic hypotension (OH) in frail, elderly nursing home residents, and assess its possible association with falling and chances of successful rehabilitation.

MATERIALS AND METHODS

A prospective observational cohort study. A total of 290 patients participated in this study, of which 128 were admitted to the rehabilitation department. OH was defined as a drop in systolic blood pressure of >20mmHg and diastolic blood pressure of >10mmHg after postural change within 3min. The analyses regarding falling and successful rehabilitation were only performed in the rehabilitation group. Multivariate binary logistic regression analyses were used to describe risk factors related with falling. Cox proportional hazard modeling was used to investigate the relation between OH and the time to successful rehabilitation.

RESULTS

The prevalence of OH in the studied nursing home population was 36.6% (95% CI (confidence interval): 31.1-42.1%). The prevalence varied from 28.6% (95% CI: 16.8-40.4%) in somatic patients, 36.7% (95% CI: 28.4-45.1%) in rehabilitation patients, to 40.6% (95% CI: 31.3-50.0%) in psychogeriatric patients. The association between orthostatic hypotension and previous falling was not significant; Odds ratio 0.66 (95% CI: 0.30-1.48). The Hazard ratio of the relationship between OH and successful rehabilitation was 2.88 (95% CI:1.77-4.69).

CONCLUSIONS

OH is highly prevalent in nursing home residents. Surprisingly, patients with OH were found to have a higher chance of successful rehabilitation compared to patients without OH. If confirmed in other studies, these results may change our view of the implications of OH.