Orthostatic Hypotension In Older Adults Research Articles

A retrospective analysis of neurogenic orthostatic hypotension in long-term care facility residents with recurrent falls

IntroductionApproximately 50 % of residents in long-term care facilities fall yearly and orthostatic hypotension accounts for a significant portion of them. Neurogenic orthostatic hypotension - a subtype of orthostatic hypotension – is important to be recognized as its management is far more complex; undertreatment of these older adults can lead to recurrent falls, high healthcare cost burden, and increased morbidity and mortality. The primary purpose of our study was to describe the rate of neurogenic orthostatic hypotension in older adults in a long-term care facility, with a secondary purpose to describe risk factors for neurogenic orthostatic hypotension in this population. MethodsWe conducted a retrospective case-control study of residents with recurrent falls at the Dayton Veteran's Affairs long-term care facility. Charts were manually reviewed. Inclusion criterion was three or more falls and age 65 or greater; we did not have exclusion criteria.ICD10 codes and most recent primary care physician notes were used to identify comorbidity diagnoses. Recent orthostatic vitals were used to assess orthostatic hypotension or neurogenic orthostatic hypotension diagnoses. ResultsOf our sample of 224 residents, we observed a prevalence of 20.5 % for neurogenic orthostatic hypotension and 32.1 % for orthostatic hypotension. Neither of them had diagnosis of neurogenic orthostatic hypotension documented. Parkinson's disease was associated with neurogenic orthostatic hypotension (OR-4.3; p = 0.002). Hypertension was prevalent in 69.6 % of residents with orthostatic vitals suggestive of neurogenic orthostatic hypotension. ConclusionOlder adults with recurrent falls at a long-term care facility meet criteria for neurogenic orthostatic hypotension diagnosis far more often than is documented. Common comorbidities associated with neurogenic orthostatic hypotension in this population include Parkinson's disease.

Abstract P436: Objective Physical Activity and Orthostatic Hypotension in Older Adults: The STURDY Trial

Introduction: Orthostatic hypotension (OH) is prevalent in older adults and associated with poor health outcomes. Physical activity (PA) may attenuate the risk of OH, but evidence of the association between daily volume and patterns of objectively measured PA and OH is lacking. Hypothesis: Lower daily volume and higher fragmentation of PA are associated with greater risk of OH. Methods: We included 196 participants (age ≥70) of the Study To Understand Fall Reduction and Vitamin D in You (STURDY) trial who wore an accelerometer for 7 days at their baseline visit and completed a supine-to-standing OH assessment at 2-year follow-up. We defined OH as a 20 mm Hg drop in systolic blood pressure or 10 mm Hg drop in diastolic blood pressure 3 minutes after changing from supine to standing position. Using accelerometry, daily total activity counts (TAC; counts/day) and time spent active (mins/day) were used to measure volume of daily PA. Active-to-sedentary transition probability (ASTP) was calculated as the reciprocal of the average PA bout duration to measure PA fragmentation. Multivariable robust Poisson regression estimated the risk ratio between baseline PA and OH after 2-years of follow up. Results: Among 196 participants, 12.2% of participants had OH after 2-years of follow up; 62.2% were male, and mean baseline age was 76.4 (SD=5.2). In this prospective analyses, lower daily activity (lowest vs highest tertile of TAC: RR = 6.49, 95% CI: 2.15-19.58; lowest vs highest tertile of time spent active: RR= 4.30, 95% CI:1.55-11.92) and higher fragmentation (highest vs lowest tertile of ASTP: RR = 5.36, 95% CI: 1.57-18.34) of PA were associated with higher risk of OH after 2 years (Figure) . Conclusions: Both lower daily activity volume and higher fragmentation of PA were associated with increased risk of OH in older adults over follow-up. Longitudinal studies to assess whether changes in PA volume or fragmentation alter the risk of OH should be explored.

331 THE USE OF BODY MASS INDEX IN PREDICTING ORTHOSTATIC HYPOTENSION IN OLDER ADULTS

Abstract Background The presence of Orthostatic Hypotension (OH) is known to be associated with an increased mortality risk. Previous Irish research has shown that elevated Body Mass Index (BMI) may be protective against OH, with overweight and obese patients having significantly smaller Systolic Blood Pressure (SBP) drops during Head-Up-Tilt (HUT) Testing. Methods Demographics, including age, height and weight, were obtained retrospectively from all head up tilt testing performed in a tertiary Irish hospital between 2000 and 2021. All incomplete records were excluded. A total of 4,717 patients were analysed. Linear regression models were used to examine the relationship between BMI and change in tilt SBP. Results 2,089 males and 2,628 females over the age of 60 years old were examined. The mean age is 77 years ± 7.8 (S.D.), with majority (51.5%) of the cohort overweight or obese. 69.7% of individuals demonstrated OH. The mean change in tilt SBP was –7mmHg in the underweight and healthy weight group, and –10mmHg in the overweight or obese group. The linear regression model established that BMI significantly predicted a change in tilt SBP (beta=0.394, 95% CI: 0.235 to 0.554, p<0.001), but remains a poor predictive variable (R2=0.004) for this cohort. This correlation was similar for both genders (male: r=0.08, female: r=0.07). Conclusion Our findings confirmed a correlation between BMI and its predictive impact on OH in older adults. Future studies should explore targeted populations with multivariate analysis, taking into consideration age and gender, to reduce the heterogeneity of data.

Orthostatic hypotension and vitamin D deficiency in older adults: systematic review and meta-analysis.

Over the latest years different studies have investigated the possible relationship between D deficiency and occurrence of orthostatic hypotension (OH), often reaching controversial results. We perform an update meta-analysis providing an update overview on the association between hypovitaminosis D and orthostatic hypotension (OH) in older adults. Data extraction was independently performed by two authors and based upon predefined criteria. The meta-analysis was performed using a random-effects model. Statistical heterogeneity between groups was measured using the Higgins I2 statistic. Eight investigations enrolling 16.326 patients (mean age 75.5years) met the inclusion criteria and were considered for the analysis. Patients with vitamin D deficiency were more likely to have OH compared to those without (OR: 1.36, 95% CI 1.14-1.63, p = 0.0001, I2 = 43.6%). A further sub-analysis, based on three studies, estimating the risk of OH in patients with hypovitaminosis D receiving antihypertensive treatment, did not reach the statistical significance (OR: 1.40, 95% CI 0.61-3.18, p = 0.418, I2 = 53.3%). Meta-regression performed using age (p = 0.12), BMI (p = 0.73) and gender (p = 0.62) as moderators did not reveal any statistical significance in influencing OH. Conversely, physical activity, Vitamin D supplementation and use of radioimmunoassay for the measurement of vitamin D serum levels showed a significant inverse relationship towards the risk of OH (Coeff.-0.09, p = 0.002, Coeff. -0.12, p < 0.001 and Coeff. -0.08, p = 0.03, respectively) among patients with hypovitaminosis D. A direct correlation between the administration of antihypertensive treatment and the risk of OH in older patients with low vitamin D level was observed (Coeff. 0.05, p < 0.001). Hypovitaminosis D is significantly associated with OH in older adults and directly influence by the administration of antihypertensive drugs. Conversely, physical activity, vitamin D supplementation and use of radioimmunoassay as analytic method inversely correlated with the risk of OH in older patients.

Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis.

BackgroundInitial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older adults.ObjectiveTo provide a prevalence estimate of initial OH in adults aged 65 years or older.MethodsLiterature search of MEDLINE (from 1946), Embase (from 1947) and Cochrane Central Register of Controlled Trials was performed until 6 December 2019, using the terms ‘initial orthostatic hypotension’, ‘postural hypotension’ and ‘older adults’. Articles were included if published in English and participants were 65 years or older. Random effects models were used for pooled analysis.ResultsOf 5,136 articles screened, 13 articles (10 cross-sectional; 3 longitudinal) reporting data of 5,465 individuals (54.5% female) from the general (n = 4,157), geriatric outpatient (n = 1,136), institutionalised (n = 55) and mixed (n = 117) population were included. Blood pressure was measured continuously and intermittently in 11 and 2 studies, respectively. Pooled prevalence of continuously measured initial OH was 29.0% (95% CI: 22.1–36.9%, I2 = 94.6%); 27.8% in the general population (95% CI: 17.9–40.5%, I2 = 96.1%), 35.2% in geriatric outpatients (95% CI: 24.2–48.1%, I2 = 95.3%), 10.0% in institutionalised individuals (95% CI: 2.4–33.1%, I2 = 0%) and 21.4% in the mixed population (95% CI: 7.0–49.6, I2 = 0%). Pooled prevalence of intermittently measured initial OH was 5.6% (95% CI: 1.5–18.9%, I2 = 81.1%); 1.0% in the general population (95% CI: 0.0–23.9%, I2 = 0%) and 7.7% in geriatric outpatients (95% CI: 1.8–27.0%, I2 = 86.7%).ConclusionThe prevalence of initial OH is high in older adults, especially in geriatric outpatients. Proper assessment of initial OH requires continuous blood pressure measurements.

The Relationship between the Most Common Subtypes of Dementia and Orthostatic Hypotension in Older Adults

Background: It is crucial to evaluate the causes of morbidity and mortality in elderly patients with dementia, such as orthostatic hypotension (OH), which may affect their daily life activities, reduce the quality of life, and increase the caregiver burden. Objective: We aimed to investigate the relationship between OH and the most common subtypes of dementia in detail. Methods: A total of 268 older adults with dementia diagnosed with Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and behavioral variant frontotemporal dementia (bvFTD), and 539 older adults without dementia were included in this prospective study. Comprehensive geriatric assessment including comorbidity, medication evaluation, and the head-up tilt test was also performed. Results: Of the participants, 13.8, 8.3, 6.4, and 4.8% had AD, DLB, bvFTD, and VaD, respectively. After adjusting for age, gender, the presence of comorbidities, and usage of OH-induced drugs; AD, DLB, and VaD were associated with OH (odds ratio [OR]: 2.23 confidence interval [CI] 95% 1.31–3.80; p = 0.003; OR: 3.68 CI 95% 1.98–6.83; p < 0.001, and OR: 3.56 CI 95% 1.46–8.69; p = 0.005, respectively). Furthermore, VaD was independently related to diastolic OH (OR: 4.19 CI 95% 1.66–10.57; p = 0.002), whereas AD and DLB were not. Conclusions: This study shows that elderly patients with DLB, AD, and VaD often have OH, a disabling autonomic dysfunction feature. Moreover, diastolic OH may play a role in the development of VaD. Therefore, considering potential complications of OH, it is essential to evaluate OH in the follow-up and management of those patients.

Orthostatic hypotension in older adults: the role of medications.

Orthostatic hypotension (OH) is defined as an abnormal blood pressure reduction when standing and is frequently diagnosed in older adults. Pharmacological therapy is one of the main causes of orthostatic blood pressure impairment, leading to iatrogenic OH. Indeed, several medications may induce hypotensive effects and influence the blood pressure response to orthostatism. Hypotensive medications may also overlap with other determinants of OH, thus increasing the burden of symptoms and the risk of complications. Potentially hypotensive medications include both cardiovascular and psychoactive drugs, which are frequently prescribed in older patients. According to the available evidence, the antihypertensive treatment "per se" does not seem to predispose to OH, even if a higher risk is associated with polypharmacy and drug classes such as with diuretics and vasodilators. As concerns psychoactive medications, OH is a well-known adverse effect of tricyclic antidepressants, trazodone and antipsychotics. The knowledge of hemodynamic consequences of drug therapy may be helpful to improve OH treatment. A medication review is advisable in all patients presenting with OH, particularly at advanced age, aiming at optimizing medical treatment with a view to minimize the risk of iatrogenic OH.

Antidepressant use and orthostatic hypotension in older adults living with mild-to-moderate Alzheimer disease.

Antidepressant use is often reported as a risk factor for Orthostatic Hypotension (OH), however this relationship has never been explored in those with mild/moderate Alzheimer Disease (AD), who may represent a particularly vulnerable cohort. We performed a cross-sectional analysis of baseline data from the NILVAD study. Participants with mild-moderate AD were recruited from 23 centres in nine countries. Systolic and Diastolic Blood Pressure (SBP/DBP) was recorded in the seated position and after both 1 and 5 minutes of standing. OH was defined as a drop of ≥20 mmHg SBP/≥10 mmHg DBP. We examined the relationship between antidepressant use, orthostatic BP drop and the presence of OH, controlling for important covariates. Of 509 participants (72.9 ± 8.3 years, 61.9% female), two-fifths (39.1%; 199/509) were prescribed a regular antidepressant. Antidepressant use was associated with a significantly greater SBP and DBP drop at 5 minutes (β: 1.83, 0.16-3.50, P = .03 for SBP; β: 1.13, 0.02-2.25, P < .05 for DBP). Selective Serotonin Reuptake Inhibitor (SSRI) use was associated with a significantly greater likelihood of OH (OR 2.0, 1.1-3.6, P = .02). Both findings persisted following robust covariate adjustment. In older adults with AD, antidepressants were associated with a significantly greater SBP/DBP drop at 5 minutes. SSRI use in particular may be a risk factor for OH. This emphasises the need to screen older antidepressant users, and particularly those with AD, for ongoing orthostatic symptoms in order to reduce the risk of falls in this vulnerable cohort.

Relationship between sarcopenia and orthostatic hypotension.

The relationship between sarcopenia and orthostatic hypotension (OH) is unclear. The aim of the present study was to investigate associations between sarcopenia/sarcopenia severity and OH. A total of 511 patients attending a geriatric outpatient clinic were included. OH was defined as a decrease in systolic and/or diastolic blood pressure of ≥ 20mmHg and/or ≥ 10mmHg, respectively, when one transitions from the supine to an upright position. OH was measured by the Head-up Tilt Table test at 1, 3 and 5min (OH1, OH3 and OH5, respectively). Sarcopenia and its severity were defined according to the revised European consensus on definition and diagnosis. The mean age of the sample was 75.40 ± 7.35years, and 69.9% were female. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was 42.2%, 6.06% and 11.1%, respectively. After adjustment for all covariates, systolic OH1, OH1 and systolic OH5 were statistically significantly different between severe sarcopenia and the robust group (odds ratio [OR]: 3.26, confidence interval [CI] 0.98-10.84; P = 0.05 for systolic OH1; OR 4.31, CI 1.31-14.15; P = 0.016 for OH1; OR 4.09, CI 1.01-16.55; P = 0.048 for systolic OH5). Only systolic OH1 was statistically different between the sarcopenia and severe sarcopenia groups (OR 2.64, CI 1.87-8.73; P = 0.012). OH1 and OH5 were statistically significant different between severe sarcopenia and probable sarcopenia groups (P < 0.05); there was no relationship between the robust group and probable sarcopenia (P > 0.05). There is a close relationship between sarcopenia and severe sarcopenia and OH in older adults. Therefore, when a healthcare practitioner is evaluating an older patient with sarcopenia, OH should also be evaluated, and vice versa.

The association between fear of falling and orthostatic hypotension in older adults.

The aim of this study was to determine the relationship between the fear of falling/the degree of fear of falling (FoF) and orthostatic hypotension (OH) in older adults. This cross-sectional study was conducted with 314 older outpatients. If the total score of the Falls Efficacy Scale-International scale was 16-19, 20-27 and ≥ 28, it was assumed that there was low FoF, moderate FoF and high FoF, respectively. OH was evaluated for the 1st (OH1) and 3rd (OH3) minutes, after transitioning from the supine position to standing. Participants were aged 65-93years (mean age 74.2 ± 8.5years) and 193 (61.5%) were female. Among the FoF groups, significant differences were found for age, gender, education, marital status, who the patient lived with, the history of falling and hypertension, Timed Up-Go test score and hemoglobin levels (p < 0.005). The prevalence of OH1 and OH3 was found to be significantly higher in those with an FoF score of 20 and above than those below 20 (p < 0.005). After adjustment for potential confounders, participants who reported a high FoF had higher risk for OH1 and OH3 (OR 2.14, 95% CI 1.14-4.0, p = 0.017; and OR 2.72, 95% CI 1.46-5.09, p = 0.002, respectively), but those with moderate FoF had no increased risk of having OH compared to low FoF (p > 0.05). There is a close relationship between high FoF andOH in older adults. Therefore, when evaluating an older patient withOH, FoF should be evaluated, orFoFshould also be questioned in older patients with OH.

Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial.

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Vitamin D Status Is Not Associated With Orthostatic Hypotension in Older Adults

There has been much interest in investigating vitamin D status with orthostatic hypotension. However, studies have been small, inconsistent, and with a lack of standardization. The aim of this study was to investigate the association with vitamin D status in a large, nationally representative older adult population using a traceable standard of measurement and an accurate assessment of beat-to-beat blood pressure (BP). This study used participants aged >50 years from The Irish Longitudinal Study on Ageing. Impaired stabilization of BP on standing was defined as a sustained drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP up to 40 seconds post stand (impaired stabilization of BP on standing). We also analyzed participants who sustained a drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP throughout the 110 seconds stand (OH110). Vitamin D was categorized into sufficient (≥50 nmol/L), insufficient (30-50 nmol/L), and deficient (<30 nmol/L) status. After exclusion criteria 4209 participants were included. Those with deficiency were more likely to be smokers, take antihypertensive medications and had higher levels of cardiovascular disorders compared with those with sufficient status. In a univariate logistic regression those with deficient (odds ratio, 1.18; 95% CI, 0.86-1.61; P=0.303) or insufficient (odds ratio, 1.13; 95% CI, 0.91; P=0.272) status were no more likely to have evidence of impaired stabilization of BP on standing on active stand compared with sufficiency. Similar findings were found for OH110: deficient (odds ratio, 0.85; 95% CI, 0.52-1.40; P=0.528) or insufficient (odds ratio, 0.86; 95% CI, 0.61-1.21; P=0.384) versus sufficiency. In conclusion, vitamin D is not significantly associated with orthostatic hypotension in older adults.

Abstract MP72: The Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: the ALLHAT Trial

Background: Hypertension treatment is believed to contribute to falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether choice of antihypertensive agent influences the incidence of these adverse outcomes is unknown. Hypothesis: Chlorthalidone and atenolol are associated with higher risk of fall, syncope, and OH, compared with amlodipine or lisinopril. Methods: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial that compared the effects of first-step therapy with amlodipine, lisinopril, or chlorthalidone on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). We linked participants to CMS and VA claims to determine the incidence of fall, syncope, OH, or a composite outcome (any of fall, syncope, or OH), using Cox regression. The association of baseline or 1-month add-on atenolol use with outcomes was determined via Cox models adjusted for age, sex, race, and randomized drug assignment. Results: Among 23,964 participants (mean age 70.4 ± 6.7 years, 43% women, 31% black), 927 participants took atenolol at baseline. Over a mean follow-up of 4.9 years, there were 267 fall, 755 syncope, 249 OH, and 1,157 composite claims with no significant differences in the cumulative incidence of events across randomized drug assignments ( Figure ). Compared with chlorthalidone, amlodipine and lisinopril were not associated with falls (HR [95%CI]: 1.36 [0.90-2.05] and 0.80 [0.47-1.36], respectively), syncope (0.96 [0.77-1.21] and 1.07 [0.85-1.34], respectively), OH (0.98 [0.66-1.45] and 1.24 [0.87-1.76], respectively), or the composite outcome (1.01 [0.84-1.21] and 1.07 [0.92-1.22], respectively). Similarly, atenolol use was not associated with any of the 3 individual or composite claims. Conclusions: Choice of antihypertensive agent has no effect on risk of fall, syncope, or OH in older adults. This observation should simplify the choice of initiating antihypertensive therapy in this population.

What is the relationship between frailty and orthostatic hypotension in older adults?

BackgroundFrailty and orthostatic hypotension (OH), which is common in older adults, is associated with morbidity and mortality. The relationship between them remains unclear. The aim of the study is to determine whether there is a relationship between frailty and OH.MethodsA total of 496 patients who were admitted to the geriatric clinic and underwent comprehensive geriatric assessment were retrospectively reviewed. In a cross-sectional and observational study, OH was measured by the Head-up Tilt Table test at 1, 3, and 5 min (respectively, OH1, OH3, and OH5) and the frailty was measured by the Fried's frailty scale.ResultsThe mean age of all patients was 75.4 ± 7.38. The prevalence of females was 69.8%. When the frail people were compared with the pre-frail and the robust ones, the frailty was associated with OH1. There was no relationship between the groups in terms of OH1 when the pre-frail group was compared with the robust group. OH3 were higher in the frail group than in the pre-frail group (P < 0.05) and the OH5 were higher in the frail group than in the pre-frail and robust group (P < 0.05), but OH3 and OH5 were not associated with frailty status when they were adjusted for age (P > 0.05). Slowness and weakness were associated with OH1 (P < 0.05), whereas the other components of the Fried's test were not.ConclusionsFrailty may be a risk factor for OH1. The 1st min measurements of OH should be routinely evaluated in frail older adults to prevent OH-related poor outcomes.

Hypotensive Drugs and Syncope Due to Orthostatic Hypotension in Older Adults with Dementia (Syncope and Dementia Study).

To determine whether hypotensive drugs may play a pivotal role in inducing orthostatic hypotension (OH)-related syncope. Prospective, observational, multicenter study. Acute care wards, syncope units, and centers for the diagnosis of dementia. Individuals aged 65 and older with a diagnosis of dementia and 1 or more episodes of transient loss of consciousness of a suspected syncopal nature or unexplained falls during the previous 3 months MEASUREMENTS: Blood pressure was measured in the supine position and in the orthostatic position after 1 and 3 minutes. OH was defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. Univariate and multivariate analyses were used to evaluate associations between hypotensive drugs and their combinations with OH-related syncope. The mean age of the study population (n=522; women, n=324) was 83.5±6.1, and the most frequent comorbidity was arterial hypertension (74.5%); 324 (67.8%) participants had had a syncopal fall and 168 (32.2%) a nonsyncopal fall. The mean number of hypotensive drugs administered (2.9±3.1) did not differ between the two groups. Syncopal falls was OH-related in 170 participants (48.0%). OH-related syncopal falls were more frequent in participants receiving nitrates (15.3% vs 9.8%, p=.06), alpha-blockers (16.5% vs 9.8%, p=.04), or combinations of angiotensin-converting enzyme inhibitors (ACE-Is) and diuretics (20.6% vs 13.0%, p=.04), alpha-blockers and diuretics (8.2% vs 3.3%, p=0.036), and ACE-Is and nitrates (8.2% vs 3.3%, p=.10). Multivariate analysis confirmed a greater risk of OH-related syncopal fall for nitrates (relative risk (RR)=1.77), combinations of ACE-Is and diuretics (RR=1.66), and combinations of ACE-Is and nitrates (RR=2.32). In older adults with dementia, OH-related syncopal falls are significantly related to treatment with nitrates, combinations of ACE-Is and diuretics, and combinations of ACE-Is and nitrates.

Malnutrition and Malnutrition Risk Can Be Associated with Systolic Orthostatic Hypotension in Older Adults.

Malnutrition and orthostatic hypotension(OH) are the two important geriatric syndromes, which have similar negative outcomes such as falls. The aim of the study is to detect whether there is any relation between malnutrition and OH. 862 geriatric patients, who had undergone comprehensive geriatric assessment (CGA),were included in the retrospective study. OH was identified as 20 and/or 10 mmHg dropped for systolic and/or diastolic blood pressures with the active standing test when patients got up from supine to standing position. Nutritional status was checked according to Mini Nutritional Assesment-Short Form(MNA-SF). The mean age of the patients was 74±8.05, and %66.3 of them were female. The prevalence of malnutrition, malnutrition-risk and OH were detected as 7.7%, 26.9 % and 21.2%, respectively. When OH, systolic OH, diastolic OH and control group were compared with CGA parameters and the effects of age and gender were removed, the frequency of falls and Timed-Up and Go Test were higher, activity daily living indexes and TINETTI-Balance scores were lower in systolic OH than without it (p<0.05).Systolic OH was more frequent in malnutrition-risk and malnutrition group than control group (p<0.002 and p<0.05, respectively). Diastolic OH was not associated with nutritional status (p>0.05).OH was only higher in malnutrition-risk group than robust (p<0.05). Our findings suggest that not only malnutrition but also malnutrition-risk may be associated with systolic OH, which leads to many negative outcomes in older adults. Because malnutrition/ malnutrition risk is preventable and reversible, nutritional status should be checked during the evaluation of OH patients.

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

BackgroundOrthostatic 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. MethodsData 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. ResultsThe 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). ConclusionsOlder 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.

Hypovitaminosis D predicts the onset of orthostatic hypotension in older adults

A number of small cross sectional studies have demonstrated that hypovitaminosis D (represented by low 25 hydroxyvitamin D (25OHD) levels) is associated with orthostatic hypotension (OH). We investigated if hypovitaminosis D is associated with the onset of OH in older adults over a follow-up of 4.4 years. 25OHD was categorized using sex-specific quartiles; OH was defined as a drop of ≤20 mm Hg in systolic or ≤10 mm Hg in diastolic blood pressure <3 minutes of standing. Among 1308 elderly without OH at baseline, using an adjusted logistic regression analysis and taking those with higher baseline serum 25OHD as reference, there was a significant increase in the onset of OH in those with lower serum 25OHD levels. The association was significant only in women when we stratified by sex. In conclusion, hypovitaminosis D predicts the onset of OH in older adults, particularly in women.

Neurogenic hyperadrenergic orthostatic hypotension: a newly recognized variant of orthostatic hypotension in older adults with elevated norepinephrine (noradrenaline).

Patients with neurogenic orthostatic hypotension (OH) typically have impaired sympathetic nervous system tone and therefore low levels of upright plasma norepinephrine (NE) (noradrenaline). We report a subset of patients who clinically have typical neurogenic OH but who paradoxically have elevated upright levels of plasma NE. We retrospectively studied 83 OH patients evaluated at the Vanderbilt Autonomic Dysfunction Center between August 2007 and May 2013. Based on standing NE, patients were dichotomized into a hyperadrenergic OH group [hyperOH: upright NE ≥ 3.55 nmol/l (600 pg/ml), n=19] or a non-hyperadrenergic OH group [nOH: upright NE < 3.55 nmol/l (600 pg/ml), n=64]. Medical history and data from autonomic testing, including the Valsalva manoeuvre (VM), were analysed. HyperOH patients had profound orthostatic falls in blood pressure (BP), but less severe than in nOH [change in SBP (systolic blood pressure): -53 ± 31 mmHg compared with -68 ± 33 mmHg, P=0.050; change in DBP (diastolic blood pressure): -18 ± 23 mmHg compared with -30 ± 17 mmHg, P=0.01]. The expected compensatory increase in standing heart rate (HR) was similarly blunted in both hyperOH and nOH groups [84 ± 15 beats per minute (bpm) compared with 82 ± 14 bpm; P=0.6]. HyperOH patients had less severe sympathetic failure as evidenced by smaller falls in DBP during phase 2 of VM and a shorter VM phase 4 BP recovery time (16.5 ± 8.9 s compared with 31.6 ± 16.6 s; P<0.001) than nOH patients. Neurogenic hyperOH patients have severe neurogenic OH, but have less severe adrenergic dysfunction than nOH patients. Further work is required to understand whether hyperOH patients will progress to nOH or whether this represents a different disorder.

Orthostatic hypotension in older adults with dementia.

Orthostatic hypotension (OH) in older adults with dementia is associated with increased confusion, dizziness, syncope, and falls. These problems may result in a negative, downward spiral accompanied by high morbidity and mortality. The literature supports that nonpharmacological interventions are effective in the reduction of symptoms and prevention of orthostasis. The purpose of this quality improvement project was to increase staff knowledge and skill in the assessment, documentation, and care of residents with OH in dementia care units within a continuing care retirement community. An in-service program using a protocol based on clinical practice guidelines was presented to RNs, licensed practical nurses, therapists, and unlicensed caregivers. Assessments, documentation of assessments, and interventions for residents with OH increased following the in-service program. As staff continue to apply their knowledge in care routines, it is expected that this evidence-based practice will reduce symptoms of OH and increase safety and quality of life within this specific population.