Prevalence of postural hypotension in primary, community and institutional care: A systematic review and meta-analysis

Abstract

Background: Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups. Methods: Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale. Results: 1816 studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2=99%) for community cohorts, 19% (15-25%; I2=98%) for 23 primary care cohorts and 31% (15-50%; I2=0%) for 3 residential care or nursing homes cohorts (P=0.16 between groups). By condition, prevalences were 20% (16-23%; I2=98%) with hypertension (20 cohorts), 21% (16-26%; I2=92%) with diabetes (4 cohorts), 25% (18-33%; I2=88%) with Parkinson’s disease (7 cohorts) and 29% (25-33%; I2=0%) with dementia (3 cohorts), compared to 14% (12-17%; I2=99%) without these conditions (P<0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P<0.01, P=0.13, respectively; R2=36%). PH prevalence was not affected by blood pressure measurement device (P=0.65) or sitting or supine resting position (P=0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P=0.01) irrespective of study quality (P=0.04). Conclusions: PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH. PROSPERO:CRD42017075423.

Incidence of postural hypotension recorded in UK general practice: an electronic health records study

“…The steep increase in incidence of recorded postural hypotension by increasing age-band was expected and consistent with our knowledge of the aetiology of this condition (2,3,10).…”

“…It is difficult therefore to evaluate the extent of under-diagnosis of incident postural hypotension in primary care. A recent systematic review and meta-analysis found the pooled prevalence of postural hypotension to be 19% for 23 screened primary care cohorts (2). A further systematic review on epidemiological studies in community-dwelling older adults found that the prevalence of orthostatic hypotension (OH) in screened populations (including therefore both asymptomatic and symptomatic OH) was 22%, and 24% for those in long-term care (3).…”

“…Postural (orthostatic) hypotension is a common, yet frequently overlooked condition, associated with serious adverse outcomes in later life (1). It is estimated to affect around 20% of community-dwelling older adults (2,3) and between 20 and 31% of those living in longterm care (2,3). In the UK, the reported prevalence of postural hypotension has ranged from 28% in older women (4), up to 81% of older adults screened using continuous blood pressure (BP) monitoring (5).…”

“…US guidelines recommend that a postural BP is checked in high-risk groups (1). A large proportion of postural hypotension cases are asymptomatic, and are therefore likely to remain undetected unless screened for in high-risk groups (2). No studies have examined the incidence of cases presenting to general practice, and it is unclear how well General Practitioners (GPs) identify symptomatic postural hypotension in normal practice and whether this varies in different population sub-groups.…”