The prevalence and pathological correlates of orthostatic hypotension and its subtypes when measured using beat-to-beat technology in a sample of older adults living in the community

Abstract

Background: beat-to-beat technology is increasingly used for investigating orthostatic intolerance (OI) but the prevalence of orthostatic hypotension (OH) diagnosed with this technology is unclear. Objectives: (i) to use beat-to-beat technology to define the prevalence of OH, (ii) to investigate the pathological correlates of OH, (iii) to report the diversity of postural BP responses. Methods: cross-sectional study of adults ≥ 65 years. BP responses to a 3-min head-up tilt were analysed. Results: of 326 participants, 203(62.3%) were females. The median (IQR) age was 73 (70-78). One hundred and ninety-one (58.6%) met standard (20 mmHg systolic/10 mmHg diastolic) criteria for OH. The prevalence was higher in females (60.1% F versus 56.1% M); 47% were arteriolar subtype, 33% were venular, 9% were mixed and 11.0% could not be classified. Morphological analysis identified 102 subjects with 'small drop, overshoot', 131 with 'medium drop, slow recovery' and 31 with 'large drop, nonrecovery'. Those with OH had a lower BMI (P = 0.02), a higher resting heart rate (P = 0.005), were more likely to take a psychotropic (P = 0.02), have vertigo (P = 0.004) and report OI (P = 0.02). The 95th centile for the duration of systolic BP (SYSBP) decay >20 mmHg was 175 s and the slope of systolic BP decay was 4.75 mmHg/s. The 5th centile for percentage recovery of SYSBP was 81.4%. Conclusion: (i) beat-to-beat methods identify a higher prevalence of OH than sphygmomanometry, (ii) the pathological correlates of OH diagnosed in this manner are similar to those described for sphygmomanometry, (iii) there is a diverse pattern of orthostatic BP decay that could be used in future research to predict adverse outcomes in OH.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment

“…In contrast, there are many studies in which no association was found between OH and cognitive changes, including community-based studies [1,18,21,24,27,28] and studies in assisted living homes, [21,23,24,27] among hospitalized patients [16,17,36] and among patients in fall clinics. [2,19,25] The present study is more similar, in terms of the composition of the study population (age and co-morbidity) and the prevalence of OH, to studies that were conducted in selected populations of elderly patients with a heavy burden of comorbidity, such as residents in assisted living homes, hospitalized elderly patients, and patients in fall clinics.…”

“…MMSE was also used in 8 studies in which no association was found between OH and cognitive impairment. [1,18,22,25–28,36] In only one of those studies, [28] the prospective Singapore Longitudinal Aging Study with 2292 participants, was there a statistically significant difference in MMSE score, but after adjusting for relevant variables OH was no longer associated with cognitive state at baseline or with cognitive decline on follow-up. Thus, one can assume that when there is a difference in cognitive state between groups of individuals with and without OH, the difference is not strong enough to be reflected in the MMSE scores.…”

Age-Related Normative Changes in Phasic Orthostatic Blood Pressure in a Large Population Study

“…14 As new methods of phasic BP measurement emerge, phasic BP patterns will require further characterization to enable a better understanding of the clinical impact of abnormal BP behavior. 15 Here, we provide for the first time normative reference data estimated in a population-representative sample for SBP, DBP, and HR responses to active standing, stratified by age and sex and suitable for clinical application. We also propose beat-tobeat definitions and report prevalence estimates of impaired BP stabilization (OH[t]), IOH, and OH.…”

“…One study sampled subjects attending a geriatric day center and reported a prevalence of 72% in fallers and 50% in nonfallers, 20 whereas the second reported a prevalence of 94% in community-dwelling elders. 18 Cooke et al 15 most recently reported a prevalence of 59% in community-dwelling older adults using head-up tilt testing. Again, methodological differences in applying the definition of OH to beat-to-beat measurements likely explain much of the differences here; that is, these studies used any drop of 20/10 mm Hg within 3 minutes of standing to identify those with OH, whereas we included a sustained drop in our definition and estimated the prevalence of OH as 6.9%, a value close to previous oscillometry-based estimates.…”

“…These responses closely resemble the morphological patterns identified by previous studies. 15,18,37 Moreover, it is our experience that significant oscillations or variability may be superimposed on these trends during supine rest, the transient or standing steady-state periods. Analytical approaches to date have used simple magnitude-and timing-based measures to capture the range of transient responses to standing, 35 with more advanced clustering methods used by Finucane et al, 40 Romero-Ortuno et al, 18 and Cooke et al 15 The use of these approaches and more advanced methods may enable us to capture the full range of responses while also providing a transparent mechanistic link between the underlying physiology and observed patterns.…”