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Clinical Autonomic Research
Published in: Clinical Autonomic Research 1/2014

01-02-2014 | Review Article

The relationship between orthostatic hypotension and falling in older adults

Authors: Brett H. Shaw, Victoria E. Claydon

Published in: Clinical Autonomic Research | Issue 1/2014

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Abstract

Falls are devastating events and are the largest contributor towards injury-related hospitalization of older adults. Orthostatic hypotension (OH) represents an intrinsic risk factor for falls in older adults. OH refers to a significant decrease in blood pressure upon assuming an upright posture. Declines in blood pressure can reduce cerebral perfusion; this can impair consciousness, lead to dizziness, and increase the likelihood of a fall. Although theoretical mechanisms linking OH and falls exist, the magnitude of the association remains poorly characterized, possibly because of methodological differences between previous studies. The use of non-invasive beat-to-beat blood pressure monitoring has altered the way in which OH is now defined, and represents a substantial improvement for detecting OH that was previously unavailable in many studies. Additionally, there is a lack of consistency and standardization of orthostatic assessments and analysis techniques for interpreting blood pressure data. This review explores the previous literature examining the relationship between OH and falls. We highlight the impact of broadening the timing, degree, and overall duration of blood pressure measurements on the detection of OH. We discuss the types of orthostatic stress assessments currently used to evaluate OH and the various techniques capable of measuring these often transient blood pressure changes. Overall, we identify future solutions that may better clarify the relationship between OH and falling risk in order to gain a more precise understanding of potential mechanisms for falls in older adults.
Literature
1.
American Geriatrics Society (2001) Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 664–672
2.
Braam EA, Verbakel D, Adiyaman A, Thien T (2009) Orthostatic hypotension: revision of the definition is needed. J Hypertens 27:2119–2120 (author reply 2120)
3.
4.
Carlson JE (1999) Assessment of orthostatic blood pressure: measurement technique and clinical applications. South Med J 92:167–173CrossRefPubMed
5.
Carroll NV, Slattum PW, Cox FM (2005) The cost of falls among the community-dwelling elderly. J Manag Care Pharm 11:307–316PubMed
6.
Claydon VE, Krassioukov AV (2006) Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma 23:1713–1725CrossRefPubMed
7.
Cooke J, Carew S, O’Connor M, Costelloe A, Sheehy T, Lyons D (2009) Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension. QJM 102:335–339CrossRefPubMed
8.
Cordeiro RC, Jardim JR, Perracini MR, Ramos LR (2009) Factors associated with functional balance and mobility among elderly diabetic outpatients. Arq Bras Endocrinol Metabol 53:834–843CrossRefPubMed
9.
Craig GM (1994) Clinical presentation of orthostatic hypotension in the elderly. Postgrad Med J 70:638–642CrossRefPubMed
10.
Czajkowska J, Ozhog S, Smith E, Perlmuter LC (2010) Cognition and hopelessness in association with subsyndromal orthostatic hypotension. J Gerontol A Biol Sci Med Sci 65:873–879CrossRefPubMed
11.
Darowski A, Chambers SA, Chambers DJ (2009) Antidepressants and falls in the elderly. Drugs Aging 26:381–394CrossRefPubMed
12.
Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA (2010) International comparison of cost of falls in older adults living in the community: a systematic review. Osteoporos Int 21:1295–1306CrossRefPubMed
13.
Dieterle T (2012) Blood pressure measurement–an overview. Swiss Med Wkly 142:w13517PubMed
14.
El-Bedawi KM, Hainsworth R (1994) Combined head-up tilt and lower body suction: a test of orthostatic tolerance. Clin Auton Res 4:41–47CrossRefPubMed
15.
Fedorowski A, Burri P, Melander O (2009) Orthostatic hypotension in genetically related hypertensive and normotensive individuals. J Hypertens 27:976–982CrossRefPubMed
16.
Folino AF (2007) Cerebral autoregulation and syncope. Prog Cardiovasc Dis 50:32
17.
Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG (2011) Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 21:69–72CrossRefPubMed
18.
Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, Lipsitz LA (2011) Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 59:383–389CrossRefPubMedCentralPubMed
19.
20.
Gehrking JA, Hines SM, Benrud-Larson LM, Opher-Gehrking TL, Low PA (2005) What is the minimum duration of head-up tilt necessary to detect orthostatic hypotension? Clin Auton Res 15:71–75CrossRefPubMed
21.
Gibbons CH, Freeman R (2006) Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology 67:28–32CrossRefPubMed
22.
Goldstein DS, Robertson D, Esler M, Straus SE, Eisenhofer G (2002) Dysautonomias: clinical disorders of the autonomic nervous system. Ann Intern Med 137:753–763CrossRefPubMed
23.
Graafmans WC, Ooms ME, Hofstee HM, Bezemer PD, Bouter LM, Lips P (1996) Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol 143:1129–1136CrossRefPubMed
24.
Guelen I, Westerhof BE, Van Der Sar GL, Van Montfrans GA, Kiemeneij F, Wesseling KH, Bos WJ (2003) Finometer, finger pressure measurements with the possibility to reconstruct brachial pressure. Blood Press Monit 8:27–30CrossRefPubMed
25.
Gupta B (2007) Invasive blood pressure monitoring. Update Anesth 23:7
26.
Gupta V, Lipsitz LA (2007) Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med 120:841–847CrossRefPubMed
27.
Hainsworth R, Claydon VE (2013) Syncope and fainting: classification and pathophysiological basis. In: Autonomic failure: a texbook of clinical disorders of the autonomic nervous system, Oxford University Press, Oxford, United Kingdom
28.
Hainsworth R, El-Bedawi KM (1994) Orthostatic tolerance in patients with unexplained syncope. Clin Auton Res 4:239–244CrossRefPubMed
29.
Heitterachi E, Lord SR, Meyerkort P, McCloskey I, Fitzpatrick R (2002) Blood pressure changes on upright tilting predict falls in older people. Age Ageing 31:181–186CrossRefPubMed
30.
Hiitola P, Enlund H, Kettunen R, Sulkava R, Hartikainen S (2009) Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older. J Hum Hypertens 23:33–39CrossRefPubMed
31.
Hohler AD, Zuzuarregui JR, Katz DI, Depiero TJ, Hehl CL, Leonard A, Allen V, Dentino J, Gardner M, Phenix H, Saint-Hilaire M, Ellis T (2012) Differences in motor and cognitive function in patients with Parkinson’s disease with and without orthostatic hypotension. Int J Neurosci 122:233–236PubMed
32.
Hosseini H, Hosseini N (2008) Epidemiology and prevention of fall injuries among the elderly. Hosp Top 86:15–20CrossRefPubMed
33.
Imholz BP, Wieling W, Langewouters GJ, van Montfrans GA (1991) Continuous finger arterial pressure: utility in the cardiovascular laboratory. Clin Auton Res 1:43–53CrossRefPubMed
34.
Imholz BP, Wieling W, van Montfrans GA, Wesseling KH (1998) Fifteen years experience with finger arterial pressure monitoring: assessment of the technology. Cardiovasc Res 38:605–616CrossRefPubMed
35.
Jansen JR, Schreuder JJ, Mulier JP, Smith NT, Settels JJ, Wesseling KH (2001) A comparison of cardiac output derived from the arterial pressure wave against thermodilution in cardiac surgery patients. Br J Anaesth 87:212–222CrossRefPubMed
36.
Jones A, Pratt O (2009) Physical principles of intra-arterial blood pressure measurement. World Anaesth Tutor Week 137:8
37.
Kario K, Tobin JN, Wolfson LI, Whipple R, Derby CA, Singh D, Marantz PR, Wassertheil-Smoller S (2001) Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study. J Am Coll Cardiol 38:246–252CrossRefPubMed
38.
Kaufmann H (1996) Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin Auton Res 6:125–126CrossRefPubMed
39.
Kennelly SP, Lawlor BA, Kenny RA (2009) Blood pressure and the risk for dementia: a double edged sword. Ageing Res Rev 8:61–70CrossRefPubMed
40.
Kenny RA (2003) Syncope in the elderly: diagnosis, evaluation, and treatment. J Cardiovasc Electrophysiol 14:S74–S77CrossRefPubMed
41.
Lagro J, Schoon Y, Heerts I, Meel-van den Abeelen AS, Schalk B, Wieling W, Olde Rikkert MG, Claassen JA (2013) Impaired systolic blood pressure recovery directly after standing predicts mortality in older falls clinic patients. J Gerontol A Biol Sci Med Sci
42.
Langewouters GJ, Settels JJ, Roelandt R, Wesseling KH (1998) Why use Finapres or Portapres rather than intra-arterial or intermittent non-invasive techniques of blood pressure measurement? J Med Eng Technol 22:37–43CrossRefPubMed
43.
Lipsitz LA, Mukai S, Hamner J, Gagnon M, Babikian V (2000) Dynamic regulation of middle cerebral artery blood flow velocity in aging and hypertension. Stroke 31:1897–1903CrossRefPubMed
44.
45.
Luukinen H, Koski K, Kivela SL, Laippala P (1996) Social status, life changes, housing conditions, health, functional abilities and life-style as risk factors for recurrent falls among the home-dwelling elderly. Public Health 110:115–118CrossRefPubMed
46.
Madden KM, Lockhart C (2009) Arterial baroreflex function in older adults with neurocardiogenic syncope. Clin Invest Med 32:E191–E198PubMedCentralPubMed
47.
Masaki KH, Schatz IJ, Burchfiel CM, Sharp DS, Chiu D, Foley D, Curb JD (1998) Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation 98:2290–2295CrossRefPubMed
48.
Matinolli M, Korpelainen JT, Korpelainen R, Sotaniemi KA, Myllyla VV (2009) Orthostatic hypotension, balance and falls in Parkinson’s disease. Mov Disord 24:745–751CrossRefPubMed
49.
Maurer MS, Cohen S, Cheng H (2004) The degree and timing of orthostatic blood pressure changes in relation to falls in nursing home residents. J Am Med Dir Assoc 5:233–238CrossRefPubMed
50.
Mehrabian S, Duron E, Labouree F, Rollot F, Bune A, Traykov L, Hanon O (2010) Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci 299:45–48CrossRefPubMed
51.
Molhoek GP, Wesseling KH, Settels JJ, van Vollenhoven E, Weeda HW, de Wit B, Arntzenius AC (1984) Evaluation of the Penaz servo-plethysmo-manometer for the continuous, non-invasive measurement of finger blood pressure. Basic Res Cardiol 79:598–609CrossRefPubMed
52.
53.
Naschitz JE, Rosner I (2007) Orthostatic hypotension: framework of the syndrome. Postgrad Med J 83:568–574CrossRefPubMed
54.
Nelesen RA, Dimsdale JE (2002) Use of radial arterial tonometric continuous blood pressure measurement in cardiovascular reactivity studies. Blood Press Monit 7:259–263CrossRefPubMed
55.
O’Loughlin JL, Robitaille Y, Boivin JF, Suissa S (1993) Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 137:342–354PubMed
56.
57.
Ooi WL, Hossain M, Lipsitz LA (2000) The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 108:106–111CrossRefPubMed
58.
Penaz J (1973) Photoelectric measurement of blood pressure, volume and flow in the finger. In: Digest 10th international conference on medical and biological engineering, Dresden, p 104
59.
Petersen ME, Williams TR, Sutton R (1995) A comparison of non-invasive continuous finger blood pressure measurement (Finapres) with intra-arterial pressure during prolonged head-up tilt. Eur Heart J 16:1641–1654PubMed
60.
Poda R, Guaraldi P, Solieri L, Calandra-Buonaura G, Marano G, Gallassi R, Cortelli P (2012) Standing worsens cognitive functions in patients with neurogenic orthostatic hypotension. Neurol Sci 33:469–473CrossRefPubMed
61.
Poon IO, Braun U (2005) High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther 30:173–178CrossRefPubMed
62.
Protheroe CL, Ravensbergen HR, Inskip JA, Claydon VE (2013) Tilt testing with combined lower body negative pressure: a “gold standard” for measuring orthostatic tolerance. J Vis Exp 73
63.
Rickards CA, Newman DG (2003) A comparative assessment of two techniques for investigating initial cardiovascular reflexes under acute orthostatic stress. Eur J Appl Physiol 90:449–457CrossRefPubMed
64.
Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, Sims-Gould J, Loughin M (2013) Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet 381:47–54CrossRefPubMedCentralPubMed
65.
Romero-Ortuno R, Cogan L, Fan CW, Kenny RA (2010) Intolerance to initial orthostasis relates to systolic BP changes in elders. Clin Auton Res 20:39–45CrossRefPubMed
66.
Romero-Ortuno R, Cogan L, Foran T, Kenny RA, Fan CW (2011) Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people. J Am Geriatr Soc 59:655–665CrossRefPubMed
67.
Romero-Ortuno R, Cogan L, O’Shea D, Lawlor BA, Kenny RA (2011) Orthostatic haemodynamics may be impaired in frailty. Age Ageing 40:576–583CrossRefPubMed
68.
Rongen GA, Bos WJ, Lenders JW, van Montfrans GA, van Lier HJ, van Goudoever J, Wesseling KH, Thien T (1995) Comparison of intrabrachial and finger blood pressure in healthy elderly volunteers. Am J Hypertens 8:237–248CrossRefPubMed
69.
Rubenstein LZ (2006) Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 35(Suppl 2):ii37–ii41
70.
Rubenstein LZ, Josephson KR (2002) The epidemiology of falls and syncope. Clin Geriatr Med 18:141–158CrossRefPubMed
71.
Ruitenberg A, den Heijer T, Bakker SL, van Swieten JC, Koudstaal PJ, Hofman A, Breteler MM (2005) Cerebral hypoperfusion and clinical onset of dementia: the Rotterdam Study. Ann Neurol 57:789–794CrossRefPubMed
72.
Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS (1992) Orthostatic hypotension in older adults. The cardiovascular health study. CHS collaborative research group. Hypertension 19:508–519CrossRefPubMed
73.
Sahota IS, Ravensbergen HR, McGrath MS, Claydon VE (2012) Cerebrovascular responses to orthostatic stress after spinal cord injury. J Neurotrauma 29:2446–2456
74.
Sato T, Nishinaga M, Kawamoto A, Ozawa T, Takatsuji H (1993) Accuracy of a continuous blood pressure monitor based on arterial tonometry. Hypertension 21:866–874CrossRefPubMed
75.
Schondorf R, Benoit J, Stein R (2001) Cerebral autoregulation in orthostatic intolerance. Ann N Y Acad Sci 940:514–526CrossRefPubMed
76.
Schutte AE, Huisman HW, van Rooyen JM, Malan NT, Schutte R (2004) Validation of the Finometer device for measurement of blood pressure in black women. J Hum Hypertens 18:79–84CrossRefPubMed
77.
Shibao C, Grijalva CG, Raj SR, Biaggioni I, Griffin MR (2007) Orthostatic hypotension-related hospitalizations in the United States. Am J Med 120:975–980CrossRefPubMed
78.
Sorond FA, Galica A, Serrador JM, Kiely DK, Iloputaife I, Cupples LA, Lipsitz LA (2010) Cerebrovascular hemodynamics, gait, and falls in an elderly population: MOBILIZE Boston study. Neurology 74:1627–1633CrossRefPubMed
79.
Sorond FA, Serrador JM, Jones RN, Shaffer ML, Lipsitz LA (2009) The sit-to-stand technique for the measurement of dynamic cerebral autoregulation. Ultrasound Med Biol 35:21–29CrossRefPubMedCentralPubMed
80.
Sprangers RL, Wesseling KH, Imholz AL, Imholz BP, Wieling W (1991) Initial blood pressure fall on stand up and exercise explained by changes in total peripheral resistance. J Appl Physiol 70:523–530CrossRefPubMed
81.
Steiner LA, Johnston AJ, Salvador R, Czosnyka M, Menon DK (2003) Validation of a tonometric noninvasive arterial blood pressure monitor in the intensive care setting. Anaesthesia 58:448–454CrossRefPubMed
82.
Stevens JA, Corso PS, Finkelstein EA, Miller TR (2006) The costs of fatal and non-fatal falls among older adults. Inj Prev 12:290–295CrossRefPubMed
83.
Stevens PM (1966) Cardiovascular dynamics during orthostasis and the influence of intravascular instrumentation. Am J Cardiol 17:211–218CrossRefPubMed
84.
85.
Streeten DH, Anderson GH Jr (1992) Delayed orthostatic intolerance. Arch Intern Med 152:1066–1072CrossRefPubMed
86.
Tanaka H, Sjoberg BJ, Thulesius O (1996) Cardiac output and blood pressure during active and passive standing. Clin Physiol 16:157–170CrossRefPubMed
87.
88.
Thomas KN, Cotter JD, Galvin SD, Williams MJ, Willie CK, Ainslie PN (2009) Initial orthostatic hypotension is unrelated to orthostatic tolerance in healthy young subjects. J Appl Physiol 107:506–517CrossRefPubMed
89.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, Koch ML, Trainor K, Horwitz RI (1994) A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 331:821–827CrossRefPubMed
90.
Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P (2001) Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 54:837–844CrossRefPubMed
91.
Ungar A, Galizia G, Morrione A, Mussi C, Noro G, Ghirelli L, Masotti G, Rengo F, Marchionni N, Abete P (2011) Two-year morbidity and mortality in elderly patients with syncope. Age Ageing 40:696–702CrossRefPubMed
92.
van der Velde N, van den Meiracker AH, Stricker BH, van der Cammen TJ (2007) Measuring orthostatic hypotension with the Finometer device: is a blood pressure drop of one heartbeat clinically relevant? Blood Press Monit 12:167–171CrossRefPubMed
93.
Wieling W, Harms MP, Kortz RA, Linzer M (2001) Initial orthostatic hypotension as a cause of recurrent syncope: a case report. Clin Auton Res 11:269–270CrossRefPubMed
94.
Wieling W, Krediet CT, van Dijk N, Linzer M, Tschakovsky ME (2007) Initial orthostatic hypotension: review of a forgotten condition. Clin Sci (Lond) 112:157–165CrossRef
95.
Wieling W, Schatz IJ (2009) The consensus statement on the definition of orthostatic hypotension: a revisit after 13 years. J Hypertens 27:935–938CrossRefPubMed
96.
Wieling W, Thijs RD, van Dijk N, Wilde AA, Benditt DG, van Dijk JG (2009) Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain 132:2630–2642CrossRefPubMed
97.
Winker R, Prager W, Haider A, Salameh B, Rudiger HW (2005) Schellong test in orthostatic dysregulation: a comparison with tilt-table testing. Wien Klin Wochenschr 117:36–41CrossRefPubMed
98.
World Health Organization (2007) WHO global report on falls prevention in older age. In: Salas-Rojas C (ed) World Health Organization, Geneva, p 53
99.
Zorn EA, Wilson MB, Angel JJ, Zanella J, Alpert BS (1997) Validation of an automated arterial tonometry monitor using Association for the Advancement of Medical Instrumentation standards. Blood Press Monit 2:185–188PubMed
Metadata
Title
The relationship between orthostatic hypotension and falling in older adults
Authors
Brett H. Shaw
Victoria E. Claydon
Publication date
01-02-2014
Publisher
Springer Berlin Heidelberg
Published in
Clinical Autonomic Research / Issue 1/2014
Print ISSN: 0959-9851
Electronic ISSN: 1619-1560
DOI
https://doi.org/10.1007/s10286-013-0219-5

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