Why orthostatic hypotension increases the risk of falls

This limits the scope of results to falls that require medical intervention only, i. In addition, given that OH may lead to localized or global cerebral hypoperfusion, it is likely that an important subgroup of fallers, i. The simplicity of the traditional consensus definition of OH belies the complexity of making a diagnosis of OH.

Misdiagnosis is a very real clinical possibility unless strict protocols and measurement methods are utilized. This study employed oscillometric BP measurement methods taken intermittently at second intervals for 2 minutes following standing.

It is well known that the initial BP response to active standing is a complex dynamic process that evolves over 3 minutes with a wide range of differing behaviors possible. Traditional oscillometric approaches cannot, however, capture fast transient hypotensive episodes such as initial OH, or increased standing BP variability. So what of the future? Those with sustained OH obviously need careful evaluation when being prescribed medications known to affect BP, cognitive function, balance, or falls risk.

It remains, however, unclear what target resting BP optimally balances these risks in older patients. Given the data presented by Juraschek et al. It remains to be seen how variations in resting BP values effect this curve—is the risk of injurious falls altered in the face of coexisting hypertension and OH?

The stratified data analysis presented in 9 suggests that this is not the case. This study raises further pertinent questions. Is searching for a threshold appropriate given that falls risk lies on a continuum as demonstrated in by Juraschek et al.? Cerebral perfusion should also not be ignored in this context. Lassen in first suggested that cerebral autoregulation maintains constant blood flow within a range of BP 60— mm Hg with hypertension resetting and narrowing the range of cerebral autoregulation activity to higher BP values.

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We showed that individuals who were frail had larger Initial and Consensus declines in blood pressure, and impaired blood pressure recovery, upon the assumption of a seated posture. These findings are important because OH is known to be associated with considerable decrements in morbidity and mortality [ 18 , 49 ] as well as cognitive decline [ 50 ].

We and others have previously described an increased risk of falling in individuals with OH, perhaps mediated by impaired cerebral perfusion [ 32 ] and this has a devastating impact, particularly in the elderly, in whom fall-associated injuries can limit independence and initiate terminal decline. Our findings are compatible with previous reports in community-dwelling older adults that showed impaired initial orthostatic blood pressure control in those with increasing severity of frailty [ 2 ], which was identified as an independent predictor for falls [ 39 ].

Indeed, we showed that when stratified according to prior falling susceptibility, those with a history of falls tended to have more severe Initial and Consensus OH. The extension of these observations to older adults residing in long-term care further highlights the importance of considering frailty and OH as risk factors for falls, and implementation of management approaches that are tailored to those most at risk. A previous study showed that a higher FI was associated with more symptoms of orthostatic intolerance in community dwelling participants [ 22 ].

However, unlike in the present study, they did not find an association between FI and objective measures of blood pressure, perhaps reflecting the different blood pressure measurement approaches employed.

In the current study we used continuous beat-to-beat blood pressure instead of intermittent monitoring, better enabling identification of orthostatic blood pressure changes and therefore revealing greater susceptibility to OH in the frail cohort. The disconnect reported previously between symptoms of OH and objective measures of orthostatic blood pressure may reflect that in some individuals with chronic hypotension it becomes somewhat well tolerated without overt symptoms, but may nevertheless be detrimental and impair cognitive function [ 51 ].

Given the previously reported associations between OH and cognitive impairment [ 50 ] we considered whether the incidence of deficits associated with cognitive symptoms was greater in those with OH than those without OH. We found that the incidence of Consensus OH the most frequently reported sub-type of OH was not greater in those with cognitive symptoms than those without.

In the present study, both Initial and Consensus blood pressure responses were associated with frailty, but not Delayed responses. This might suggest that frail individuals are at particular risk for OH and associated falls in the first minutes after posture change or transfer, and suggests that care home staff pay particular attention to risk mitigation for frail older adults as they perform transfers or change posture.

Further investigation could help elucidate the relationship between Delayed OH and frailty in older adults. In frail older adults, there may be particular benefit to screening for OH, using this simple seated orthostatic stress test. The results of this test may be a warning sign for more conservative management of OH, such as medication adjustment, maintenance of adequate hydration, and sleeping with the head of the bed elevated [ 52 ].

Risks of falling increase in those with gait disturbance, poor balance, cognitive impairments, multiple comorbidities, and polypharmacy. These risk factors are associated with OH and are criteria often used to derive many FI [ 32 ]. This simple test could accompany the existing FI and provide further risk stratification of patients. Older adults who are both frail and exhibit impaired orthostatic blood pressure control are at particular risk for future falls and should receive tailored management accordingly.

We showed that individuals who were frail were more likely to have fallen in the past year, and went on to have more falls in the subsequent year. Further studies should evaluate the usefulness of the combination of FI-MDS and retrospective fall data to predict prospective falls.

These results are comparable to other ROC analysis examining the utility of a FI to predict future falls in community dwelling adults [ 54 ]. This could be followed up with additional evaluation, to better identify those who are less likely to experience future falls [ 55 ].

As noted previously, older adults who are both frail and exhibit impaired orthostatic blood pressure control are at particular risk for future falls and should receive tailored management to mitigate this risk.

This is also seen in other studies, suggesting that the FI does not exhibit a ceiling effect for individuals living in long term care [ 56 ]. In community dwelling adults, the presence of frailty increases the risk of death at any age [ 57 ]. This can be observed even among cohorts with high levels of frailty, such as individuals living in long term residential care facilities [ 15 , 44 , 56 , 57 , 58 ].

While this approach was in keeping with the philosophy of previously validated frailty indices based on deficit accumulation [ 3 , 10 ], and has been validated in the acute care hospital setting [ 18 ], the MDS was not designed for this purpose. Accordingly, while this does provide a convenient tool, the approach has not been fully validated. Given that the mean FI derived from our FI-MDS was similar to other FI in home care populations, it is likely that this approach is suitable, but further validation of this method is needed.

The relatively small sample size in the present study, particularly for the OH measures, provides an obvious potential limitation impacting statistical power. Nevertheless, we were able to detect significant differences in orthostatic cardiovascular control between frail and non-frail individuals, and between fallers and non-fallers, as well as links to all-cause mortality, suggesting statistical confidence in our data.

Future expansion of these observations to larger cohorts would be of benefit. We did not include potential confounding factors in our analyses; however, they are incorporated within the frailty score by definition. These confounding factors would be considered as deficits according to specific criteria outlined previously [ 3 ] and so would be indirectly incorporated. While we found significant relationships between frailty, falling, OH and mortality, it is likely that our measures of OH represent an underestimation of the true presence of OH in this cohort, because we evaluated OH during a relatively mild orthostatic stress, with passive seated orthostatic stress.

The use of a standing posture might be expected to induce larger blood pressure declines and therefore reveal the presence of OH in more individuals. We opted to use seated orthostatic stress in this frail cohort because many participants would have found it difficult to complete a standing test. One benefit of this approach is that a key factor associated with frailty and falling was the systolic blood pressure 1-min after the assumption of a passive seated position Recovery OH. This test is simple, quick, practical and well-tolerated and could easily be incorporated into routine assessments.

In six individuals mortality data were not available because they were discharged from the facility to a higher level of care.

In this cohort of individuals this is typically a herald of end of life care, and mortality occurs soon after discharge. We, therefore, included these individuals in our analysis as if the mortality end-point was met within one month of that time, which may not always have been the case.

However, we do not believe this impacted our results, because when we repeated our analyses excluding these participants our results were unchanged. We have demonstrated that frailty can be captured using a validated frailty index [ 3 ] generated using MDS data in elderly individuals living in long term care, and is related to orthostatic cardiovascular control, falling risk and all-cause mortality.

Frail individuals had larger Initial and Consensus orthostatic reductions in SAP, with impaired blood pressure recovery, a higher prevalence of OH and a higher mortality rate. Use of the MDS to generate a frailty index may represent a simple and convenient tool for risk assessment of falling, OH and mortality in older adults living in long term care. Vaupel JW. Biodemography of human ageing. Rockwood K, Song X.

Changes in relative fitness and frailty across the adult lifespan: evidence from the Canadian National Population Health Survey. Can Med Assoc J [Internet]. Google Scholar. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.

Toward a conceptual definition of frail community dwelling older people. Nurs Outlook [Internet]. Frailty: an emerging public health priority. PubMed Google Scholar. Old or frail: what tells us more?

Defining the concept of frailty: a survey of multi-disciplinary health professionals. Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation. J R Coll Physicians Edinb.

A standard procedure for creating a frailty index. BMC Geriatr. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc. The frailty phenotype and the frailty index: different instruments for different purposes. Age Ageing. Rockwood K. Conceptual models of frailty: accumulation of deficits. Can J Cardiol. Article Validation of an index to estimate the prevalence of frailty among community -dwelling seniors ;24 82 — A multistate model of cognitive dynamics in relation to frailty in older adults.

Ann Epidemiol [Internet]. Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surg. Derivation of a frailty index from the interRAI acute care instrument.

Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Wieling W, Schatz IJ. The consensus statement on the definition of orthostatic hypotension: a revisit after 13 years.

J Hypertens. Stimulus-response paradigm for characterizing the loss of resilience in homeostatic regulation associated with frailty. Mech Ageing Dev. Arch Gerontol Geriatr [Internet]. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. Trajectories of disability in the last year of life.

N Engl J Med [Internet]. CAS Google Scholar. Orthostatic hypotension OH and mortality in relation to age, blood pressure and frailty. Arch Gerontol Geriatr. Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people.

Impaired systolic blood pressure recovery directly after standing predicts mortality in older falls clinic patients. The effect of orthostatic stress type on cardiovascular control. Blood Press Monit [Internet]. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet [Internet]. World Health Organization. Community Health Bristol [Internet].

The relationship between orthostatic hypotension and falling in older adults. Clin Auton Res. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Falls and fall prevention in the nursing home. Falls in hospitals are the most common patient safety incidents — more than , are reported in hospital trusts in England and Wales every year, which equates to nearly a day National Patient Safety Agency, Put another way, patient falls make up two-fifths of all reported patient safety incidents NPSA, Falls have both a human and financial cost: for individual patients, the consequences range from distress and loss of confidence to injuries that can cause pain and suffering, loss of independence and, occasionally, death.

In addition, relatives and hospital staff may often feel anxiety and guilt after a fall. The costs for healthcare providers can include additional treatment, increased lengths of stay, increased care costs on discharge, complaints and, in some cases, litigation. Falls prevention in hospitals is challenging and a careful balance has to be struck between patient safety, autonomy to make their own decisions about care and risk and also issues of privacy and dignity.

Although national guidance is available National Institute for Health and Care Excellence, , evidence suggests many organisations struggle to put it into practice. A recent national audit demonstrated that although many organisations had falls prevention policies in place, there was no association between what those policies included and the assessments and interventions patients actually received once they were admitted to hospital Royal College of Physicians, ; Stevenson, Patients in hospital are at increased risk of falling.

Many are older people and have multiple pre-existing health problems that make them vulnerable to falls; this risk can be compounded by their acute illness, its treatment, and the fact that they are in an unfamiliar environment Oliver et al, Additionally, the prevalence of delirium in patients over 65 in acute general hospitals has been found to be as high as one in three British Geriatrics Society and Royal College of Physicians, , making the falls prevention management of patients with impaired cognition and restlessness a challenge in all inpatient settings.

NICE published guidance on falls risk factors, the effectiveness for interventions and prevention in hospitals. In addition, it has been argued that such tools may create a false dependence on scores at the expense of good clinical judgment Haines et al, Instead, NICE advises that all patients aged 65 and those aged years who are considered clinically to be at risk be offered a comprehensive multifactorial falls assessment NICE, to prompt staff to identify and act on common reversible fall risks and formulate personalised intervention plans.

Orthostatic hypotension OH is an abnormal decrease in systolic blood pressure BP within three minutes of standing, and has been defined as:. It is a common disorder, particularly in older people, with symptoms ranging from visual disturbances and dizziness to syncope. However, some older people do not experience symptoms, while others who fall may not remember having had the symptoms immediately beforehand, meaning that OH might be missed if not part of a structured assessment Petkar et al, Changing from a lying to standing position causes approximately ml of blood to pool in the lower extremities due to gravity.

In a healthy person this is counteracted by the autonomic nervous system, which increases the heart rate, cardiac contractility and vascular tone, thereby regulating the BP to maintain adequate cerebral perfusion.

Inadequate physiological response to such postural changes, especially in older people, can lead to an abnormally large drop in BP, resulting in symptoms that can increase the risk of falls. These symptoms normally resolve on returning to a seated or supine position. It is estimated that about 0. It appears, therefore, that opportunities are being missed to identify and manage this common potential risk factor for falls in older hospitalised patients.

Decreased autonomic function associated with normal ageing can cause OH, but in hospitals it is more commonly related to acute illness, dehydration, delirium and certain types of medications in common usage among older patients Gibbons et al, Disorders such as dementia, multiple system atrophy or diabetic autonomic neuropathy are also often associated with OH.

Normally a drop in BP on standing is regulated by a physiological response called the baroreceptor reflex see Part 2 for more detail on this reflex. However, this response can be delayed in older patients or, for example, those with extensive periods of immobility — patients who have been in bed for long periods are particularly prone to OH NICE, a.

A transient low BP can lead to dizziness, postural instability and even a momentary loss of consciousness, which makes these patient groups more prone to falls. However, OH may be asymptomatic in some people and often after a fall, they may not be able to recall preceding symptoms. Patients with diabetic autonomic neuropathy may be more likely to fall as a result of OH Mankovsky et al, , and a study by Gray-Miceli et al found that many older nursing home residents did not report dizziness before falls, making it even more important for nurses to be vigilant.