Acta Medica Mediterranea, 2015, 31: 1001 IMPROVING QUALITY OF LIFE IN ELDERLY PATIENTS WITH ORTHOSTATIC HYPOTENSION AURELIA ROMILA, A. NECHITA, D. TUTUNARU Faculty of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania ABSTRACT Orthostatic hypotension is a complex syndrome common in the elderly, which involves neuronal and humoral control disorders that cause the dysfunctioning of the mechanisms managing, in physiological terms, blood pressure when the body has an erect standing position (orthostatism). The study aims to assess a group of 57 selected patients diagnosed with orthostatic hypotension and to highlight certain aspects regarding the sex, age, origin, influence of associated diseases, and the monitoring of the elderly. Key words: orthostatic hypotension, syncope, repeated falls, baroreceptors. Received November 30, 2014; Accepted May 02, 2015 Introduction The current demographic evolution has brought to the fore the phenomenon of demographic aging relating to the increasing number of elderly people in the general population structure. Although old people have always been an important part of the population, it is only in the last decade that nations and the global community turned their attention on the social, economic, and scientific issues raised by ageing and its universal character. The causes that explain population ageing are declining birth-rates, the progress of medicine and raising living standards, all of which increase numerically the growth rate of elderly population by improving morbidity and mortality (1,2). Clinical statistical research sought to define the frequency of this disease in the elderly population. It was found that, in erect standing position, 17% of hospitalized elderly patients had a 20 mm Hg or more decrease in systolic pressure, and 5%, a 40 mm Hg decrease. The phenomenon has also been studied in the elderly population who stay home. Similarly, Caird et al. (1973) investigated the postural decrease of systolic pressure in 494 people aged 65 or more who stay at home and found orthostatic hypotension in 24% of the subjects. The increasing incidence of this disease with age has led many researchers to consider it an expression of the ageing process, age-related degenerative changes representing the prerequisite for the development of the atherosclerotic process. With age, the enzymatic systems of the vascular walls are less active, issues that correlate with a decrease in elastase (3,4). Orthostatic hypotension is defined as the drop in systolic blood pressure with more than 20mmHg in the transition from supine to standing position. Orthostatic hypotension is a complex syndrome common in the elderly, which involves neuronal and humoral control disorders that cause the dysfunctioning of the mechanisms managing, in physiological terms, blood pressure when the body has an erect standing position (orthostatism).
1002 Aurelia Romila, A. Nechita et Al The clinical picture of orthostatic hypotension may be characterized by nonspecific symptoms: physical and mental fatigue, palpitations, precardialgy, vertigo, syncope, repeated falls (4-6% of them occurring when moving from supine to standing position). A positive clinical diagnosis is achieved through thorough anamnesis, detailed objective physical exam, blood pressure measurements in supine and standing positions, and Schellong testing (5,6). Materials and methods The study was conducted on a group of 57 patients, aged 65-85, hospitalized in the Department of Geriatrics, Sf. Apostol Andrei Clinical Emergency County Hospital in Galati, between 2012 and 2014. The patients were selected based on the orthostatic hypotension diagnosis. The positive diagnosis was made based on the presence of neurological symptomatology (vertigo, syncope, repeated falls), correlated with the determination of blood pressure in clinostatism and orthostatism. The study method was Schellong testing with the following characteristics: the test took place in the morning, blood pressure and pulse were measured simultaneously in clinostatism and orthostatism at 1, 3, 6 and 10 minute intervals, and the symptoms were recorded. The clinical statistical study aims to identify aspects relating to: age, sex, place of residence, risk factors, symptoms at admission, and influence of associated diseases. The statistical method used was the statistical software SPSS 1.1.1. Results The 70-74 age group represents the largest category (33.33%) of the total number of patients under study (Table 3 and Figure 3). Figure 1: Graphic representation of patients by sex. Total Urban Rural 57 32 (56.14%) 25 (43.86%) Table 2: Distribution of patients by place of residence. Figure 2: Graphic representation of patients by place of residence. Total 65-69 years 70-74 years 75-79 years 80-84 years >85 years 57 12 (21.05%) 19 (33.33%) 13 (22.80%) 9 (15.78%) 4 (7.04%) Table 3: Distribution of patients by age group. The analysis of statistical data revealed that this disease is much more frequent in women (71.93%) than in men (28.07%) (Table 1 and Figure 1). Total no. Males Females 57 16 (28.07%) 41 (71.93%) Table 1: Distribution of patients by gender. Regarding the place of residence, there is a difference of 12.28% between urban and rural. Comparing the data collected, it can be noted a clear predominance of urban patients (Table 2 and Figure 2). Figure 3: Graphic representation of patients by age group. Most often than not, orthostatic hypotension manifests in elderly people and may be associated
Improving quality of life in elderly patients with orthostatic hypotension 1003 mainly with people who had a previous stroke. In the group under study, this is the case for 43.86% of the patients. Orthostatic hypotension may also be associated with old age and osteoporosis (Table 4 and Figure 4). As revealed by the analysis of this parameter, one of the associated diseases in orthostatic hypotension patients is the pseudobulbar syndrome, with the highest rate (40.35%) of the cases studied (Table 6 and Figure 6). Risk factors Number of cases (%) Stroke 25 (43.86%) Osteoporosis 18 (31.57%) Age 14 (24.57%) Table 4: Risk factors in patients with orthostatic hypotension. Pseudobulbar palsy Obesity Urinary tract infections Psychoinvolution 23 (40.35%) 11 (19.30%) 14 (24.56%) 9 (15.79%) Table 6: Associated diseases in patients with orthostatic hypotension. Figure 6: Graphic representation of associated diseases. Discussion Figure 4: Graphic representation by risk factors. Of the total number of patients, we notice that 59.65% have dizziness, 14.03% cephalalgia, 7.02% dispnoea, 50.88% walk disorders, and 29.82% sleep disorders (Table 5 and Figure 5). Symptoms Number of cases (%) Dizziness 34 (59.65%) Cephalalgia 8 (14.03%) Dispnoea 4 (7.02%) Walking disorders 29 (50.88%) Sleep disorders 17 (29.82%) Table 5: Symptoms at admission. Figure 5: Distribution of patients by symptoms at admission. Statistical data show that the incidence of orthostatic hypotension is higher in women (71.93%). The frequency of orthostatic hypotension affecting the elderly is higher in urban areas (56.14%); in most cases, the rural elderly person does not care for his health, not only out of lack of health education but also because of the more difficult access to health services. In the patients under study, we found that orthostatic hypotension is commonly associated with diseases frequent in elderly patients: pseudobulbar palsy/syndrome (40.35%), urinary tract infection (24.56%), obesity (19.30%) and psychoinvolution (15.79%). The symptomatology in elderly people with orthostatic hypotension at admission includes: dizziness (59.65%), walking disorders (50.88%), sleep disorders (29.82%), headaches (14.03%) and dyspnoea (7.02%). The aged person presents hypotension when the maximum blood pressure drops below 100 mmhg and the minimum, below 55 mmhg. Normal value or slightly lower blood pressure is a contributing factor in longevity. Maintaining blood pressure values for the elderly means a proper functioning of the central and peripheral regulatory
1004 Aurelia Romila, A. Nechita et Al mechanisms. The orthostatic position quickly mobilizes these control systems. With ageing, as a consequence of degenerative modifications in the neurovegetative system, there is a certain retardation of the baro- and chemoreceptor mechanisms (7-9). Besides changes of the arteriolar tone, the elders are also confronted with physiological involution and limitation of peripheral vein control function, with negative consequences on the circulating volume. Under these conditions, minimal effort to accommodate (change of position, defecation, diarrhea, vomiting) may cause marked hypotension or even shock. Idiopathic orthostatic hypotension occurs in the elderly without a probable cause to explain the low values of blood pressure. Aged people accuse, especially in the morning or after meals, a state of weakness, dizziness; they can hardly bear high temperature. Systolic blood pressure has values of 60-70 mmhg. Secondary orthostatic hypotension is common in geriatric clinics (10,11). Respiratory failure, anemia, hydroelectrolytic disturbances, different clinical forms of neuropathy, extensive bilateral venous disease, chronic diseases, all also manifest by hypotension. The incidence of hypotension is increased during careless administration of antihypotensive medication, diuretics, beta-blockers, hypnotics and anxiolytics (12,13). The determinism of the syndrome is complex and includes nervous control disorders (nerve regulation occurs in correcting subtle changes in blood pressure) and humoral disorders (occurring to correct slow changes); elders are more susceptible to dysfunctions of the neurological mechanisms that physiologically control blood pressure in orthostatism. Other associated etiologic factors are hemodynamic disorders such as: reduction of blood volume or of cardiac efficiency, acute infections, varicose veins, anemia, decreased concentration of serum sodium, ingestion of drugs with hypotensive effect (14,15). The neurological symptomatology of orthostatic hypotension (dizziness, syncopes) is correlated with decreased cerebral blood flow, not with low pressure in the cerebral vessels. Some patients may experience symptoms of orthostatic hypotension without blood pressure values to be low. It was also observed that some patients with lower orthostatic blood pressure are asymptomatic while others are not, the symptomatology depending less on the amplitude of blood pressure falling and more on the initial blood pressure. Orthostatic hypotension in the elderly is often a non-pathological sign; it may be the result of prolonged bed rest, of electrolytic and hydrolytic imbalances, of endocrine or systemic diseases, and of the effects of certain drugs. Orthostatic hypotension is a common problem among elderly patients, and it is associated with significant morbidity and mortality (16,17). Conclusion It can be concluded that the elderly represent an important segment of the overall population, but they have low immunity, a more accentuated metabolic and vascular fragility, which explains the high frequency of chronic diseases overlapping numerous acute ones. Early positive diagnosis is essential for proper treatment, prevention of consequences, and, implicitely, an improved quality of elderly patients lives. Orthostatic hypotension is a common cause of syncope and may contribute to disability and even death, due to the potential risk of significant damage. This may be the initial sign of autonomic dysfunction and can cause major symptoms in many primary and secondary diseases of the autonomous nervous system. References 1) Dumitru M. -Geriatrie, Ed. Medicala, 1982. 2) Abrams W.B., R. Berchow, A. Flechter: The Merck Manual of Geriatrics. Mrek and Co.Inc.Rahway, New York, 1990. 3) Bogdan C. - Elemente de geriatrie practica, Ed. Medicala, 1997. 4) Brocklehurst J.C. - Textbook of geriatric medicine and gerontology, Churchil Livingstone, London, 1978. 5) Buyat J.M., Junod J.P. - Hypotension orthostatique - diagnostic et traitement, Med.Hyg., 1984. 6) Caird F, Andrews G, Kennedy R. - Effect of posture on blood pressure in the elderly. Br. Heart J 1973. 7) Arcand M., Hebert R. - Precis pratique de Geriatie, Edit.Inc.Quebec, 1987. 8) Buyat J.M., Junod J.P. - Hypotension orthostatique diagnostic et traitement, Med.Hyg., 1984. 9) Carp C. - Tratat de Cardiologie, vol.i, Ed. Nationala, Bucuresti, 2002. 10) Judd L., Richard & colab. - Geriatric Emergencies, Aspen Publisher, Inc.,1986. 11) Katz R. - Psysiologie de l equilibre, La Revue de Geriatrie, tome 18, nr.2, fevrier 1993. 12) Dawson S.G. - Adverse drug reaction in the elderly, Drug treatment in the elderly, Rev. Vestal (Ed.Adis Health Science Press), 1984.
Improving quality of life in elderly patients with orthostatic hypotension 1005 13) Spreux A., Brocker P. - Risque medicamenteux:experiences geriatriques du centre de pharmacovigilance de Nice, La Revue de Geriatrie, 1992, tome 17, nr.4. 14) Jonsson A. et al. - Coronary atherosclerosis and myocardial infarction in nonagenarians; a retrospective autopsy study, Age Ageing, 1985. 15) Falcof J. - Hyponatremie, conduit pratique chez la sujet age, La Revue de Geriatrie, 1992. 16) Aronow S. Wilbert - Risk factors for geriatric stroke:identification and follow-up, Geriatrics, 1990. 17) Berger I.E. - Preventive medicine in the aged, Bulletion of the New-York Academy of Medicine, 1985. Corresponding author: AURELIA ROMILA No. 1, Vadu Sacalelor Street Pescarus/8, Galati (Romania)