The association between orthostatic hypotension and recurrent falls in nursing home residents. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmö Preventive Project) Pretreatment orthostatic hypotension as a predictor of response to nortriptyline in geriatric depression. Postural hypotension and EEG variables predict cognitive decline: results from a 5-year follow-up of healthy elderly women. Prevalence of orthostatic hypotension among patients presenting with syncope in the ED. Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older The Impact of Autonomic Dysfunction on Survival in Patients with Dementia with Lewy Bodies and Parkinson's Disease with Dementia Distribution and observed associations of orthostatic blood pressure changes in elderly general medicine outpatients. 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. l-threo-dihydroxyphenylserine (l-threo-DOPS; droxidopa) in the management of neurogenic orthostatic hypotension: A multi-national, multi-center, dose-ranging study in multiple system atrophy and pure autonomic failure Capillary refill--is it a useful predictor of hypovolemic states? Neurogenic orthostatic hypotension: a double-blind, placebo-controlled study with midodrine. Cardiovascular and Neurological Adverse Events Associated With Antidepressant Treatment in Children and Adolescents The degree and timing of orthostatic blood pressure changes in relation to falls in nursing home residents. Effect of yohimbine on blood pressure in patients with depression and orthostatic hypotension induced by clomipramine Hypovitaminosis D in the Middle East and North Africa Orthostatic hypotension predicts incidence of heart failure: the Malmö preventive project. A home-based resistance-training program
using elastic bands for elderly patients
with orthostatic hypotension The mechanism of adverse events associated with terazosin: an analysis of the Veterans Affairs cooperative study. Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group. Cardiovascular effects of imipramine and bupropion in depressed patients with congestive heart failure. Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly.
PURPOSE Orthostatic hypotension is common among the elderly , but its relation to falls is not certain . We determined whether orthostatic hypotension , including its timing and frequency , was associated with falls in elderly nursing home residents . SUBJECTS AND METHODS We conducted a prospect i ve study of 844 elderly ( 60 years of age and older ) , long-stay residents at 40 facilities that were part of a multistate nursing home chain . All subjects were able to maintain weight-bearing for at least 1 minute .  Orthostatic hypotension was defined as a 20 mm Hg or greater decrease in systolic blood pressure from supine to st and ing , as measured after 1 or 3 minutes of st and ing on four occasions ( before or after breakfast , or before or after lunch ) . The outcome was any subsequent fall during a mean of 1.2 years of follow-up . RESULTS  Orthostatic hypotension  was present ( at least on one measurement ) in 50 % of the subjects but was not associated with subsequent falls . However , among subjects with a history of previous falls in the past 6 months , those with orthostatic hypotension had an increased risk of recurrent falls [ adjusted relative risk ( RR ) = 2.1 ; 95 % confidence interval ( CI ) , 1.4 to 3.1 ] . The risk of subsequent falls was greatest in previous fallers who had orthostatic hypotension at two or more measurements ( RR = 2.6 ; 95 % CI , 1.7 to 4.6 ) . The association between orthostatic hypotension and recurrent falls was independent of measured demographic or clinical risk factors for falls . The timing of orthostatic hypotension ( before or after meals ) did not affect the risk of falls . CONCLUSIONS Orthostatic hypotension is an independent risk factor for recurrent falls among elderly nursing home residents . Although the benefit of treating orthostatic hypotension will require further study , it may be prudent to identify high-risk residents and institute pre caution ary measures OBJECTIVES To determine the prognostic role of orthostatic hypotension for cardiovascular disease ( CVD ) and all-cause mortality in elderly people . DESIGN Prospect i ve study . SETTING Community based . PARTICIPANTS Five thous and sixty-four subjects from the Rotterdam study aged 55 and older . MEASUREMENTS  Orthostatic hypotension  was measured using a Dinamap automatic blood pressure recorder . Orthostatic hypotension  is defined as a decline in systolic blood pressure of 20 mmHg or more or a decline in diastolic blood pressure of 10 mmHg or more from supine to st and ing position at any of three measurements taken 1 , 2 , and 3 minutes after st and ing . RESULTS At baseline , 901 subjects had  orthostatic hypotension  . During follow-up , 668 subjects had  coronary heart disease  ( CHD ) ( mean follow-up 6.0 + /- 3.5 years ) , and 1,835 subjects died ( mean follow-up period 7.8 + /- 3.8 years ) . Orthostatic hypotension increased the risk of CHD ( hazard ratio (HR)=1.31 , 95 % confidence interval (CI)=1.08 - 1.57 ) and all-cause mortality ( HR=1.22 , 95 % CI=1.09 - 1.36 ) , in models adjusted for age and sex . The risk was slightly lower after additional adjustment for cardiovascular risk factors . In analyses stratified for age , the HRs for all-cause mortality were 1.80 ( 95 % CI 1.25 - 2.60 ) , 1.13 ( 0.89 - 1.42 ) , and 1.27 ( 95 % CI=1.11 - 1.44 ) , in the first , second , and third tertile of age , respectively . CONCLUSION Orthostatic hypotension increases the risk of CHD and all-cause mortality in elderly people . The risk of CVD and mortality is strongest in younger and very old subjects Aims Orthostatic hypotension ( OH ) has been linked to increased mortality and incidence of cardiovascular disease in various risk groups , but determinants and consequences of OH in the general population are poorly studied . Methods and results Prospect i ve data of the Swedish ‘ Malmö Preventive Project ’ ( n = 33 346 , 67.3 % men , mean age 45.7 ± 7.4 years , mean follow-up 22.7 ± 6.0 years ) were analysed .  Orthostatic hypotension  was found in 6.2 % of study participants and was associated with age , female gender , hypertension , antihypertensive treatment , increased heart rate , diabetes , low BMI , and current smoking . In Cox regression analysis , individuals with OH had significantly increased all-cause mortality ( in particular those aged less than 42 years ) and coronary event ( CE ) risk . Mortality and CE risk were distinctly higher in those with systolic blood pressure ( BP ) fall ≥30 mmHg [ hazard ratio ( HR ) : 1.6 , 95 % CI 1.3–1.9 , P < 0.0001 and 1.6 , 95 % CI 1.2–2.1 , P = 0.001 ] and diastolic BP fall ≥15 mmHg ( HR : 1.4 , 95 % CI 1.1–1.9 , P = 0.024 and 1.7 , 95 % CI 1.1–2.5 , P = 0.01 ) . In addition , impaired diastolic BP response had relatively greater impact ( per mmHg ) on CE incidence than systolic reaction .  Conclusion Orthostatic hypotension can be detected in ∼6 % of middle-aged individuals and is often associated with such comorbidities as hypertension or diabetes . Presence of OH increases mortality and CE risk , independently of traditional risk factors . Although both impaired systolic and diastolic responses predict adverse events , the diastolic impairment shows stronger association with coronary disease The consequences of orthostatic hypotension , a serious and common problem among the elderly , are falls , transient ischemic attacks , strokes , and myocardial infa rct ions .  Depressed elderly taking tricyclic antidepressants ( TCAs )  are at increased risk , and the pretreatment presence of orthostatic hypotension is considered a relative contraindication to TCA treatment . Recently , it was reported that the presence of pretreatment orthostatic hypotension in geriatric out patients with unipolar depression predicted good clinical response to imipramine or doxepin . We investigated the predictive value of pretreatment systolic orthostatic pressure changes ( PSOP ) in unipolar depressed elderly out patients ( mean age , 64 ) who were to receive a 16-week course of nortriptyline or interpersonal psychotherapy .  Overall , PSOP was significantly correlated with improvement on both the Beck Depression Inventory and the Hamilton Depression Rating Scale . Although both groups responded equally to treatment , PSOP was more strongly correlated with improvement on the Beck Depression Inventory ( r = 0.74 , p less than 0.01 ) in the nortriptyline-treated group than in the group treated with interpersonal therapy ( r = 0.31 , not significant ) . The nortriptyline-treated subjects with a PSOP of greater than or equal to 10 mm Hg had a greater improvement than those with a PSOP of less than 10 mm HG ( t = -2.36 , p less than 0.05 ) . No episodes of symptomatic orthostatic hypotension occurred in the nortriptyline-treated subjects . The results suggest that orthostatic hypotension , a relative contraindication to TCA use , may potentially identify patients more likely to respond to TCAs Quantified  electroencephalographic activity ( EEG )  has been used to study normal ageing and dementia . Few studies have described longitudinal changes in the very old . A cognitive decline has been described in subjects with white-matter lesions and hypertension but the association with hypotension is unclear . Our aim was to study the predictive value of  quantified EEG  for the development of cognitive decline and associations with postural hypotension . Participants . Thirty-three healthy women aged 75 - 95 years , with no signs of cerebrovascular disease , dementia or acute illness at baseline examination took part in a longitudinal 5-year follow-up study . The women were recruited from a r and om selection using the Municipal Registry .  Quantified EEG  was assessed twice and recorded on a Siemens-Elema connected to a Biological Banker . The medical and neuropsychological examination was conducted twice . Dementia was classified according to DSM criteria . The assessment included Mini-Mental Scale Examination ( MMSE ) , spatial and vocabulary tests . Blood pressure was measured in supine position and an  orthostatic test  was performed with continuous ECG recording . Seven women ( cases ) developed cognitive decline at the 5-year follow-up , defined as newly developed MMSE < 27 and dementia symptoms . Low beta activity at baseline predicted development of cognitive decline . The women who remained healthy at follow-up showed an increase of alpha and theta activity . The cases had a higher orthostatic blood pressure fall during tilting at baseline ( 16 mm Hg ) than the controls ( 1 mm Hg , p < 0.01 ) . The orthostatic reaction was correlated with increased levels of theta and alpha activity at follow-up ( r = -0.47 to -0.52 ; p < 0.01 ) . Low beta activity predicts for cognitive decline in the elderly and an orthostatic blood pressure reaction is a risk factor for cognitive decline We sought to determine the prevalence of orthostatic hypotension as a cause of syncope in the emergency setting , and describe the characteristics of patients diagnosed with this condition .  Blood pressure orthostatic changes  were measured prospect ively in a st and ardized fashion up to 10 minutes , or until symptoms occurred , in all consecutive patients with syncope as a chief complaint presenting in the emergency department ( ED ) of a primary and tertiary care hospital . Patients unable to st and -up were excluded . Hypotension was considered to be the cause of syncope when there was : ( 1 ) a decrease in systolic blood pressure ( SBP ) > or= 20 mm Hg with simultaneous symptoms ; ( 2 ) a decrease in SBP between 10 and 20 mm Hg , but a SBP < or= 90 mm Hg with or without symptoms ; and ( 3 ) a nonsignificant decrease in SBP in the ED , but a prehospital value < or= 80 mm Hg was documented that prompted fluid therapy before st and ardized measurements . Among 788 patients with syncope seen in the ED during a 20-month period , 650 were included in the study , and 579 ( 89 % ) had st and ardized measurements of SBP .  According to diagnostic criteria , orthostatic hypotension was considered to be the cause of syncope in 156 of them ( 24 % ) . Fifty-eight patients ( 37 % ) had drug-induced hypotension , 33 ( 21 % ) hypovolemia , 19 ( 12 % ) postpr and ial hypotension , and 46 ( 29 % ) idiopathic hypotension . Asymptomatic SBP changes > or= 20 mm Hg were found in 10 % of patients with syncope attributed to other causes . Compared with patients with vasovagal disorder , those with orthostatic hypotension were older ; had more comorbid conditions including hypertension , organic heart disease , and abnormal electrocardiogram ; were taking more hypotensive medications ; and required more frequently hospitalization ( P < .01 ) . We concluded that st and ardized blood pressure measurement in the ED enabled to strongly implicate orthostatic hypotension as a cause of syncope in 24 % of patients with this symptom . Drug-related hypotension was the most frequent cause for this disorder This cross-sectional analysis of a population -based cohort investigates the postural changes in blood pressure ( BP ) and heart rate and assesses the prevalence of orthostatic hypotension ( OH ) and its associations with the medicines used by an elderly population . The study population ( n=1000 ) was a r and om sample of persons aged 75 years or older in the City of Kuopio , Finl and . In 2004 , altogether , 781 persons participated in the study . After the exclusion of persons living in institutional care ( n=82 ) and those without orthostatic test ( n=46 ) , the final study population comprised 653 home-dwelling elderly persons .  OH was defined as a ⩾20 mm Hg drop of systolic BP or a ⩾10 mm Hg drop of diastolic BP or both 1 or 3 min after st and ing up from supine position . Systolic BP dropped for more than half of the home-dwelling elderly when they stood up from a supine to a st and ing position . The total prevalence of OH was 34 % ( n=220 ) . No significant gender or age differences were seen . The prevalence of OH was related to the total number of medicines in regular use ( P<0.05 ) . OH and postural changes in BP are more common among the home-dwelling elderly than reported in previous studies . The prevalence of OH is related to the number of medicines in regular use . There is an obvious need to measure orthostatic BP of elderly persons , as low BP and OH are important risk factors especially among the frail elderly persons Introduction Autonomic dysfunction is a well-known feature in neurodegenerative dementias , especially common in α-synucleinopathies like dementia with Lewy bodies and Parkinson 's disease with dementia . The most common symptoms are orthostatic hypotension , incontinence and constipation , but its relevance in clinical practice is poorly understood . There are no earlier studies addressing the influence of autonomic dysfunction on clinical course and survival . The aim of this study was to investigate the frequency of the three most common features of autonomic dysfunction and analyze how it affects survival . Methods Thirty patients with dementia with Lewy bodies and Parkinson 's disease with dementia were included in this prospect i ve , longitudinal follow-up study . Presence of incontinence and constipation was recorded at baseline .  Blood pressure was measured at baseline , after 3 months and after 6 months according to st and ardized procedures , with 5 measurements during 10 minutes after rising . Orthostatic hypotension was defined using consensus definitions and persistent orthostatic hypotension was defined as 5 or more measurements with orthostatic hypotension . Difference in survival was analyzed 36 months after baseline . Results There was a high frequency of persistent orthostatic blood pressure ( 50 % ) , constipation ( 30 % ) and incontinence ( 30 % ) . Patients with persistent orthostatic hypotension had a significantly shorter survival compared to those with no or non-persistent orthostatic hypotension ( Log rank x2 = 4.47 , p = 0.034 ) . Patients with constipation and /or urinary incontinence  , in addition to persistent orthostatic hypotension , had a poorer prognosis compared to those with isolated persistent orthostatic hypotension or no orthostatic hypotension ( Log rank x2 = 6.370 , p = 0.041 ) . Discussion According to our findings , the identification of autonomic dysfunction seems to be of great importance in clinical practice , not only to avoid falls and other complications , but also as a possible predictor of survival Factors associated with orthostatic blood pressure change in elderly out patients were determined by surveying 398 medical clinical out patients aged 65 years and older .  Blood pressure  was measured with r and om-zero sphygmomanometers after patients were 5 minutes in a supine and 5 minutes in a st and ing position .  Orthostatic blood pressure changes were at normally distributed levels with systolic and diastolic pressures dropping an average of 4 mm Hg ( st and ard deviation [SD]=15 mm Hg ) and 2 mm Hg ( SD=11 mm Hg ) , respectively . Orthostatic blood pressure changes were unassociated with age , race , sex , body mass , time since eating , symptoms , or other factors . According to multiple linear regression analysis , supine systolic pressure , chronic obstructive pulmonary disease ( COPD ) , and diabetes mellitus were associated with a decrease in systolic pressure on st and ing . Hypertension , antiarthritic drugs , and abnormal heartbeat were associated with an increase in systolic pressure on st and ing . For orthostatic diastolic pressure changes , supine diastolic pressure and COPD were associated with a decrease in diastolic pressure on st and ing . Congestive heart failure was associated with an increase in st and ing diastolic pressure . Using logistic regression analysis , only supine systolic pressure was associated with a greater than 20-mm Hg drop in systolic pressure ( n=53 , prevalence=13 % ) . Supine diastolic pressure and COPD were the only variables associated with a greater than 20-mm Hg drop in diastolic pressure ( n=16 , prevalence=4 % ) . These factors may help physicians in identifying older persons at risk for having orthostatic hypotension OBJECTIVES To investigate the relationships between uncontrolled and controlled hypertension , orthostatic hypotension ( OH ) , and falls in participants of the Maintenance of Balance , Independent Living , Intellect , and Zest in the Elderly of Boston Study ( N=722 , mean age 78.1 ) . DESIGN Prospect i ve population -based study . SETTING Community . PARTICIPANTS Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston .  MEASUREMENTS Blood pressure ( BP ) was measured at baseline in the supine position and after 1 and 3 minutes of st and ing .  Systolic OH ( SOH ) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon st and ing . Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications ( controlled if BP < 140/90 mmHg and uncontrolled if ≥ 140/90 mmHg ) . Falls data were prospect ively collected using monthly calendars . Fallers were defined as those with at least two falls within 1 year of follow-up . RESULTS OH was highest in participants with uncontrolled hypertension ; SOH at 1 minute was 19 % in participants with uncontrolled hypertension , 5 % in those with controlled hypertension , and 2 % in those without hypertension ( P ≤ .001 ) ) . Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls ( hazard ratio=2.5 , 95 % confidence interval = 1.3 - 5.0 ) than those with uncontrolled hypertension without OH . OH by itself was not associated with falls . CONCLUSION Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year . Hypertension control , with or without OH , is not associated with greater risk of falls in older community-dwelling adults This study was design ed to determine the efficacy and tolerability of increasing doses ofl-threo-dihydroxyphenylserine ( l-threo-DOPS ) in treating  symptomatic orthostatic hypotension associated with multiple system atrophy ( MSA ) and pure autonomic failure ( PAF ) . Following a one-week run-in , patients ( 26 MSA ; 6 PAF ) with symptomatic orthostatic hypotension  received increasing doses ofl-threo-DOPS ( 100 , 200 and 300 mg , twice daily ) in an open , dose-ranging study . Incremental dose adjustment ( after weeks two and four of outpatient treatment ) was based on clinical need until blood pressure ( BP ) , and symptoms improved . Final dosage was maintained for six weeks . Withl-threo-DOPS  , systolic BP decrease was reduced during orthostatic challenge ( −22±28 mm Hg reduction from a baseline decrease of 54.3±27.7 mm Hg , p=0.0001 , n=32 ; supine systolic BP at final visit was 118.9±28.2 mm Hg ) . By the end of the study , 25 patients ( 78 % ) improved , and in 14 patients ( 44 % ) orthostatic hypotension was no longer observed . Decreased orthostatic systolic BP decrease occurred in 22 % ( 7/32 ) , 24 % ( 6/25 ) and 61 % ( 11/18 ) of patients treated with 100 , 200 , and 300 mgl-threo-DOPS twice daily , respectively . An improvement occurred in symptoms associated with orthostatic hypotension , such as light-headedness , dizziness ( p=0.0125 ) , and blurred vision (p=0.0290).l-threo-DOPS was well tolerated , with the 2 serious adverse events reported being a possible complication of the disease under study , and with no reports of supine hypertension . I conclusion , l-threo-DOPS ( 100 , 200 , and 300 mg , twice daily ) was well tolerated . The dosage of 300 mg twice dailyl-threo-DOPS seemed to offer the most effective control of symptomatic orthostatic hypotension in MSA and PAF STUDY OBJECTIVES To evaluate whether the capillary refill test can correctly differentiate between hypovolemic and euvolemic emergency department patients . DESIGN A prospect i ve , nonr and omized , nonblinded time series . SETTING The orthostatic and hypotensive patients were seen in a university hospital ED with 44,000 visits per year . Blood donors were studied in the hospital 's blood donor center . TYPE OF PARTICIPANTS Thirty-two adult ED patients who presented with a history suggestive of hypovolemia and either abnormal orthostatic vital signs ( 19 ) or frank hypotension ( 13 ) , and 47 volunteer blood donors who ranged in age from 19 to 83 participated . INTERVENTIONS  Capillary refill was measured before rehydration in the ED subjects and , in the donor group , before and after a 450-mL blood donation . MEASUREMENTS Sensitivity , specificity , accuracy , and positive and negative predictive values were calculated . Analyses were stratified by age , sex , and study group . MAIN RESULTS For the blood donor group , mean capillary refill time before donation was 1.4 seconds and after donation was 1.1 seconds . Mean capillary refill time for the orthostatic group was 1.9 seconds and for the hypotensive group was 2.8 seconds . When scored with age-sex specific upper limits of normal , the sensitivity of capillary refill in identifying hypovolemic patients was 6 % for the 450-mL blood loss group , 26 % for the orthostatic group , and 46 % for the hypotensive group . The accuracy of capillary refill in a patient with a 50 % prior probability of hypovolemia is 64 % . Orthostatic vital signs were found to be more sensitive and specific than capillary refill in detecting the 450-mL blood loss . CONCLUSION Capillary refill does not appear to be a useful test for detecting mild-to-moderate hypovolemia in adults PURPOSE To investigate the efficacy and safety of midodrine for treatment of patients with orthostatic hypotension due to autonomic failure . PATIENTS Ninety-seven patients with orthostatic hypotension were r and omized in a 4-week , double-blinded , placebo-controlled study with a 1-week placebo run-in period . Patients ranged in age from 22 to 86 years ( mean : 61 years ) . METHODS After a 1-week run-in phase , either placebo or midodrine at a dose of 2.5 mg , 5 mg , or 10 mg was administered three times a day for 4 weeks . Both the placebo group and the 2.5-mg midodrine group received constant doses throughout the double-blind phase . The patients receiving 5 mg or 10 mg of midodrine were given doses that were increased at weekly intervals by 2.5-mg increments until the design ated dose was reached . Efficacy evaluations were based on an improvement at 1-hour postdose in st and ing systolic blood pressure and in symptoms of orthostatic hypotension ( syncope , dizziness/lightheadedness , weakness/fatigue , and low energy level ) . RESULTS Midodrine ( 10 mg ) increased st and ing systolic blood pressure by 22 mm Hg ( 28 % , p < 0.001 versus placebo ) . Midodrine improved ( p < 0.05 ) the following symptoms of orthostatic hypotension compared to placebo : dizziness/lightheadedness , weakness/fatigue , syncope , low energy level , impaired ability to st and , and feelings of depression . The overall side effects were mainly mild to moderate . One or more side effects were reported by 22 % of the placebo group compared with 27 % of the midodrine-treated group . Scalp pruritus/tingling , which was reported by 10 of 74 ( 13.5 % ) of the midodrine-treated patients , was most frequent . Other reported side effects included supine hypertension ( 8 % ) and feelings of urinary urgency ( 4 % ) . CONCLUSION We conclude that midodrine is an effective and well-tolerated treatment for moderate-to-severe orthostatic hypotension associated with autonomic failure A retrospective cohort design of Medicaid medical and pharmacy cl aims for 1996 through 2005 was employed for 14 171 children and adolescents prescribed an antidepressant medication and a r and om sample of 4500 children not treated with any class of psychotropic medication to compare the prevalence rates of cardiovascular and neurological adverse events . The treated cohort evinced a higher prevalence of cardiovascular events , orthostatic hypotension , seizures , insomnia , and headaches . In the treated cohort , patients were at a significantly higher risk for incident cardiovascular events when exposed to selective serotonin reuptake inhibitors and weight-inducing antidepressants , mood stabilizers , and antipsychotics .  Incident orthostatic hypotension was associated with weight-inducing antidepressants and mood stabilizers .  Incident seizures and extrapyramidal symptoms were unrelated to antidepressant or co-prescribed psychotropic medications , but both were significantly associated with comorbid central nervous system , organic brain/mental retardation , or preexisting cardiovascular or cerebrovascular conditions . Headaches and dizziness were significantly related to taking mood stabilizers BACKGROUND Orthostatic hypotension ( OH ) is traditionally defined as a decline in systolic or diastolic blood pressure of > 20 or > 10 mm Hg , respectively , after 1 or 3 minutes of upright posture . OH is common in the elderly , but has not been consistently demonstrated to be an independent risk factor for falls in nursing home residents . Previous studies have used the st and ard definition of OH in assessing fall risk . No study has sought to determine if the timing of postural changes in blood pressure adds prognostic value ; if changes in systolic , diastolic , or mean blood pressure are equivalent in predicting subsequent falls ; and what degree of decline in blood pressure has the best predictive value . OBJECTIVE We sought to define the timing and degree of orthostatic changes in blood pressure in a cohort of elderly nursing home residents during active st and ing and to explore the relationship to subsequent falls to test the hypothesis that orthostatic changes in blood pressure with noninvasive beat-to-beat technology would predict falls in nursing home residents better than the st and ard definition of OH . METHODS One hundred eleven elderly ( 88 + /- 7 years ) residents of a long-term care facility had measurement of orthostatic blood pressure changes during active st and ing for up to 3 minutes with a real-time continuous , noninvasive beat-to-beat blood pressure device .  Falls were determined prospect ively over a median follow-up period of 270 days ( range , 8 - 657 days ) . The degree and timing of declines in systolic , diastolic , or mean blood pressure and their association with subsequent falls was determined using a time-to-event analysis . RESULTS Forty-six subjects ( 41 % ) fell . The st and ard definition of OH was not predictive of subsequent falls ( hazard ratio 1.03 at 1 minute and 1.32 at 3 minutes , P = not significant ) . Other measures of orthostatic blood pressure changes were also not associated with a significant increase in risk for subsequent falls , including declines in blood pressure within the first minute of st and ing . CONCLUSION The st and ard definition of OH was not an independent predictor of falls in frail nursing home residents . A one-time measure for the presence of postural hypotension using beat-to-beat tonometry was not predictive of fall risk . The timing and degree of orthostatic changes in blood pressure does not significantly enhance risk prediction for falls Orthostatic hypotension , one of tricyclic antidepressant treatment 's side effects , is also a factor in limiting adequate antidepressant dosing . We tested in a double‐blind , crossover , placebo‐controlled study the effect of low doses ( 4 mg/t.i.d . ) of yohimbine in 12 patients with depression with ciomipramine‐induced orthostatic hypotension .  Yohimbine , a selective α2‐adrenoceptor antagonist , had a favorable effect in orthostatic hypotension and induced a significant increase in blood pressure . A pharmacodynamic and pharmacokinetic interaction between yohimbine and clomipramine or demethylclomipramine was discussed Background : The Middle East and North Africa ( MENA ) region registers some of the highest rates of hypovitaminosis D worldwide . Aim : We systematic ally review ed the prevalence of hypovitaminosis D , rickets and osteomalacia , their predictors and impact on major outcomes , in the region . Methods : Medline , Pubmed and Embase search engines , entering keywords and concepts , combined with individual countries of interest , were used . Search was limited years 2000–2012 ; and review articles were used for the period preceding year 2000 . Results : Rickets and osteomalacia still occur in this sunny region . Hypovitaminosis D prevails , with rates varying 30–90 % , considering a desirable serum 25 hydroxy-vitamin D [ 25(OH)D ] of 20 ng/ml . Advancing age , female gender , multi-parity , clothing style , season , socio-economic status and urban living are recognized predictors of hypovitaminosis D in adults . Prolonged breastfeeding without vitamin D supplementation and low dietary calcium intake are the recognized risk factors for rickets and hypovitaminosis D in children .. Associations with pain score and disease activity in rheumatologic disorders , viral load and interleukins in hepatitis C , BMI , lipids and insulin sensitivity , blood pressure , heart failure and mortality are described . Sun exposure in adults decreased prevalence of metabolic syndrome in one study . Few r and omized vitamin D trials revealed that the majority of mothers or children failed to achieve a desirable 25(OH)D level , even with doses by far exceeding current recommendations . A trial in adolescent girls reveals substantial bone and lean mass increments . Conclusion : Hypovitaminosis D is prevalent in MENA . The lack of population s based studies , gaps in studies in infants , pre-pubertal children and pregnant women , hinder the development of region specific guidelines and constitute a major obstacle to impact this chronic and most often sub clinical disease BACKGROUND The presence of orthostatic hypotension ( OH ) predicts all-cause mortality and incident cardiovascular disease . Whether or not OH is associated with the development of  heart failure ( HF )  remains unknown . METHODS In this Swedish population -based prospect i ve study ( the Malmö Preventive Project ) , the incidence of HF in relation to baseline OH , defined as decrease in systolic ( SBP ) ≥20 mm Hg and /or diastolic blood pressure ( DBP ) ≥10 mm Hg upon st and ing , was studied in 32,669 middle-aged individuals ( 68.2 % men ; mean age , 45.6 ± 7.4 years ) over a mean follow-up period of 24 years . RESULTS At baseline , 1,991 ( 6.1 % ) participants were found to have OH . During follow-up , 1,293 persons ( 4.0 % , mean age at presentation : 67.9 ± 7.9 years ) were hospitalized for HF , 912 ( 2.8 % ) of whom without previous or concurrent myocardial infa rct ion ( MI ) ( " nonischemic HF " ) . Among those who had OH , the corresponding numbers were 6.5 % ( n = 129 ) and 4.6 % ( n = 92 ) , respectively . In multivariable Cox proportional hazard models , taking conventional HF risk factors into account , OH was associated with both all-cause and " nonischemic " HF events ( hazard ratio ( HR ) : 1.22 , 1.01 - 1.46 , and 1.31 , 1.05 - 1.63 , respectively ) . The association between OH and HF was more pronounced in younger ( aged < 45 years ) than older individuals ( 2.05 ; 1.31 - 3.22 vs. 1.12 , 0.92 - 1.38 , respectively , P < 0.001 for interaction between age and OH on incident HF ) . CONCLUSIONS The presence of OH among middle-aged adults  predicts long-term incidence of HF hospitalizations independently of conventional risk factors . Our findings add to the available data indicating that OH is a potential independent cardiovascular risk factor , especially with regard to younger individuals and nonischemic HF Abstract .Falls are a common hazard in the elderly . Orthostatic hypotension ( OH ) is prevalent in older patients and contributes to the high incidence of falls . Our aim was to test whether a home-based resistance-training program ( HBRT ) using elastic resistance b and s could safely and effectively increase muscle strength and functional ability , and attenuate the orthostatic fall in blood pressure .  Eight subjects ( > 60 yrs ) underwent orthostatic provocations ; muscle strength testing ( isometric and dynamic ) , and a functional test of gait and mobility ( Timed Up & Go ) , at baseline and following 8 weeks of training . Ten exercises were assigned and customized to each participant . At 8 weeks , significant increases occurred in dynamic strength in the chest press ( p = 0.017 ) , quadriceps extension ( p = 0.017 ) , and leg press ( p = 0.025 ) ; no significant differences occurred in isometric strength or in blood pressures . Functional mobility increased in 7 of 8 subjects . There were no falls during the investigation period . Conclusion A HBRT program using elastic resistance b and s effectively increases dynamic muscle strength in elderly individuals with OH . Although no changes occurred in orthostatic blood pressures , which could be attributed to the limited length of the program , this therapy may be recognized as a safe method to improve strength , functional ability , and promote physical activity – variables that can reduce the incidence of falls and enhance the quality of life in this population PURPOSE We determined the mechanism of adverse events associated with alpha1-blockers for treating benign prostatic hyperplasia ( BPH ) . MATERIAL S AND METHODS We r and omized 1,229 men with clinical BPH at 31 Veterans Affairs medical centers into equal treatment groups , including those who received placebo , terazosin , finasteride , and combined terazosin and finasteride therapy , respectively . Adverse events were captured at all study visits during our 1-year study . Our current review of adverse events is limited to patients r and omized to the placebo and terazosin groups . We compared the incidence of orthostatic blood pressure change , postural symptoms and orthostatic hypotension in men who were normotensive and hypertensive at baseline , respectively . We also determined the association of changes in systolic blood pressure with the incidence of treatment related adverse events . RESULTS The treatment related rates of dizziness , asthenia , postural hypotension and syncope were 19 % , 6 % , 6 % and 1 % , respectively . Of these adverse events only postural hypotension was associated with orthostatic blood pressure changes . The incidence of asthenia , dizziness and postural hypotension was not significantly greater in patients with a systolic blood pressure decrease of 5 or greater and less than 5 mm . Hg , respectively . CONCLUSIONS Dizziness and asthenia are not associated with changes in blood pressure , suggesting that these treatment related adverse events associated with alpha1-blockers are not related to vascular events . Design ing a subtype selective alpha1 antagonist that has less effect on blood pressure may not result in marked improvement in tolerability over commercially available alpha1-blockers OBJECTIVE To evaluate the efficacy of a 10-mg dose of midodrine 3 times per day in improving blood pressure ( BP ) and ameliorating symptoms of orthostatic hypotension in patients with neurogenic orthostatic hypotension .  Midodrine hydrochloride , an alpha-agonist , could improve orthostatic BP by increasing vasomotor and venomotor tone . DESIGN / METHODS A total of 171 patients with orthostatic hypotension participated in a multicenter , r and omized , placebo-controlled study . They were r and omized to a 10-mg dose of midodrine or placebo 3 times per day in a 6-week study , comprising single-blind run-in ( at week 1 ) and washout at weeks 5 and 6 , with an intervening double-blind period ( weeks 2 to 4 ) . SETTING Twenty-five centers , with most patients evaluated in referral centers . MAIN OUTCOME MEASURES The primary end points were improvement in st and ing systolic BP , symptoms of lightheadedness , and a global symptom relief score ( by the investigator and patient separately ) . RESULTS Nine patients were not evaluable because of noncompliance or taking concomitant vasoactive medications ( 3 in the midodrine group , 6 in the placebo group ) . In the evaluable patients , midodrine result ed in improvements in st and ing systolic BP at all time points ( P<.001 at visits 2 , 3 , 4 , and 5 ) , in reported symptoms by the end of the second week of treatment ( P=.001 ) , and in the global symptom relief score rated by both the patient ( P=.03 ) and the investigator ( P<.001 ) . There was no effect by center , severity of orthostatic hypotension , use of fludrocortisone or compression garments , or diagnosis . The main adverse effects were those of pilomotor reactions , urinary retention , and supine hypertension . CONCLUSIONS Midodrine is efficacious and safe in the treatment of neurogenic orthostatic hypotension There has been a long-st and ing concern over the cardiovascular effects of tricyclic antidepressants , particularly in patients with preexisiting cardiac disease . Recent studies have demonstrated that imipramine causes no deleterious effect on ejection fraction as determined by radionuclide angiography in patients with impaired left ventricular function ( LVF ) . However , the high rate of severe orthostatic hypotension induced by imipramine makes use of the drug problematic in these patients . Bupropion is a new antidepressant of the aminoketone class which is structurally unrelated to the tricyclics and which is relatively free of cardiac side effects in healthy depressed patients . We compared imipramine and bupropion in 10 depressed patients with impaired LVF in a r and om , double-blind crossover study . Neither imipramine nor bupropion adversely affected ejection fraction or other indices of LVF . However , as previously reported , severe orthostatic hypotension requiring discontinuation of drug developed in 50 % of patients on imipramine . This difficulty did not occur with bupropion . From a cardiac perspective , bupropion may offer a safe alternative to imipramine in depressed patients with congestive heart failure OBJECTIVES We investigated the prognostic significance of orthostatic hypotension on the risk of  myocardial infa rct ion ( MI ) amongst the elderly . DESIGN Prospect i ve population -based study . SETTING Home-dwelling population . SUBJECTS Orthostatic testing was performed between 8 a.m. and 2 p.m. , irrespective of having had meals , on 792 persons , representing 82 % of all home-dwelling persons aged > or = 70 years living in five municipalities around the city of Oulu . MAIN OUTCOME MEASURES Occurrence of cases of MI were recorded during mean 3.58 ( SD 1.09 ) years follow-up period , from national mortality statistics and local hospital discharge registers . RESULTS Ninety cases of MI , of which 40 were fatal after initial hospitalization , occurred during the follow-up period . Orthostatic diastolic blood pressure ( BP ) drop 1 min after st and ing up was associated with subsequent MI , but systolic BP reactions had no predictive value . According to the Cox regression model , the strongest predictor of the occurrence of subsequent MI was found in regard to > or = 8 mmHg drop in diastolic BP 1 min after st and ing up ; adjusted for history of MI , diabetes mellitus , chest pain , use of calcium antagonist , beta-blocker , nitrate and diuretic medication , hazard ratio of MI being 2.00 ( 1.11 - 3.59 ) . CONCLUSIONS Orthostatic testing offers a novel means to assess the risk of MI amongst elderly persons .  Diastolic BP drop immediately after st and ing up identifies elderly subjects at a high risk of subsequent MI
CONCLUSION Our meta- analysis highlights that hypovitaminosis D is associated with orthostatic hypotension , independent of potential confounders .
OBJECTIVES Orthostatic hypotension is a common condition among older adults and is associated with a range of deleterious outcomes .
Recently , interest has developed in hypovitaminosis D ( defined as low 25 hydroxiyvitamin D levels ) as a potential risk factor for orthostatic hypotension .
We conducted a systematic review and meta- analysis examining the association of orthostatic hypotension between study participants with and without hypovitaminosis D , including the adjustment of potential confounders ( age , sex , BMI , renal function , comorbidities , seasonality , use of antihypertensive medications , and supplementation with cholecalciferol ) .