Orthostatic hypotension: often a neglected problem in community dwelling older people

Orthostatic hypotension (OH) prevalence seems to increase with age being 20% in community dwelling people 65 year old or older and 30% in those major than 75 years of age (1). Even if in healthy elderly this disorder is less prevalent (1.25%) (2), aging per se is characterized by system dysfunctions promoting OH. Common co-morbidities as hypertension (particularly the reverse dipping pattern), diabetes, malnutrition, vascular encephalopathy, pernicious anemia and Parkinson disease further increase the risk (3). Moreover, age-related changes in drugs’ pharmacokinetic and pharmacodynamics and polypharmacy can enhance medicament effects (4) causing hypotension OH diagnosis is challenging: symptoms are non-specific (5) and can overlap with other diseases or drugs side effects (6, 7). What is more, asymptomatic OH is most common and older people frequently remain unaware of this condition until an additional stress unmasks it. In 2011 the OH diagnostic criteria were updated (8). MATERIALI E METODI: We performed a retrospective analysis of patients’ medical records afferent to the geriatric ambulatory service in a tertiary hospital in Milan during the years 2011-2014 to evaluate the prevalence of diagnosed OH in clinical practice; we compared characteristics of people diagnosed with OH versus other patients to assess if there was any predisposing factor for OH. The variables analysed were: age, gender, Mini Mental State Examination (MMSE), Activity of Daily Living (ADL), Instrumental Activity of Daily Living (IADL), Performance Oriented Mobility Assessment (POMA), symptoms possibly related to OH, comorbidities associated with OH, drugs inducing OH and the median number of medicaments assumed. People not diagnosed with OH were further divided in symptomatic (at least one symptom related to OH) and asymptomatic ones. According to Shapiro Wilk test variables were mainly not normally distributed thus we used non-\parametric tests for statistical analyses. Categorical variables were compared with Fisher exact test and quantitative variables with Kruskal-Wallis test when comparing three groups and Mann-Whitney test when comparing two groups. RISULTATI: Figure  1 illustrates the main characteristics of the study population. Among the 465 records analysed, only 14 people (3%) were diagnosed with OH according to the 2011 criteria. In the OH group median age was 83.5 years and only 4 people were males. Cognitive function was on average good, autonomy preserved and risk of falling moderate. The median number of assumed drugs was 5 and among the medicaments possibly related to OH antihypertensive were the ones most frequently prescribed (57.1%) followed by sympatholytics (42.9%), diuretics (35.7%), vasodilators (28.6%) and antidepressant in 5 (35.7%). Only one patient (7.1%) took antiparkinson drugs. Half of the OH sample presented at least one symptom possibly related to OH: confusion (28.6%), weakness (21.4%) and dizziness (21.4%) were the most prevalent ones. Considering comorbidities usually associated with OH hypertension (42.9%), multi-infartual encephalopathy (38.5%) and anemia (36.4%) were more frequent than bradyarrhythmia, diabetes, chronic kidney disease and neoplasm (14.3% each). Among the patients not diagnosed with OH: 164 people were symptomatic and 287 asymptomatic. Symptomatic patients displayed more frequently potus, hypertension and a worse me dian score at POMA than asymptomatic ones (Fig. 1). When comparing the OH group with the not OH group fluid restriction and sympatholytic drug use were more frequent in the first one (Fig. 1). CONCLUSIONI: Considering the low prevalence of OH in our series (3%) respect to what reported in literature (30%) we can suppose that this diagnosis was frequently missed among the patients of our study. Due to the small sample we can’t speculate if the more elevated prevalence of fluid restriction and sympatholyc drug use in the OH group could be predictors for OH diagnosis. It is true that the prevalence of OH in older people could be unrelated to symptoms. However, in the symptomatic group we detected a more elevated prevalence of potus, hypertension and risk of developing falls; these factors could potentially alert the physicians to seek for OH. Early detection of OH could avoid adverse and expensive consequences. Unfortunately, the presence of multiple co-morbid conditions and the non-specificity of signs and symptoms make OH disclosure very challenging. Therefore performing a routine screening, non-invasive and not time consuming, could avoid many missed diagnosis. The advantage is even greater considering that the treatment mainly consists in educational measures without side effects and in medication review which has the additional advantage of avoiding a medication cascade in over treated olderpeople. Further studies are needed to evaluate the true impact of adequate OH diagnosis on OH outcomes in older people.