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Hypotensive Drugs and Orthostatic Hypotension–Related Syncopal Falls in Older Adults With Dementia
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVES
To determine whether hypotensive drugs may play a pivotal role in inducing orthostatic hypotension (OH)-related syncope.
DESIGN
Prospective, observational, multicenter study.
SETTING
Acute care wards, syncope units, and centers for the diagnosis of dementia.
PARTICIPANTS
Individuals aged 65 and older with a diagnosis of dementia and 1 or more episodes of transient loss of consciousness of a suspected syncopal nature or unexplained falls during the previous 3 months MEASUREMENTS: Blood pressure was measured in the supine position and in the orthostatic position after 1 and 3 minutes. OH was defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. Univariate and multivariate analyses were used to evaluate associations between hypotensive drugs and their combinations with OH-related syncope.
RESULTS
The mean age of the study population (n=522; women, n=324) was 83.5±6.1, and the most frequent comorbidity was arterial hypertension (74.5%); 324 (67.8%) participants had had a syncopal fall and 168 (32.2%) a nonsyncopal fall. The mean number of hypotensive drugs administered (2.9±3.1) did not differ between the two groups. Syncopal falls was OH-related in 170 participants (48.0%). OH-related syncopal falls were more frequent in participants receiving nitrates (15.3% vs 9.8%, p=.06), alpha-blockers (16.5% vs 9.8%, p=.04), or combinations of angiotensin-converting enzyme inhibitors (ACE-Is) and diuretics (20.6% vs 13.0%, p=.04), alpha-blockers and diuretics (8.2% vs 3.3%, p=0.036), and ACE-Is and nitrates (8.2% vs 3.3%, p=.10). Multivariate analysis confirmed a greater risk of OH-related syncopal fall for nitrates (relative risk (RR)=1.77), combinations of ACE-Is and diuretics (RR=1.66), and combinations of ACE-Is and nitrates (RR=2.32).
CONCLUSION
In older adults with dementia, OH-related syncopal falls are significantly related to treatment with nitrates, combinations of ACE-Is and diuretics, and combinations of ACE-Is and nitrates.
Additional Info
Hypotensive Drugs and Syncope Due to Orthostatic Hypotension in Older Adults with Dementia (Syncope and Dementia Study)
J Am Geriatr Soc 2018 Jun 13;[EPub Ahead of Print], G Testa, A Ceccofiglio, C Mussi, G Bellelli, F Nicosia, M Bo, D Riccio, F Curcio, AM Martone, G Noro, F Landi, A Ungar, P AbeteFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This study compared 522 Italian women ≥65 years of age (average, 83 years) with a diagnosis of dementia who had a syncopal episode (n = 324; 67.8%) with those who had an unexplained fall (n = 168; 32.2%) in the previous 3 months. Syncopal falls were related to orthostatic hypotension in 170 participants (48.0%) and occurred more frequently in patients receiving nitrates, alpha blockers, and combinations of diuretics with either ACE inhibitors or alpha blockers. Multivariate analysis confirmed greater risk with nitrates (RR, 1.77), combinations of ACE inhibitors and diuretics (RR, 1.66), and combinations of ACE inhibitors and nitrates (RR, 2.32).
Patients with worse dementia had significantly more falls and patients with better cognition had more syncopal episodes. Patients with a pacemaker had syncopal falls but no other falls. ACE inhibitors alone were not associated with a difference in risk between the groups, but the combinations with diuretics or nitrates were significantly associated, as were combinations of alpha blockers and diuretics. There was no comparison with non-fallers.
The definition of syncope was a decrease of 20 mm Hg or more in systolic blood pressure and 10 mm Hg or more in diastolic blood pressure measured at 1 and 3 minutes of standing, within 72 hours of the last episode of fall or syncope. This definition may have missed many patients with orthostasis, as the recent TILDA study measured blood pressure continually and showed that the blood pressure nadir occurs at 15 seconds after standing. TILDA showed a correlation with orthostatic hypotension and falls in 4127 cognitively intact Irish adults ≥50 years of age. A recent analysis of the SPRINT trial, where orthostatic blood pressure was also measured after the 1-minute interval in cognitively intact patients, showed no correlation with falls in the more tightly controlled group.
In this study, ACE inhibitors, ARBs, and calcium channel blockers were not associated with an increased risk of syncope, and the MOBILIZE study showed a lower risk of falls associated with these three classes of blood pressure meds.1 Medications that have been shown to cause orthostatic hypotension—alpha blockers, nitrates, and diuretics and their combinations—were associated with syncope. We need to treat our older adults’ hypertension aggressively to prevent strokes and mortality, but it seems that the choice of blood pressure meds matters. Evidence is mounting that we should use ACE inhibitors, ARBs, and calcium channel blockers, and, if possible, avoid alpha blockers, nitrates, and diuretics.
The authors of this study, as in the TILDA and SPRINT trials, did not mention the rates of dehydration, as that may be significantly contributing to falls and syncope. And diuretics may be contributing to dehydration. We can make sure our patients have adequate fluid intake of ≥2 liters. As explained previously, older adults need more fluid intake, and most do not adequately sense thirst. Limiting diuretic use to CHF exacerbation only and looking for causes of edema in the absence of pulmonary edema, such as obstructive sleep apnea, allows us to decrease use of diuretics.
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