Orthostatic hypotension in Parkinson disease

ObjectiveTo determine the frequency, evolution, and associated features of orthostatic hypotension (OH) over 7 years of prospective follow-up in a population-based, initially drug-naive Parkinson disease (PD) cohort.MethodsWe performed repeated lying and standing blood pressure measurements in 185 patients with newly diagnosed PD and 172 matched normal controls to determine the occurrence of (1) OH using consensus-based criteria and (2) clinically significant OH (mean arterial pressure in standing position ≤75 mm Hg). We applied generalized estimating equations models for correlated data to investigate associated features of these 2 outcomes in patients with PD.ResultsOH was more common in patients with PD than controls at all visits, with the relative risk increasing from 3.0 (95% confidence interval [CI] 1.6–5.8; p < 0.001) at baseline to 4.9 (95% CI 2.4–10.1; p < 0.001) after 7 years. Despite a high cumulative prevalence of OH (65.4%) and clinically significant OH (29.2%), use of antihypotensive drugs was very rare (0.5%). OH was independently associated with older age (odds ratio [OR] 1.06 per year; 95% CI 1.03–1.10), lower Mini-Mental State Examination score (OR 0.91 [0.85–0.97] per unit), and longer follow-up time (OR 1.12 [1.03–1.23] per year). Clinically significant OH was associated with the same characteristics, in addition to higher levodopa equivalent dosage (OR 1.16 [1.07–1.25] per 100 mg).ConclusionsIn this population-based study, we found OH to be a very frequent but undertreated complication in early PD, with associations to both disease-specific symptoms and drug treatment. Our findings suggest that clinicians should more actively assess and manage OH abnormalities in PD.

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Changes in insomnia subtypes in early Parkinson disease

Neurology ◽

10.1212/wnl.0000000000003540 ◽

2016 ◽

Vol 88 (4) ◽

pp. 352-358 ◽

Cited By ~ 16

Author(s):

Lena K. Tholfsen ◽

Jan P. Larsen ◽

Jörn Schulz ◽

Ole-Bjørn Tysnes ◽

Michaela D. Gjerstad

Keyword(s):

Parkinson Disease ◽

Rating Scale ◽

Estimating Equation ◽

Population Based ◽

Sleep Maintenance ◽

Statistical Measures ◽

Number Of Patients ◽

Scale Scores ◽

Drug Naïve

Objective:To examine the development of factors associated with insomnia in a cohort of originally drug-naive patients with incident Parkinson disease (PD) during the first 5 years after diagnosis.Methods:One hundred eighty-two drug-naive patients with PD derived from a population-based incident cohort and 202 control participants were assessed for insomnia before treatment initiation and were repeatedly examined after 1, 3, and 5 years. Insomnia was diagnosed according to the Stavanger Sleepiness Questionnaire. The Parkinson's Disease Sleep Scale was used to differentiate sleep initiation problems from problems of sleep maintenance. Generalized estimating equation models were applied for statistical measures.Results:The prevalence of insomnia in general was not higher in patients with PD compared to controls at the 5-year follow-up. There were changes in the prevalence of the different insomnia subtypes over the 5-year follow-up. The prevalence of solitary problems in sleep maintenance increased from 31% (n = 18) in the drug-naive patients at baseline to 49% (n = 29) after 1 year and were associated with the use of dopamine agonists and higher Montgomery-Åsberg Depression Rating Scale scores. The prevalence of solitary sleep initiation problems decreased continuously from 21% (n = 12) at baseline to 7.4% (n = 4) after 5 years; these were associated with less daytime sleepiness.Conclusions:The prevalence rates of the different insomnia subtypes changed notably in patients with early PD. The frequency of sleep maintenance problems increased, and these problems were associated with dopamine agonist use and depressive symptoms, while the total number of patients with insomnia remained stable. Our findings reflect the need for early individual assessments of insomnia subtypes and raise the possibility of intervention to reduce these symptoms in patients with early PD.

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Long-term trajectories of decline in cognition and daily functioning before and after stroke

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2021-326043 ◽

2021 ◽

pp. jnnp-2021-326043

Author(s):

Alis Heshmatollah ◽

Lisanne J. Dommershuijsen ◽

Lana Fani ◽

Peter J. Koudstaal ◽

M. Arfan Ikram ◽

...

Keyword(s):

Continuous Monitoring ◽

Mini Mental State Examination ◽

Functional Decline ◽

Population Based ◽

Daily Functioning ◽

Linear Mixed Effects ◽

Before And After ◽

State Examination

ObjectiveAlthough knowledge on poststroke cognitive and functional decline is increasing, little is known about the possible decline of these functions before stroke. We determined the long-term trajectories of cognition and daily functioning before and after stroke.MethodsBetween 1990 and 2016, we repeatedly assessed cognition (Mini-Mental State Examination (MMSE), 15-Word Learning, Letter–Digit Substitution, Stroop, Verbal Fluency, Purdue Pegboard) and basic and instrumental activities of daily living (BADL and IADL) in 14 712 participants within the population-based Rotterdam Study. Incident stroke was assessed through continuous monitoring of medical records until 2018. We matched participants with incident stroke to stroke-free participants (1:3) based on sex and birth year. Trajectories of cognition and daily functioning of patients who had a stroke 10 years before and 10 years after stroke and the corresponding trajectories of stroke-free individuals were constructed using adjusted linear mixed effects models.ResultsDuring a mean follow-up of 12.5±6.8 years, a total of 1662 participants suffered a first-ever stroke. Patients who had a stroke deviated from stroke-free controls up to 10 years before stroke diagnosis in cognition and daily functioning. Significant deviations before stroke were seen in scores of MMSE (6.4 years), Stroop (5.7 years), Purdue Pegboard (3.8 years) and BADL and IADL (2.2 and 3.0 years, respectively).ConclusionPatients who had a stroke have steeper declines in cognition and daily functioning up to 10 years before their first-ever stroke compared with stroke-free individuals. Our findings suggest that accumulating intracerebral pathology already has a clinical impact before stroke.

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Abstract P179: Comparison of Earlier versus Later Orthostatic Hypotension Assessment Times in Middle-Age Adults of the Atherosclerosis Risk in Communities Study (ARIC)

Circulation ◽

10.1161/circ.135.suppl_1.p179 ◽

2017 ◽

Vol 135 (suppl_1) ◽

Author(s):

Stephen P Juraschek ◽

Natalie Daya ◽

Andreea M Rawlings ◽

Lawrence J Appel ◽

Edgar R Miller ◽

...

Keyword(s):

Orthostatic Hypotension ◽

Standing Position ◽

Adverse Outcomes ◽

Cox Models ◽

Atherosclerosis Risk In Communities ◽

Adverse Health Outcomes ◽

History Of ◽

Risk Of Fall

Background: Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. Hypothesis: Measurements performed immediately after standing will be as informative as measurements performed closer to 3 minutes after standing with regards to symptoms of dizziness or risk of adverse outcomes. Methods: OH, defined as a drop in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, was measured up to five times at 25 seconds intervals in middle-aged (range 44 to 66 years) ARIC participants (1987-1989). Associations between each measurement and history of dizziness upon standing were examined via logistic regression. We used Cox models to examine the association between each of five measurements with risk of fall, fracture, syncope, and all-cause mortality over a median follow-up of 23 years. Results: In 11,449 participants (mean age 54 years, 54% women, 26% black) 10% reported a history of dizziness upon standing. OH assessed at measurement 1 (performed at a mean of 28 seconds after standing) was associated with risk of fall ( P = 0.03), fracture ( P = 0.05), syncope ( P <0.001), and mortality ( P < 0.001) ( Table ). Furthermore, measurement 1 was the only measurement associated with higher odds of dizziness upon standing (OR: 1.5; P = 0.001). Measurement 2 (performed on average 53 seconds after standing) was associated with all long-term outcomes. Measurements 4 and 5 (mean 100 and 116 seconds after standing) were generally less informative with regards to prospective outcomes than earlier measurements and were not statistically associated with history of dizziness. Conclusions: OH measurements obtained, on average, within the first 30 seconds of standing were predictive of long-term adverse health outcomes and were the most strongly related to symptoms of dizziness compared to later measurements. These findings suggest that BP measurements for determining orthostatic hypotension should be performed immediately after standing.

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Orthostatic intolerance: orthostatic hypotension and postural orthostatic tachycardia syndrome

ESC CardioMed ◽

10.1093/med/9780198784906.003.0472_update_001 ◽

2018 ◽

pp. 2032-2037

Author(s):

Artur Fedorowski

Keyword(s):

Orthostatic Hypotension ◽

Orthostatic Intolerance ◽

Wide Spectrum ◽

Standing Position ◽

Diagnostic Methods ◽

Postural Orthostatic Tachycardia Syndrome ◽

Unexplained Syncope ◽

Clinical Variants ◽

Age Range ◽

Specific Symptoms

The impairment of adaptive mechanisms during orthostatic challenge may evoke orthostatic intolerance, a heterogeneous condition, in which the standing position elicits a fall in blood pressure and/or excessive tachycardia, accompanied by a wide spectrum of subjective symptoms such as dizziness, discomfort, nausea, and palpitations. Apart from chronic and potentially debilitating symptoms, orthostatic intolerance may occasionally lead to sudden loss of consciousness and fall injuries. Consequently, orthostatic intolerance should be considered as a possible cause of unexplained syncope. Two main forms of orthostatic intolerance are orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS). Clinical variants of OH include initial, classical, and delayed forms. The prevalence of OH increases with age, ranging from less than 5% under 40 years to about 20% above 70 years of age, and is higher in chronic diseases, such as hypertension and diabetes, reaching above 35% in Parkinson’s disease and advanced kidney failure. The presence of OH is associated with a higher mortality and an increased incidence of cardiovascular disease, with the majority of patients being asymptomatic in normal conditions. In contrast, POTS affects predominantly young women (70–80%) within an age range of 15–40 years and is usually accompanied by non-specific symptoms: deconditioning, headache, cognitive impairment, and gastrointestinal dysfunction. Management of orthostatic intolerance includes both non-pharmacological and pharmacological methods with limited efficacy in the severe cases. Empirical treatment with vasoactive and volume expanding drugs for OH and POTS, and rhythm controlling therapy for POTS are recommended. Future studies on syndromes of orthostatic intolerance should focus on mechanisms leading to OH and POTS, novel diagnostic methods, and more effective therapeutic options.

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Orthostatic intolerance: orthostatic hypotension and postural orthostatic tachycardia syndrome

ESC CardioMed ◽

10.1093/med/9780198784906.003.0472 ◽

2018 ◽

pp. 2032-2037

Author(s):

Artur Fedorowski

Keyword(s):

Orthostatic Hypotension ◽

Orthostatic Intolerance ◽

Wide Spectrum ◽

Standing Position ◽

Diagnostic Methods ◽

Postural Orthostatic Tachycardia Syndrome ◽

Unexplained Syncope ◽

Clinical Variants ◽

Age Range ◽

Specific Symptoms

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Associations of orthostatic hypotension with dementia in older adults: A 12‐year follow‐up population‐based study

Alzheimer s & Dementia ◽

10.1002/alz.046327 ◽

2020 ◽

Vol 16 (S10) ◽

Author(s):

Xin Xia ◽

Rui Wang ◽

Davide Liborio Vetrano ◽

Giulia Grande ◽

Erika J Laukka ◽

...

Keyword(s):

Older Adults ◽

Orthostatic Hypotension ◽

Population Based ◽

Population Based Study

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Venlafaxine-Induced Orthostatic Hypotension in a Geriatric Patient

Case Reports in Psychiatry ◽

10.1155/2013/761567 ◽

2013 ◽

Vol 2013 ◽

pp. 1-3

Author(s):

Vidyashree Chikkaramanjegowda ◽

Jose de Leon

Keyword(s):

Adverse Drug Reaction ◽

Drug Reaction ◽

Orthostatic Hypotension ◽

Extended Release ◽

Geriatric Patients ◽

Standing Position ◽

Low Doses ◽

History Of ◽

Clinically Significant ◽

Caucasian Female

Venlafaxine is not usually associated with risk of orthostatic hypotension. A 65-year-old US Caucasian female taking 225 mg/day of venlafaxine extended-release developed symptomatic orthostatic hypotension. The systolic and diastolic blood pressure dropped by 25 and 18 mm Hg, respectively, from supine position to standing position within 3 minutes. The patient was otherwise healthy and the orthostatic hypotension resolved with venlafaxine discontinuation. This was a probable venlafaxine adverse drug reaction according to the Naranjo scale. This case contributes to the scarce literature that indicates that clinicians need to be aware that occasionally venlafaxine can induce clinically significant orthostatic hypotension, particularly in geriatric patients. Our patient did not have orthostatic hypotension when she was taking venlafaxine at 60 years of age in higher venlafaxine doses (300 mg/day) but developed this adverse drug reaction when venlafaxine was restarted at the geriatric age. This case indicates that a history of prior tolerance to venlafaxine does not guarantee tolerance after 65 years of age. If a clinician decides to use venlafaxine in geriatric patients, the clinician should warn the patient about the risk of orthostatic hypotension and consider very slow titration and low doses.

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Delayed orthostatic hypotension in Parkinson’s disease

npj Parkinson s Disease ◽

10.1038/s41531-021-00181-y ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Sang-Won Yoo ◽

Joong-Seok Kim ◽

Ji-Yeon Yoo ◽

Eunkyeong Yun ◽

Uicheul Yoon ◽

...

Keyword(s):

Parkinson’S Disease ◽

Parkinson's Disease ◽

Orthostatic Hypotension ◽

Disease Severity ◽

Cortical Thickness ◽

Early Stage ◽

Brain Magnetic Resonance Imaging ◽

Clinical Scales ◽

Drug Naïve

AbstractOrthostatic hypotension (OH) is relatively common in the early stage of Parkinson’s disease (PD). It is divided into delayed OH and classical OH. Classical OH in PD has been investigated widely, however, the clinical implications of delayed OH in PD have seldom been studied. The purpose of this study is to characterize delayed OH in PD. A total of 285 patients with early drug-naïve PD were enrolled and divided into three groups according to orthostatic change: no-OH, delayed OH, and classical OH. The disease severity in terms of motor, non-motor, and cognitive functions was assessed. The cortical thickness of 82 patients was analyzed with brain magnetic resonance imaging. The differences among groups and linear tendency in the order of no-OH, delayed OH, and classical OH were investigated. Seventy-seven patients were re-evaluated. Initial and follow-up evaluations were explored to discern any temporal effects of orthostasis on disease severity. Sixty-four (22.5%) patients were defined as having delayed OH and 117 (41.1%) had classical OH. Between-group comparisons revealed that classical OH had the worst outcomes in motor, non-motor, cognitive, and cortical thickness, compared to the other groups. No-OH and delayed OH did not differ significantly. Linear trends across the pre-ordered OH subtypes found that clinical parameters worsened along with the orthostatic challenge. Clinical scales deteriorated and the linear gradient was maintained during the follow-up period. This study suggests that delayed OH is a mild form of classical OH in PD. PD with delayed OH has milder disease severity and progression.

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B-type natriuretic peptide for prediction of incident clinically significant abdominal aortic aneurysm: A population-based prospective study

Vascular Medicine ◽

10.1177/1358863x17745150 ◽

2018 ◽

Vol 23 (1) ◽

pp. 46-51 ◽

Cited By ~ 3

Author(s):

Stefan Acosta ◽

Anders Gottsäter ◽

Gunnar Engström ◽

Olle Melander ◽

Moncef Zarrouk ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Natriuretic Peptide ◽

Population Based ◽

Plasma Biomarker ◽

Reactive Protein ◽

Abdominal Aortic ◽

Clinically Significant ◽

Prospective Longitudinal

Pathogenesis of abdominal aortic aneurysm (AAA) is unclear. The aim of this study was to evaluate inflammatory and hemodynamic plasma biomarkers as predictors for AAA in the prospective longitudinal cohort of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer Study ( n=5551; 1991–94). C-reactive protein, cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional pro-atrial natriuretic peptide (MR-proANP) and conventional risk factors at baseline were measured in patients with incident AAA during follow-up and compared to individuals without a diagnosis of AAA. Subjects were followed until 31 December 2013. Multivariable analyses were expressed in terms of hazard ratios (HR) per 1 standard deviation increment of each respective log-transformed plasma biomarker in the Cox proportional hazard models. Mean follow-up time was 20.7 years. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry and AAA was diagnosed on average 14 years later. Adjusting for age, sex, smoking, body mass index, hypertension and diabetes mellitus, N-BNP (HR 1.29; 95% CI 1.03–1.62), but not MR-proANP (HR 1.20; 95% CI 0.95–1.50), was independently associated with incident AAA. In conclusion, the plasma biomarker N-BNP was associated with future development of AAA, which implies that this marker is a sensitive indicator of early subclinical cardiovascular disease.

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