When Is The Most Opportune Time to Assess Older Patients For Orthostatic Hypotension?

In this video, Aldis H. Petriceks, BA, discusses his team's study, which set out to determine the optimal timepoints for assessing orthostatic hypotension in older adults, as well as the association between orthostatic hypotension and its impact on fall risk on this patient population. Mr. Petriceks discusses the implications of his team's research, the main takeaways from their research results, and the next steps for this type of research.

Additional Resource: Petriceks AH, Appel LJ, Miller ER 3rd, et al. Timing of orthostatic hypotension and its relationship with falls in older adults. J Am Geriatr Soc. 2023;71(12):3711-3720. doi:10.1111/jgs.18573

TRANSCRIPT:

Aldis Petriceks, BA: My name is Aldis Petriceks. I am currently a fourth-year medical student at Harvard Medical School. 

Consultant360: What prompted this study?

Mr. Petriceks: I think there were several strands of it. You know it was, it was originally the study is a secondary analysis originally of a larger randomized control trial. The sturdy trial, which was kind of evaluating the, the effects on fall risk of different vitamin D doses in older adults. But you know, from that randomized control trial, there was a lot of kind of auxiliary data to, to analyze. And so part of this trial, there had been a whole kind of blood pressure assessment component in which, you know, throughout the, the kind of duration of the trial during study visits patients had went through kind of one, if two or both orthostatic blood pressure assessments. And, you know, the idea was that we already had a lot of data about, you know, fall risk because we had followed these people and were able to track their falls over time.

But we also had this, this blood pressure data which, you know, not only track blood pressure, but was, was orthostatic. And so we were able to kind of look at the relationship between orthostatic blood pressures and or static hypotension, for instance and fall risk. And I think the kind of clinical importance of the study or of the purpose of the study was that, you know, there's a, there's still a pretty big uncertainty and kind of debate of when should clinicians be, you know, evaluating for orthostatic hypotension and more specifically when they're evaluating for orthostatic hypotension. You know, what the timing of that should, should be, you know, so there's, as someone who's just getting to the end of medical school, you know you'll hear different kind of times thrown out. You know, people tell you to measure after one minute, you know, measure after three minutes, measure after both.

And you know, when you're certainly in your clinical training. And then I imagine after it as well, there can be an uncertainty of you know, what am I looking for when I measure after one minute? What am I looking for when I measure after two minutes? So part of the study was to see, you know, what are there different utilities? Do, do measurements vary shortly after standing, tell us something different than measurements, you know, a few minutes after standing. And hopefully to, you know, help contribute to the literature that will, you know, guide clinicians in their assessments of checking for, oh, measuring, oh, and then how that informs especially their assessments and management of fall risk in older adults. Perfect.

C360: Can you provide an overview of your study results?

Mr. Petriceks: Yeah. The, the, the primary results and that, that struck us were twofold. So on the one hand, the earlier blood pressure measurements, the earlier orthostatic measurements were, I, we would kind of say more sensitive for orthostatic hypotension. So more, there was more orthostatic hypotension, say within one minute of standing. Which in itself is intuitive in the sense that, you know, these are older adults. You're you have less time for your kind of autonomic nervous system to respond and increase the blood pressure upon standing, which tells us that, you know, if you, if your purpose is, I want to, you know, find out whether say my patient has orthostatic hypotension, you know, these early measurements are, are gonna be really important because after a minute or so, you know, you have a drop off. And so you might not, you know, catch people if you're only measuring, say, after three minutes.

But another really important nuance to that was, you know, approximately four minutes and after you had a, a much stronger association between the presence of orthostatic hypotension and fall risk. And so this, you know, tells us that if you do catch orthostatic hypotension, you know, say at four minutes, if you wait four minutes and you catch orthostatic hypotension in a patient, that patient is probably more likely, or that orthostatic hypo is more likely maybe to contribute to a fall than or static hypotension that you pick up within one minute. And so both of those factors are really important, obviously, for a clinician to keep in mind and suggest that a couple things. One being that, you know, one, how you approach the orthostatic hypotension assessment in terms of timing should be guided by your clinical question, you know, is your question, does this patient have orthostatic hypotension?

Or is your question, you know, more broadly, what is this person's fall risk? Maybe you've seen that they have orthostatic hypotension already and you're wondering, you know, is this how much might this be contributing to my patient's fall risk? And that will lead maybe to different strategies. And, you know, certainly obviously suggests that there is a utility to, you know, using both of them. And so to have a kind of fuller picture of any given patient, you know, you might want those kind of spaced out time lengths. And and again, I mean, some of, some of what people will hear when they're in medical training, things like that, you'll hear like one minute and three minute, for instance. And this study, I think suggests that if you go a little bit longer than three minutes, you actually might pick up even more, you know, meaningful or static hypotension in terms of what that contributes to fall risk. So I think there's a really, obviously there, there always is room for and a need for kind of more follow-up studies and kinda assessment of, of our own findings. But I think there, in this study, there is a, you know, strong suggestion that we can, we can be tailoring our orthostatic hypotension assessments based on the clinical questions. And that orthostatic hypotension at different times actually tells us different things about, especially about fall risk.

C360: What is the next step for the clinician after the 4-to-6–minute assessment?

Mr. Petriceks: Yeah, that's a really great question. And obviously what, you know, what everyone is most you know, concerned about in that situation. And that would obviously really depend you know, would depend on what else is going on in the patient you know, their comorbidities, other medications they might be taking. One of the things that's exciting, you know for Dr. Jarek and I, who is, you know, the, the kind of the senior author on, on the paper is that we're, you know, currently now looking at what the effects of what the effects of orthostatic hypotension might be, say on cardiovascular disease. And in patients say who have you know, both hypertension, high blood pressure as well as, you know, show orthostatic hypotension may be at, you know, this kind of later with the static hypotension. What is the what are the trade-offs of say, you know, removing anti-hypertensives in that kind of patient?

Because one of the, obviously one of the reflexive ideas and thoughts and is often done in the setting of orthostatic hypotension would be to decrease antihypertensives, especially, you know, a lot of these older adults do end up having antihypertensives. And a big part of that debate, or a big part of that practice is, you know, if if we go down the antihypertensives, we might reduce the risk of oh, and reduce the, the fall risk. And then there, you know, so that, that's one of the common, I think, current practices, which is obviously again sort of is, is intuitive and can, can be helpful for people. Also, obviously apart from antihypertensives, you know, oh, can lead to maybe a reassessment of other medications that might be impacting blood pressure. But impacting the autonomic nervous system, also impacting, you know, things like cognition and other aspects of fall risk certainly oh, is not, doesn't exist in a vacuum when it comes to fall risk.

But on the other side there, there, I think the, especially within the context of this study when clinicians, you know, find the, oh, I think there, this also opens up a question of, you know, especially in the context of anti-hypertensives question of what are the, the really big concerns in this patient? So, you know, if you have a, a patient who has high blood pressure, has high risk for cardiovascular disease but now also has, you know, fall risk and has orthostatic hypotension what do you do when, when that comes up? You know do you, do you remove the anti-hypertensives but then maybe increase the risk for cardiovascular disease and other, you know adverse events related to cardiovascular disease? So, you know, there's no one size fits all response to the finding of orthostatic hypotension in these in these folks.

C360: How dangerous are falls for this patient population?

Mr. Petriceks: You know, especially in older adults, especially in, in frail, older adults falls, falls and falls that lead to complications like fractures or head trauma can be really, really serious. And, you know, is, is as ends up being a lot different from a fall between, you know, you or me where you, you know, you fall down and, and you know, kind of hurts a little bit for, you know, you're bruised or something. So that's the big thing. I think, you know, fractures and, and, you know, kind of musculoskeletal injuries in older adults is big and obviously beyond any given injury. And, and, you know, it's like something that would lead to a hospitalization, like a, a hip fracture, you know, falls have a really significant psychological impact on older adults as well.

And, you know, someone has, has a history of falls or they're, they're very afraid of falls. They don't feel confident in their ability to move around. That will often limit, you know, what they end up doing during the day and how they end up living. And obviously, you know, we know by now that, you know, remaining active reactive physically or remaining active socially mentally is, is incredibly important for the function of older adults. And if you don't have that confidence, you know, a lot of people can end up kind of restricting themselves and not, not exercising, not going out to, you know, talk to their friends in the park or wherever it might be. And so that can just, just the psychological fear of a fall, whether you've had one or not, can end up diminishing quality of life quite significantly.

C360: What are the main takeaways from your study?

Mr. Petriceks: Definitely the big, the big factors were, you know, the timing of growth, static hypertension, that you know, multiple measurements can be really important for, you know, the, the clinical data that a clinician wants to discern and that, but that also, the approach might not be a one size fits all assessment. And so, you know, there's no reason to restrict yourself just to one minute or even restrict yourself just to one minute and three minute, you know if you're really concerned about what the fall risk of oh might mean or might be for a patient, you know, and you have time in the, in the visit, which is obviously often a limiting factor, you might extend that assessment, you know, a minute or two to get more data.

But I, yeah, I think another, like another sort of reiteration of, of the emphasis being that even once you found OH as, as you pointed out in your question there remains a, you know, really deep clinical judgment and clinical consideration process of what the overarching concerns are for that patient. Especially, you know, oftentimes in the case of cardiovascular risk and anti-hypertensives, and what should a clinician do in a patient who has both high blood pressure and orthostatic hypotension and fall risk and risk for, you know, a heart attack, things like that. And that remains, you know, a, a non-trivial consideration that, you know, requires more work part of which, you know we are hoping to contribute to, you know, in the near future but will, you know, need to be elucidated further. So there's still more work to be done, but I do think, yeah, again, this, this study hopefully will give clinicians a better idea of, you know, what, what orthostatic hypotension might mean when they find it, and how to how they might structure their assessments of that.