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Reconsidering Orthostatic Vital Signs in Older Emergency Department Patients

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Reconsidering Orthostatic Vital Signs in Older Emergency Department Patients Emergency Medicine Australasia (2018) 30, 705–708 doi: 10.1111/1742-6723.13119 ACUTE GERIATRICS Reconsidering orthostatic vital signs in older emergency department patients Maura KENNEDY,1 Kathleen TP DAVENPORT,1 Shan Woo LIU1 and Glenn ARENDTS 2 1Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA, and 2Department of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia A 75-year-old woman with a past Epidemiology and • ventricular and vasculature stiff- medical history of dementia, coro- pathophysiology of orthostatic ening impeding early diastolic nary artery disease, and diabetes hypotension in older adults filling. presents to your ED after a fall. The patient does not know why OH is common in the community- she fell and states she is unsure of dwelling older population with an Orthostatic vital sign – whether she lost consciousness estimated prevalence rate of 16 20% measurement before or after. She has normal in individuals over 65 years of age, 4,5 How is orthostatic hypotension vital signs and her physical exam and 35% in those over 75. Not all defined? is normal with no evidence of of these patients will have symptoms traumatic injury. An electrocar- associated with OH. The prevalence A consensus statement was issued in fi 7 diogram, chest X-ray and basic of OH is even higher in certain high- 2011 de ning OH as a sustained blood tests are normal. She is trea- risk populations, such as institutiona- drop in systolic BP (SBP) by ≥ ted with intravenous fluids and lised older adults and individuals with 20 mmHg or diastolic BP ’ 4,5 ≥ admitted to the hospital for a syn- Parkinson s disease or diabetes. 10 mmHg within 3 min of standing. cope and fall work-up. The admit- In a healthy adult, blood pools in This definition has been broadly ting general physician asks you the legs and in the splanchnic and pul- adopted and should be used clini- whether orthostatic vital signs monary circulation when moving cally. However, European syncope 5,6 were obtained. You answer ‘no’ from lying to standing, which tran- guidelines also add standing SBP of but should the answer be ‘yes’? siently results in decreased venous <90 mmHg to this definition of OH.3 blood return to the heart, cardiac out- put and blood pressure (BP).4 These Introduction changes activate baroreceptors, trig- How should orthostatic vital signs be measured? – gering a nearly instantaneous increase Medical societies1 3 recommend in sympathetic and decrease in para- The optimal timing of orthostatic mea- obtaining orthostatic vital sign (OVS) sympathetic tone, which results in surements is a source of debate. Many in the evaluation of syncope and falls increased vascular resistance, heart geriatricians advocate delaying the in all older patients. However, in our rate (HR) and restoration of normal measurement of BP for at least 3, and experience there are variable views and 4,6 BP. Ageing-related changes (Fig. 1) sometimes5ormoreminutes,after some misconceptions regarding the role that result in older adults being sus- standing, to increase diagnostic yield. of OVS in the ED, and practice varia- ceptible to OH include: Some studies have found delayed tions in OVS measurement. The pre- • a reduction in baroreflex-mediated (up to 10 min or more after standing) sent study will review orthostatic cardioacceleration preventing the OH occurs almost as frequently as hypotension (OH) in older patients, typical compensatory increase early OH.8,9 However, a study in and provide guidance on when to in HR, patients aged 44–6610 found that obtain OVS and how to measure, inter- • decreased vasoconstriction, orthostatic BP measurements at 1 min pret and treat OH in older ED patients • reduced water and salt conserva- were associated with the largest mean presenting with syncope or fall. tion and reduction in SBP and were more pre- dictive of long-term outcomes, includ- Correspondence: Dr Maura Kennedy, Department of Emergency Medicine, ing future falls, fractures, syncope and Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. mortality, than measurements at later Email: [email protected] times. If repeatable in older adults Maura Kennedy, MD, MPH, Assistant Professor; Kathleen TP Davenport, MD, these results would support a simpli- Clinical Fellow; Shan Woo Liu, MD, SD, Assistant Professor; Glenn Arendts, MBBS, fied ED measurement protocol. MMed, PhD, FACEM, Associate Professor. Currently, we recommend that BP Accepted 25 May 2018 be measured after a patient has been © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine 706 M KENNEDY ET AL. Normal Response to Position Change these guidelines in the ED setting. The proportion of syncopal events attributed to OH in these studies • Blood pools in 15–20 Lying Flat peripheral varied widely from 5% to 24%. circulation Part of the variation is likely due to the frequency with which OVS were actually obtained, ranging from • Transient drop 14.5%21 to 94%18,20 of syncope in venous Standing up blood return to patients. One study found that the heart implementing a decision-making software program to ensure adher- ence to the ESC guidelines resulted • Increased sympathetic tone Baroreceptor • Decreased parasympathetic tone in an increase in the diagnosis of Activation • Increased vascular resistance orthostatic syncope from 6% to • Increased heart rate 10% (P = 0.002), lower hospitalisa- tion rates, shorter lengths of stay, fewer tests performed and fewer diagnoses of ‘unexplained syn- Factors that Occur with Ageing that Degrade Normal Response to Position Change cope’.15 As a result of the low cost and high yield of orthostatic BP mea- surements in these studies, some Reduction in Decreased authors have concluded that of all baroreceptor diastolic filling due syncope-related diagnostic tests in mediated heart to ventricular and ED, OVS have the highest yield and rate acceleration vascular stiffening are the most cost-effective.22,23 Given the prevalence of OH in older patients, one concern is that routine measurement of OVS may Reduced water Decreased and salt result in misdiagnosing the cause of vasoconstriction conservation Increased syncope as OH, missing another risk of more immediately life threatening orthostatic cause. Indeed, asymptomatic OH has hypotension been reported in up to 10% of patients diagnosed with a non- orthostatic aetiology of syncope.16,17 Therefore, a diagnosis of orthostatic Figure 1. Impact of ageing on the normal physiologic response to position change. syncope requires a patient who has a history consistent with OH and have symptoms of OH during measure- 13,14 relaxed and supine for 5 min, then antihypertensive medications. ment. Many studies implementing again after 1 and 3 min of standing, Additionally, in older adults there is a the ESC guidelines required patients while asking the patient to report strong negative correlation between 5,12 to have both OH and either syncope any symptoms. age and any orthostatic HR change. or presyncopal symptoms at the time Syncope and falls guidelines, therefore, standing BP measurements were recommend obtaining and interpreting – obtained.16 18 Patients diagnosed with orthostatic BP measurements1–3 as the Should orthostatic heart rate be OH syncope in the ED had an goal is to determine whether a patient measured in older adults with 18-month mortality rate of 9% – lower had a syncopal event or fall due to syncope and falls? than that of cardiac-related syncope brain hypoperfusion from OH. 17,18 Another area of confusion is whether, but greater than vasovagal syncope. or when, postural HR changes should be recorded. Early ED studies focused Orthostatic hypotension and Orthostatic hypotension and on whether OVS could be used to reliably diagnose hypovolemia, and syncope falls measured both HR and BP responses After the European Society of Cardi- Geriatric ED guidelines24 and guide- to posture change.11–13 These studies ology (ESC) released new syncope lines on fall prevention in the are of questionable relevance to older guidelines, which includes routinely elderly2 recommend obtaining OVS adults, as they enrolled predominantly obtaining orthostatic BP measure- when evaluating older patients after young subjects with mild hypovolemia ments in the initial evaluation,3 sev- a fall; however, there is limited ED- and excluded individuals on eral studies looked at the impact of based literature on this topic. Many © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine ACUTE GERIATRICS 707 non-ED-based studies demonstrated high diagnostic yield of OVS. Addi- definition of orthostatic hypotension, an association between OH and tional research is needed on the util- neurally mediated syncope and the prior falls,25,26 recurrent falls27–29 ity of routine OVS in older patients postural tachycardia syndrome. Clin. and future falls,30 and OH has been presenting to the ED after a fall, and Auton. Res. 2011; 21:69–72. demonstrated to be associated with the clinical impact of ED-based inter- 8. Gibbons CH, Freeman R. Delayed an increased risk of death due to ventions for OH in geriatric falls. orthostatic hypotension: a frequent injury.31 Only two ED-based studies Orthostatic BP measurements cause of orthostatic intolerance. have assessed OH in older patients should be routine in patients older Neurology 2006; 67:28–32. presenting to the ED after a fall. Nei- than 65 years who report dizziness, 9. Ricci F, De Caterina R, ther study actually measured OVS, lightheadedness, presyncope, syn- Fedorowski A. Orthostatic hypo- instead surveying subjects about cope or unexplained falls. OVS rep- tension: epidemiology, prognosis symptoms attributable to OH and resent an inexpensive, safe and treatment. J. Am. Coll. Cardiol. reported that symptoms of OH were assessment that may provide valu- 2015; 66: 848–60. associated with an increased risk of able diagnostic information and 10. Juraschek SP, Daya N, recurrent falls.32,33 No ED studies avoid a costly and potentially bur- Rawlings AM et al.
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