Fluctuating blood pressure has become a hot topic among seniors as it negatively impacts their quality of life. Fluctuating blood pressure, although a normal phenomenon for many, in elderly becomes a life-threatening nuisance leading to falls.
Current health guidelines are inadequate and leave seniors frustrated over fluctuating blood pressure and its effects. It would seem that dealing with erratic blood pressure and resulting falls is a daunting task. However, recent studies suggest that that better fall prevention may not be difficult or far-fetched after all. There are many lesser known treatment modalities that are effective in stabilizing blood pressure and, as a result, preventing falls in seniors.
The article below sheds a light on a few new possibilities. Because of ease of their implementation and significant benefits I would like every senior, every health care professional, and every person taking care of an elderly to get familiar with these basic treatment possibilities.
Here is a reprint of my article on fluctuating blood pressure and falls in seniors. It was published in a peer-reviewed journal VitalLink in 2016. Since the intended audience of the journal is made up of naturopathic physicians the article refers to naturopathic modalities however, these treatment modalities can be adopted by virtually any health care practitioner regardless of their background. For those unfamiliar with medical terminology “dysautonomia” and “orthostatic hypotension” can be loosely translated in this article as “fluctuating blood pressure.”
For the ease of reading, all supporting references have been removed from this blog post. They are however, available through accessing VitalLink. You will find the article on page 15 of the issue.
VitalLink is a leading Canadian peer-reviewed journal for naturopathic physicians published and distributed by Canadian Association of Naturopathic Doctors. It is a great source of information for practitioners with inclination towards natural medicine.
If you prefer to read on fluctuating blood pressure without battling medical jargon please click through to the articles below:
- Fluctuating blood pressure 101
- How common is erratic blood pressure
- Reasons behind fluctuating blood pressure
Dysautonomia, orthostatic hypotension and falls in the elderly
Prevalence of dysautonomia and its characteristic presentation as orthostatic hypotension is largely underestimated and current fall prevention strategies are usually limited to use of assistive devices, pharmacological management of comorbid diseases, and environmental modification targeting prevention of accidents. This article brings awareness to dysautonomia and its role in falls in the elderly and recommends fall prevention strategies that utilize pertinent naturopathic modalities.
Recognizing dysautonomia as a factor contributing to falls is an emerging opportunity for naturopathic doctors, as current intervention programs are insufficient. Between 2003 and 2010 fall-related injury in Canada increased from 47.2% to 57.5% per 1,000 falls. Fall-related deaths also experienced a statistically significant rise. Between 1997 and 1999 fall-related deaths jumped from 8.1 to 9.4 per 10,000 elderly. Inclusion of naturopathic modalities can potentially reduce mortality, injury, and recurrences of falls through avenues not widely pursued. Recommendations to routinely screen for orthostatic hypotension, thoroughly identifying nutritional deficiencies, and assessing lifestyle factors that contribute to falls, such as lack of physical conditioning and gut dysbiosis, are not well highlighted in current Canadian fall-prevention guidelines.
Statistics for falls in seniors
Falls in the elderly are debilitating, serious, and costly. Falls cause anxiety, disrupt daily activities, restrict movement, limit independence, contribute to depression and despondence and seriously diminish quality of life; yet despite precautions, one in three seniors experience a fall each year. The risk goes up with age reaching 50% in those over 80 years of age.2 However, these statistics may represent only a fraction of the problem as a large number of falls are unreported due to fear of consequences for those who fall. Seventy-six percent of those who fall need emergency care and 24% require further hospitalization. Falls account for 70% of accidental deaths in elderly and are associated with 27% risk of mortality within two years. The financial cost associated with falls are estimated at $2 billion CAD annually. Falls can be precipitated by variety of factors including poor gait, poor vision, cognitive impairment and muscle weakness, as well as acute and chronic illness, some of which may be secondary to dysautonomia.
Dysautonomia, or autonomic nervous system failure, includes a family of disorders, such as postural orthostatic tachycardia syndrome (POTS), neurocardiogenic syncope, and multiple system atrophy. Dysautonomia occurs frequently in diabetes, alcoholism and Parkinson’s disease.
Dysautonomia disrupts mechanisms that depend heavily on the autonomic nervous system, which include: muscular reflexes, sensory adjustments, cognitive abilities, and cardiovascular regulation, all of which are necessary for the body’s adaptation to a changing environment.
Orthostatic hypotension is a key feature of dysautonomia. In seniors residing in institutions orthostatic hypotension is a contributing factor for about 55% of falls, syncope, dizziness that results in head injury from a fall, bone fractures or hospitalization. In non-institutionalised population orthostatic hypotension is present in 20% of the older population. However, this number appears to be understated; a study published in Neurology 2006 revealed that 47% of patients reporting dizziness, light-headedness or syncope had orthostatic hypotension, 54% of whom experienced a blood pressure drop only after three minutes, which could not be diagnosed by orthostatic tests of shorter duration.
Sporadic hypotensive events, with or without an orthostatic feature, are also more common than previously thought. A study published by Journal of Human Hypertenion (2000) revealed that up to 49% of the general adult population is affected. Sporadic hypotension is especially common in “thin subjects”, subjects with low creatinine levels and lower muscle mass.
Research from 2009 pointed out that there is general hypotension unawareness even in severe orthostatic hypotension cases. A study published in Am J Med (2009) demonstrated that even in severe orthostatic hypotensive cases, where diastolic drop was greater than 60 mmHg from the baseline only 43% of subjects had typical symptoms (mainly light-headedness). Twenty-four percent of patients had atypical symptoms and 33% were completely asymptomatic. Other studies suggest that up to 80% of patients with a “lesser degree of orthostatic hypotension” may be asymptomatic. Atypical symptoms such as fatigue, weakness, palpitations, back and neck pain, dizziness, precordial pain, seizures, hyperhidrosis, cognitive slowing, visual and hearing disturbances are features of delayed orthostatic hypotension.
Postprandial hypotension, which occurs within two hours of a meal is a common cause of syncope in elderly and reaches 67% of prevalence. Postprandial hypotension follows inadequate peripheral vasoconstriction and insufficient heart rate increase. It is frequently precipitated by ingesting hot meals, ingesting vasodilators, ingesting high carbohydrate meal, or sitting in a hot environment. Breakfast is the most common meal leading to syncope. Post-meal syncope is considered an atypical presentation of orthostatic hypotension. Syncope requires systolic blood pressure to drop below 90 mmHg.
Detection of dysautonomia
There are many physiological reasons for the increased prevalence of orthostatic hypotension in the elderly. Among them are reduced arterial compliance and increased venous tortuosity, cardiac hypertrophy impairing diastolic filling, decreased renal sodium conservation, age-dependent decline in renin and angiotensin, reduced maximum heart rate during exercise, change in heart rate after hypotensive maneuvers, and reduced cerebral blood flow.
Current detection methods for autonomic system malfunction are cumbersome and not widely employed. Available tests that include autonomic reflex screen, thermoregulatory sweat test, supine compared to standing serum norepinephrine, and 24-hour urinary sodium tests, are not part of routine physical examinations and blood pressure diaries recorded by patients are typically unreliable.
Heart rate variability (HRV) is currently investigated as a more clinic-friendly screening method for dysautonomia. Preliminary studies done by Brain Injury Rehabilitation Service, Westmead Hospital, Australia suggested that post-injury dysatonomia can be seen in HRV test as a large increase in sympathetic phase and reduced parasympathetic activity. Another study on autonomic abnormalities published by J Affect Discord (2011) found that lower HRV was a frequent feature of depression and that depression was an independent predictor for developing systolic orthostatic hypertension.
Absence of easily accessible and reliable clinical tests leaves a void and suggests that clinicians may find that pre-screening for dysautonomia through a more in-depth interview may be preferred. Nocturia, stress incontinence, erectile dysfunctions, bowel irregularities and changes to sweating pattern may be one of the earlier clues as to presence of autonomic dysfunction. Later stages of dysautonomia often presents with symptoms such as persistent weakness, post-exercise syncope, excessively fluctuating blood pressure, speech slurring and unsteady gait. Atypical presentation of autonomic nervous system failure may also include: asymmetrical or oscillating feature, such as significant right/left blood pressure asymmetry, alternating unilateral nasal congestion, migraines or daily headaches, arrhythmia, sleep apnea, dysfunctional esophageal peristalsis, panic attacks and cravings for sweets and salt.
Causes of dysautonomia
Dysautonomia can be caused by inherent nervous system disorders or degenerative neuropathies. However, recent research suggests that dysautonomia has several modifiable causes that are nutrition-, environmental-, and lifestyle-dependent. Although these causes are rarely addressed, they may constitute the most effective strategy to fall prevention. This concept is elaborated, below.
Frequency of falls in elderly is dependent on nutritional status. Public Health Agency of Canada reported in 2014 that malnourished elderly who were treated by emergency care were more likely to report having fallen within the previous six months.
Others studies indicated that nutritional deficiencies of specific vitamins and minerals can trigger or contribute to dysautonomia. Insufficiencies of thiamin (vitamin B1), magnesium, vitamin B12, and vitamin D are most commonly implicated.
Thiamin deficiency, known as beriberi, has been proposed as a prototype of functional dysautonomia. Its neurological symptoms including cardiac palpitations on mental or physical exertion, abnormal response to adrenalin, vagotonia/sympathicotonia, paresthesias and decreased proprioceptive perception are also features of autonomic nervous failure.
Beriberi is believed to be rare in developed countries and today few clinicians consider thiamin deficiency when assessing a patient. This belief has been recently questioned. Observations showed that thiamin deficiency does not occur only in visibly malnourished individuals, but can be present in robust patients without any signs of nutritional inadequacy.
Thiamin is needed for phosphorylation of thiamin pyrophosphate (TPP) and synthesis of thiamin triphosphate (TTP). TPP and TTP are necessary to complete oxidative pathways during caloric metabolism. High-calorie diets carry a higher need for thiamin. The need for thiamine increases with ingestion of simple carbohydrate, thus it has been suggested that developed countries suffer widespread hidden deficiency of thiamine due to high sugar/high simple carbohydrate diet. It has been demonstrated that supplementation of thiamin in early stages reverses beriberi-like symptoms corrects previously noted autonomic system malfunctions.
Magnesium deficiency has been noted in relationship to mitral valve prolapse. Symptoms of mitral valve prolapse frequently overlap with symptoms of dysautonomia. Both can present with dyspnea, fatigue, dizziness, syncope, palpitations, resting bradycardia, poor exercise tolerance and orthostatic hypotension.
According to a paper presented by Gesell Institute of Human Development, New Haven, Conn, USA, supplementation of 300mg of magnesium lactate over 16 weeks produced significant improvement in serum magnesium as well as a marked improvement in symptoms listed above.
It has been well-documented that proper function of the nervous system depends on adequate vitamin B12 levels. Lack of B12 is responsible for defective sympathetic activation and even low-normal levels of this vitamin can produce changes in autonomic nervous system, result in orthostatic hypotension and syncope. Vitamin B12 is necessary for release of noradrenaline. Its lack leads to failure of sympathetic nervous system, which results in orthostatic hypotension.
Clin Auton Res (2004) reported that supplementation of vitamin B12 in deficient elderly produces statistically significant reduction in orthostatic hypotension. A marked decrease in blood pressure drop from 44/29 mmHg to 14/9 mmHg was seen after vitamin B12 supplementation. It has been postulated that orthostatic hypotension may be one of the earlier signs of B12 insufficiency. Not surprisingly, many cases of orthostatic hypotension were found to be the first manifestation of pernicious anemia.
Many investigators suggest that B12 screening should be implemented in everyone experiencing orthostatic hypotension even in the absence of clinical neurologic signs or typical hematologic manifestations. Orthostatic hypotension is reversible with B12 supplementation in cases with established deficiency.
Vitamin D is well-known for its value in increasing bone mineral density. However, recently Public Health Agency of Canada started recommending it not only as a therapeutic adjunct for osteoporosis, but also for a valuable therapy in fall prevention. J Intern Med (2014) reported that orthostatic hypotension is common in vitamin-D-deficient women over 80 years old and can be reversed by vitamin D supplementation. The study demonstrated significant inverse linear association between 25-hydroxyvitamin D serum concentration and delayed orthostatic hypotension. Vitamin D supplementation was shown to be effective in reduction of falls among elderly who were deficient.
American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons stress that muscle weakness is the most important risk factor for falls, increasing the risk by four to five times. Studies done on New Mexico population found that sarcopenia prevalence is 12% for persons 60 to 70 years of age and nearly 30% for persons over 80 years.
Pharmacologic intervention to counteract sarcopenia has limited efficacy. Physical exercise is so far demonstrated to be the best intervention for maintaining and enhancing muscular strength. According to Statistics Canada data pooled between 2007 and 2011, however, seniors do not exercise adequately. Only 11% seniors aged 60-79 meet Canada’s physical activity guidelines.
Lack of exercise not only contributes to sarcopenia, but also precipitates nervous system malfunction. The relationship between lack of exercise, physical deconditioning and dysautonomia has been addressed in a paper presented in Neurology (2012). A study done at Mayo Clinic between 2006 and 2011 demonstrated that orthostatic intolerance and VO(2max)% are inversely correlated. Reduced VO(2max)%, which is consistent with deconditioning, was present in almost all patients with orthostatic intolerance. This suggested that lack of exercise and subsequent deconditioning may play a central role in pathophysiology of dysautonomia.
Attempts to improve nervous system function with exercise have been proven to be very effective in various types of dysautonomia. A three-month progressive endurance training caused remission in 71% of postural orthostatic tachycardia syndrome patients. Eight-week strength training for elderly with orthostatic hypotension resulted in significant alteration of orthostatic response. A 1998 study presented by J Cardiopulm Rehabil. noted an average systolic increase of 9.7 mmHg and an average diastolic increase of 4.7 mmHg after intervention.
Gut health and gut irritants
The effect of gut dysbiosis on general well-being has been long acknowledged by naturopathic medicine; however, recent research has provided more details on how gut health affects the autonomic nervous system.
The vagus, a long cranial nerve whose branches extend to digestive tract, contributes to regulation of heartbeat and blood pressure. It is worth mentioning that 90% of signals passing via vagus nerve go from the gut to the brain, not the other way around, therefore gut health is of prime interest in all nervous-system disturbances.
The vagus nerve and its function are seldom taken into consideration by clinicians who assess the risk of falls. However, gut-ANS connection needs to always be taken into consideration given a large prevalence of digestive disturbances among seniors. Improper signals derived from the gut may cause over- or under-expression of various branches of autonomic nervous system.
Research indicates that 50% of patients with inflammatory bowel disease have some sort of autonomic system dysfunction. Autonomic dysfunction has been found in 46% of patients with Crohn’s disease and 35% of patients with ulcerative colitis. Digestive disturbances and falls have even a stronger correlation. Patients taking laxatives are two times more likely to experience falls than patients not using them.
Dietary irritants are now being researched as a possible contributor to autonomic system dysregulation. Despite limited studies in this area gluten intolerance has already been implicated. A paper presented in J Neurol Neurosurg Psychiatry (2005) showed that 2.4% of symptomatic patients with idiopathic orthostatic hypotension had celiac disease confirmed by biopsy.
Autonomic nervous system is in constant communication with enteric microbiota of the gut. Evidence exists that gut microbiota can alter autonomic nervous system function. Recent research is suggestive that imbalanced gut microbiota plays an important part in variety of neurodegenerative conditions including MS, Guillain-Barre syndrome, Alzheimer’s as well as Parkinson’s disease.
Preliminary assessment showed that microbiota in Parkinson’s disease has reduced abundance of the Prevotellaceae bacteria as compared with healthy controls and greater abundance of Enterobacteriaceae. This alteration is especially noted among patients with postural instability. Small intestinal bacterial overgrowth (SIBO) is present in 54%-67% of Parkinson’s patients and is correlated with pronounced motor symptoms. It has been postulated that Parkinson’s disease does not start in the central nervous system, but originates in the gut and spreads via neuroendocrine, immunological and direct neural pathway to the brain. It is worth noting that Parkinson’s patients are three times more prone to falls than healthy controls.
Prescription medications have also been found to largely contribute to dysautonomia. The prevalence of orthostatic hypotension seems to be directly proportional to the drug burden. A 2008 study revealed that orthostatic hypotension is present in 35% of seniors who do not take any drugs, 58% in those who take one drug, 60% in those with two, and 65% in those who take three drugs. Medications identified to have the highest orthostatic effect are: hydrochlorodiazide (65%), lisinopril (60%), furosemide (56%), trazodone (58%), and terazosin (54%).
Besides the obvious volume depletion caused by diuretics other drugs can also contribute to falls through different mechanisms. Elisabete Pinto in her article published in Postgrad Med J. mentioned that 11% of syncope in elderly is reported to be drug induced. Among the drugs most implicated in falls are:
- Analgesics – due to reduced alertness and slow central processing
- Anti-arrhythmics – due to impaired cerebral perfusion
- Anticholinergics – due to confusion
- Antihypertensives – due to impaired cerebral perfusion
- Antipsychotics – due to antiadrenergic effects
- Psychoactive drugs – due to reduced alertness, slow central processing2
Emerging opportunity for naturopathic doctors
Dysautonomia (and its feature, orthostathic hypotension) is much more prevalent than generally believed. It is also a condition not so much gene-dependent, but largely influenced by dietary choices and lifestyle habits. With better understanding of presentation as well as pathophysiology of dysautonomia we should no longer limit our intervention to proverbial “hydration, salt and incline”, but include restoration of nutritional reserves, digestive repair, physical conditioning, and communication with other key health care providers.
Naturopathic doctors are well-positioned to recognize early signs of dysautonomia, design a fall-preventing lifestyle plan for the patient, and educate patient-sharing clinicians on effects of drugs, causes of dysautonomia, and naturopathic alternatives.
Naturopathic doctors, besides being able to competently address dietary and lifestyle habits, are also uniquely positioned to treat dysautonomia as hydrotherapy, homeopathy, acupuncture and breathing techniques have been found capable of influencing autonomic nervous system. Incorporation of naturopathic wisdom and naturopathic modalities can prove to be one of the better and more comprehensive interventions for fall prevention in elderly.
For a more comprehensive list of causes and treatment possibilities for low and fluctuating blood pressure please refer to The Ultimate Guide to Low & Fluctuating Blood Pressure
Hypotension – Hypotension is defined as a blood pressure below 90/60 mmHg.
Orthostatic Hypotension – Orthostatic hypotension is defined as a systolic drop of at least 20 mmHg and/or at least 10 mmHg drop in diastolic value within three minutes of standing.
Sarcopenia – Sarcopenia is consistent with a gait speed of less than one metre/second and an objectively measured low muscle mass.
Syncope – Syncope is a sudden loss of consciousness characterised by immediate and spontaneous recovery that does not necessitate electrical or chemical cardiac rehabilitation. An average syncope lasts 12 seconds and is precipitated by cerebral hypoperfusion.
VO(2Max)% – maximal oxygen uptake is generally considered the best indicator of cardiorespiratory endurance and aerobic fitness.