Aging Clin. Exp. Res. 4: 139-144, 1992
Orthostatic reactions in the 85-year olds P.O. Jantti Department of Gerontology, University of Tampere, and Department of Geriatric Medicine, Tampere City Hospital, Tampere, Finland
ABSTRACT. Testing of the orthostatic reaction is recommended in the examination of elderly fallers. This test usually includes blood pressure and instantaneous heart rate measurement but is difficult to perform in veryelderly people according to the quidelines suggested for younger subjects. One reason for this is that old people often stand up slowly. The use of a tilt table, which enables a rapid change in posture from recumbent to erect position, is tempting as it could provide a method for a better standardized test. To study the usefulness of the tilt table as well as the degree of orthostatic reaction in the very elderly, we examined a sample of 85-year olds who did not suffer from falls. All were tested both with the tilt table and with active rising. The drop in blood pressure was equal in the two test types, but the increase in heart rate was significantly larger in active rising. Many test subjects were afraid of the tilt table, and two developed cardiac arrythmia, i.e., atrial fibrillation, during the test. In our opinion, active rising is the method of choice in old persons. While the test subjects were in unusually good health for their age and thus could proVide a suitable reference group for this test, the systolic blood pressure dropped considerably in several during the test. Criteria and indexes developed for younger subjects are not useful, and different evaluation criteria should be developed for the very elderly. (Aging Clin. Exp. Res. 4: 139-144, 1992)
INTRODUCTION Testing of the orthostatic blood pressure reaction
is recommended as part of the routine examination
of elderly people suffering from dizziness or falls (1). Earlier studies of orthostatic reaction have dealt mostly with subjects under 85 years of age; the very elderly, 85 years or older, however, differ in many ways from younger subjects. The reference values for many laboratory examinations are different and the principles of treatment for many disorders, like overweight (2), are different from those of younger subjects. Furthermore, old people are often afraid of many diagnostic procedures. The muscle power is diminished and movements like rising up from a supine position are slow. There are several variations in the orthostatic test regarding methods, timing, and measurements performed. The test can be performed actively, i.e., the subject rises from a supine or sitting to a standing position, or passively, on a bed that can be tilted from a horizontal to a vertical or nearly vertical position. Some workers record blood pressure only (3) while others simultaneously measure ECG and heart rate (4). In Ewing's method, the test subject first lies at rest for 2 minutes, then gets up and stands one minute (5). The blood pressure is measured immediately before rising, and after one minute of standing; the interbeat, R-R intervals are measured from the simultaneous ECG recording. In Thulesius' method, the subject first rests for 6-10 minutes, and blood pressure and heart rate are then measured (6). After reaching the upright position, the subject stands for 7 minutes; blood pressure and heart rate are measured immediately after rising, and again after at least 3 minutes of standing.
Key words: Blood pressure, heart rate, orthostatic reaction. Correspondence: Pirkko .Jantti, M.D., Pohjankulma 4 A 7, SF - 33500 Tampere, Finland. Received March 28, 1991; accepted October 24, 1991.
Aging Clin. Exp. Res., Vol. 4, N. 2 139
P.O. Jiintti
After standing up from a recumbent position, the instantaneous heart rate, i.e., inverse of interbeat intervals, fluctuates rapidly, and usually two main phases, i.e., a biphasic reaction, are seen. The interbeat intervals decrease, i.e., the heart rate accelerates, and reaches a maximum at approximately the 15th beat after starting to rise. The intervals then increase again to reach a maximum at about the 30th beat. The ratio of the 30th and 15th interval (7), or maximum and minimum intervals at about the same time points (8), are used to evaluate the function of the autonomic nervous system. In old subjects, the biphasic reaction is, however, less clear or not seen (4, 9) as the rapid heart rate variability decreases. The purpose of the present study is to evaluate the methods of orthostatic testing, and the degree of postural hypotony in very old subjects; we compared the active rising and tilt table methods in a group of very elderly. Changes in blood pressure and heart rate were measured to see if there were significant differences between the two methods of rising, and results were compared with findings in a group of younger control subjects. SUBJECTS AND METHODS
Thirty-nine test subjects, aged 85 or 86 years, participated in this study, as a part of a health survey in 85-year-old persons; all were living on their own. Six test subjects were eventually excluded: 3 had technically unsatisfactory recordings; 2 developed atrial fibrillation on the tilt table; and 1 refused the tilt table test. Thus, 33 subjects form the basis of this study: 20 test subjects had no regular medication; 6 subjects had minor medication for cardiac failure; and 3 others for stenocardia; 1 for rheumatoid arthritis; 1 for hypothyroidism; and 2 for intermittent claudication. At the time of examination, none had clinical symptoms nor neurological disease. Thus, all test subjectswere much healthier than average for this age group. Eight younger individuals (aged 24 to 37 years) served as control subjects. When the subject came to the laboratory, the nature of the experiment was explained. All test subjects performed both the active rising and passive tilt table tests. Every other subjectfirst per-
140 Aging Clin. Exp. Res., Vol. 4, N. 2
formed the active rising test, then the tilt table; the others were studied in inverse order. At the start of the test, the test subjects lay down on a bed or a tilt table, and the ECG electrodes were attached. After 3 minutes at rest, blood pressure was measured. Two minutes later, the tilt table was raised 70° vertically by the examiner in less than 3 seconds, or the test subject started to rise actively; blood pressure was measured 30 seconds later, and again after 3 minutes. The test subject then resumed the supine position, and blood pressure was measured for the fourth time 2 minutes later. Systolic and diastolic blood pressures were measured by the same examiner with the cuff on the right arm and a mercury manometer. Korotkoff's sound 4 was taken as the point of diastolic blood pressure. All limb electrodes and two chest electrodes at positions VI and V5 were attached to produce three channels of ECG. Tracings, done with an ink jet ECG recorder (Mingograph M24, Elema, Sweden), were started 1/2 minute before rising up in both tests, and were continued for a minute after reaching the erect position. After the return to the supine position, the ECG was recorded for 30 seconds. The ECG was recorded on paper at 50 mm/sec, and heart rate measurements were done from the R-peak intervals by hand. In the analysis, individual interpeak intervals of R-peaks in ECG were measured from the paper recording. The duration of the 15th and 30th intervals after reaching the upright position was measured to calculate the "30:15 ratio" (7). To estimate the average heart rate at rest, the number of R-R intervals in the 20 seconds preceding the start of rising up was counted. To measure the average heart rate after the immediate biphasic heart rate reaction to standing up, the number of R-R intervals during the 20 seconds, beginning 30 seconds after starting to rise, was counted. A third measurement of average heart rate was done from the 20 seconds immediately after lying down again. Statistics The difference between the two test conditions in elderly subjects was evaluated by Wilcoxon's signed rank test, and the difference between
Orthostatic testing
controls and old subjects by the Mann-Whitney Utest. Correlation coefficient r was calculated for the fall in blood pressure in the two tests.
RESULTS 1. Systolic and diastolic blood pressure Table 1 shows the mean systolic and diastolic blood pressures when the subjects actively stood up or were passively tilted to erect position; no significant differences between these two test conditions were observed with regard to changes in the systolic and diastolic blood pressure. In both test conditions, the systolic (p
Orthostatic reactions in the 85-year olds P.O. Jantti Department of Gerontology, University of Tampere, and Department of Geriatric Medicine, Tampere City Hospital, Tampere, Finland
ABSTRACT. Testing of the orthostatic reaction is recommended in the examination of elderly fallers. This test usually includes blood pressure and instantaneous heart rate measurement but is difficult to perform in veryelderly people according to the quidelines suggested for younger subjects. One reason for this is that old people often stand up slowly. The use of a tilt table, which enables a rapid change in posture from recumbent to erect position, is tempting as it could provide a method for a better standardized test. To study the usefulness of the tilt table as well as the degree of orthostatic reaction in the very elderly, we examined a sample of 85-year olds who did not suffer from falls. All were tested both with the tilt table and with active rising. The drop in blood pressure was equal in the two test types, but the increase in heart rate was significantly larger in active rising. Many test subjects were afraid of the tilt table, and two developed cardiac arrythmia, i.e., atrial fibrillation, during the test. In our opinion, active rising is the method of choice in old persons. While the test subjects were in unusually good health for their age and thus could proVide a suitable reference group for this test, the systolic blood pressure dropped considerably in several during the test. Criteria and indexes developed for younger subjects are not useful, and different evaluation criteria should be developed for the very elderly. (Aging Clin. Exp. Res. 4: 139-144, 1992)
INTRODUCTION Testing of the orthostatic blood pressure reaction
is recommended as part of the routine examination
of elderly people suffering from dizziness or falls (1). Earlier studies of orthostatic reaction have dealt mostly with subjects under 85 years of age; the very elderly, 85 years or older, however, differ in many ways from younger subjects. The reference values for many laboratory examinations are different and the principles of treatment for many disorders, like overweight (2), are different from those of younger subjects. Furthermore, old people are often afraid of many diagnostic procedures. The muscle power is diminished and movements like rising up from a supine position are slow. There are several variations in the orthostatic test regarding methods, timing, and measurements performed. The test can be performed actively, i.e., the subject rises from a supine or sitting to a standing position, or passively, on a bed that can be tilted from a horizontal to a vertical or nearly vertical position. Some workers record blood pressure only (3) while others simultaneously measure ECG and heart rate (4). In Ewing's method, the test subject first lies at rest for 2 minutes, then gets up and stands one minute (5). The blood pressure is measured immediately before rising, and after one minute of standing; the interbeat, R-R intervals are measured from the simultaneous ECG recording. In Thulesius' method, the subject first rests for 6-10 minutes, and blood pressure and heart rate are then measured (6). After reaching the upright position, the subject stands for 7 minutes; blood pressure and heart rate are measured immediately after rising, and again after at least 3 minutes of standing.
Key words: Blood pressure, heart rate, orthostatic reaction. Correspondence: Pirkko .Jantti, M.D., Pohjankulma 4 A 7, SF - 33500 Tampere, Finland. Received March 28, 1991; accepted October 24, 1991.
Aging Clin. Exp. Res., Vol. 4, N. 2 139
P.O. Jiintti
After standing up from a recumbent position, the instantaneous heart rate, i.e., inverse of interbeat intervals, fluctuates rapidly, and usually two main phases, i.e., a biphasic reaction, are seen. The interbeat intervals decrease, i.e., the heart rate accelerates, and reaches a maximum at approximately the 15th beat after starting to rise. The intervals then increase again to reach a maximum at about the 30th beat. The ratio of the 30th and 15th interval (7), or maximum and minimum intervals at about the same time points (8), are used to evaluate the function of the autonomic nervous system. In old subjects, the biphasic reaction is, however, less clear or not seen (4, 9) as the rapid heart rate variability decreases. The purpose of the present study is to evaluate the methods of orthostatic testing, and the degree of postural hypotony in very old subjects; we compared the active rising and tilt table methods in a group of very elderly. Changes in blood pressure and heart rate were measured to see if there were significant differences between the two methods of rising, and results were compared with findings in a group of younger control subjects. SUBJECTS AND METHODS
Thirty-nine test subjects, aged 85 or 86 years, participated in this study, as a part of a health survey in 85-year-old persons; all were living on their own. Six test subjects were eventually excluded: 3 had technically unsatisfactory recordings; 2 developed atrial fibrillation on the tilt table; and 1 refused the tilt table test. Thus, 33 subjects form the basis of this study: 20 test subjects had no regular medication; 6 subjects had minor medication for cardiac failure; and 3 others for stenocardia; 1 for rheumatoid arthritis; 1 for hypothyroidism; and 2 for intermittent claudication. At the time of examination, none had clinical symptoms nor neurological disease. Thus, all test subjectswere much healthier than average for this age group. Eight younger individuals (aged 24 to 37 years) served as control subjects. When the subject came to the laboratory, the nature of the experiment was explained. All test subjects performed both the active rising and passive tilt table tests. Every other subjectfirst per-
140 Aging Clin. Exp. Res., Vol. 4, N. 2
formed the active rising test, then the tilt table; the others were studied in inverse order. At the start of the test, the test subjects lay down on a bed or a tilt table, and the ECG electrodes were attached. After 3 minutes at rest, blood pressure was measured. Two minutes later, the tilt table was raised 70° vertically by the examiner in less than 3 seconds, or the test subject started to rise actively; blood pressure was measured 30 seconds later, and again after 3 minutes. The test subject then resumed the supine position, and blood pressure was measured for the fourth time 2 minutes later. Systolic and diastolic blood pressures were measured by the same examiner with the cuff on the right arm and a mercury manometer. Korotkoff's sound 4 was taken as the point of diastolic blood pressure. All limb electrodes and two chest electrodes at positions VI and V5 were attached to produce three channels of ECG. Tracings, done with an ink jet ECG recorder (Mingograph M24, Elema, Sweden), were started 1/2 minute before rising up in both tests, and were continued for a minute after reaching the erect position. After the return to the supine position, the ECG was recorded for 30 seconds. The ECG was recorded on paper at 50 mm/sec, and heart rate measurements were done from the R-peak intervals by hand. In the analysis, individual interpeak intervals of R-peaks in ECG were measured from the paper recording. The duration of the 15th and 30th intervals after reaching the upright position was measured to calculate the "30:15 ratio" (7). To estimate the average heart rate at rest, the number of R-R intervals in the 20 seconds preceding the start of rising up was counted. To measure the average heart rate after the immediate biphasic heart rate reaction to standing up, the number of R-R intervals during the 20 seconds, beginning 30 seconds after starting to rise, was counted. A third measurement of average heart rate was done from the 20 seconds immediately after lying down again. Statistics The difference between the two test conditions in elderly subjects was evaluated by Wilcoxon's signed rank test, and the difference between
Orthostatic testing
controls and old subjects by the Mann-Whitney Utest. Correlation coefficient r was calculated for the fall in blood pressure in the two tests.
RESULTS 1. Systolic and diastolic blood pressure Table 1 shows the mean systolic and diastolic blood pressures when the subjects actively stood up or were passively tilted to erect position; no significant differences between these two test conditions were observed with regard to changes in the systolic and diastolic blood pressure. In both test conditions, the systolic (p
