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(Stroke. 1997;28:2169-2173.)
© 1997 American Heart Association, Inc.

Articles

Postural Dysregulation in Systolic Blood Pressure Is Associated With Worsened Scoring on Neurobehavioral Function Tests and Leukoaraiosis in the Older Elderly Living in a Community

Kozo Matsubayashi, MD; Kiyohito Okumiya, MD; Tomoko Wada, MD; Yasushi Osaki, MD; Michiko Fujisawa, MD; Yoshinori Doi, MD; Toshio Ozawa, MD

From the Department of Medicine and Geriatrics, Kochi Medical School (K.M., K.O., T.W., Y.O., M.F., Y.D.), Kochi, Tokyo Metropolitan Geriatric Hospital (T.O.), Tokyo, Japan.

Correspondence to Kozo Matsubayashi, MD, Department of Medicine and Geriatrics, Kochi Medical School, Okocho, Kohasu, 783, Nankoku City, Kochi, Japan.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose Postural hypotension, which occurs frequently in community-living, apparently healthy elderly adults, is usually asymptomatic. However, the relation between postural changes in blood pressure and quantitative higher cerebral function or silent brain lesions remains unclear. We examined the association of exaggerated postural changes in systolic blood pressure with cognitive and quantitative neurobehavioral functions and with brain lesions on MRI in the community-dwelling older elderly.

Methods The study population consisted of 334 community-dwelling elderly adults, aged 75 years or older (mean age, 80 years). Postural changes in systolic blood pressure (SBP) were assessed using an autosphygmomanometer (BP-203 I). By the difference between the mean of two measurements of SBP at standing and at supine position (dSBP=SBP at upright-SBP at supine position), we divided the subjects into three groups: (1) 20 subjects with postural hypotension (d-SBP -20 mm Hg), (2) 29 subjects with postural hypertension (dSBP 20 mm Hg), and (3) 285 subjects with postural normotension (20<dSBP<20 mm Hg). We defined the former two groups as the postural dysregulation group. Scores in four neurobehavioral function tests (Mini-Mental State Exam, Hasegawa Dementia Scale Revised, computer-assisted visuospatial cognitive performance score, and the Up and Go Test) and activities of daily living were compared among the three groups. Brain lesions on MRI, including number of lacunes and periventricular hyperintense lesions, were compared among 15 age- and sex-matched control subjects with postural hypotension, 15 with postural hypertension, and 30 with postural normotension.

Results Twenty subjects (6.0%) exhibited postural hypotension and 29 (8.7%) postural hypertension. Scores in neurobehavioral functions and activities of daily living were significantly lower in the postural dysregulation group (both postural hypotension and hypertension groups) than in the postural normotension group. The postural dysregulation group exhibited significantly more advanced periventricular hyperintensities than the normotension group.

Conclusions Asymptomatic community-dwelling elderly individuals with postural hypotension as well as those with postural hypertension had poorer scores on neurobehavioral function tests and more advanced leukoaraiosis demonstrated on MRI than those without exaggerated postural changes in SBP.

Key Words: blood pressure • elderly • leukoaraiosis

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
With advancing age, SBP rises¹ and postural change in BP increases.² PH may have clinical significance in geriatric medicine as an important risk factor for falls and syncope in older patients.^{3 4} On the other hand, PH in community-living healthy elderly is usually asymptomatic.^{5 6} Prevalence rates of PH in the elderly population range from 4% to 33%, according to study populations or the definition of PH.⁷ Although PH found frequently among older elderly people is associated with a variety of chronic disorders, the prognostic significance of PH remains controversial.^{8 9} The relationship between PH and silent brain lesions in the apparently healthy elderly population also remains undetermined. In contrast to PH, the clinical significance of a postural elevation in BP has received scant attention. Although a few authors have referred to "orthostatic hypertension" in case reports,^{10 11} its clinical significance in the elderly population also remains unclear.

Since 1991, we have conducted a comprehensive geriatric assessment in the community-dwelling elderly in Kahoku, a rural Japanese town in which 32% of the population is 65 years or older (Kahoku Study).^{12 13 14} We assessed postural variability in BP and neurobehavioral functions in elderly subjects aged 75 or older in Kahoku in a cross-sectional study and found some elderly subjects who showed exaggerated postural changes in SBP associated with worsened scoring on neurobehavioral function tests. We have also reported incidental leukoaraiosis associated with cognitive and neurobehavioral impairments in apparently normal elderly individuals.¹⁵ In this report, we discuss the association between postural variability in SBP and neurobehavioral functions as well as silent brain lesions on MRI in community-dwelling elderly individuals in Japan.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Study Population
The study population consisted of 334 elderly people aged 75 years or older (152 men and 182 women; mean age, 80±5 years) living in Kahoku, who constituted 49% of the eligible population in this town. All subjects were people who visited and utilized the free health screening, counseling, and educational services of the Kahoku Study. Subjects with definite neurological diseases, such as parkinsonism and stroke, and those who were too severely ill to stand without help were excluded. Subjects with definite dementia diagnosed based on DSM-III-R¹⁶ by our neurological examinations were also excluded.

Blood Pressure Measurements and Classification
Two BP and pulse readings were recorded first with subjects in the sitting position. Subsequently, subjects were supine for at least 5 minutes, and then two BP and pulse readings were recorded in the next 5 minutes. BP and pulse rate were measured with a autosphygmomanometer (BP-203 I), with an appropriately sized cuff around the upper arm, resting next to the chest wall. We used the mean of two measurements of BP and pulse rate taken in the supine position as the baseline. The subject was then asked to stand upright without support, and BP and pulse rate were again measured in the same arm, relaxed at the side, at approximately the same level, relative to the heart, as while supine. The measurements were recorded at 1 and 2 minutes after standing.^{5 7 17} After the measurements, subjects were queried about any symptoms that developed while they were standing. We similarly used the mean of two measurements of BP and pulse rate taken in the standing position.

Using differences between the mean of two measurements of SBP while subjects were standing and while supine (dSBP=SBP at upright-SBP at supine position), we divided the subjects into three groups: (1) 20 subjects with postural hypotension (dSBP -20 mm Hg),^{5 17} (2) 29 subjects with postural hypertension (dSBP 20 mm Hg), and (3) 285 subjects with postural normotension (20<dSBP<20 mm Hg). We defined the former two groups as the postural dysregulation group.

Cognitive and Neurobehavioral Functional Assessment
We assessed cognitive and neurobehavioral function using four tests: the MMSE,¹⁸ the HDSR, the VCPS (mentioned elsewhere^{15 19} ), and the UG.²⁰ In the HDSR,²¹ a Japanese screening test for dementia that assesses verbal memory, scores range from 0 to 30. The VCPS is an eye-tracking and vigilance task. Briefly, a computer displays 10 circles, each of which corresponds to 1 of 10 keys on the keyboard. At random intervals any 1 circle abruptly changes to a star for several seconds. If a subject can correctly tap the corresponding key in time, the duration of the star's appearance (appearance time) is progressively shortened. If the tap is delayed or wrong, the next appearance time of star becomes one step longer. A test session consists of 40 trials. The accumulated shortening of each appearance time of 100 arbitrary units was regarded as the VCPS. The mean±SD score of the 68 normal Japanese elderly (mean age, 70 years) was 2261±194, while that of 25 dementia patients (mean age, 68 years) was 1090±860.²² This test measures attention, nonverbal visuospatial orientation, and reaction time, with a high score indicating better visuospatial performance. The UG is reliable and valid scale assessing balance, gait speed, and postural impairment.²⁰ The subject is observed and timed while he or she rises from an armchair, walks 3 meters, turns, walks back, and sits down again. The mean±SD time of the 68 normal Japanese elderly individuals (mean age, 70 years) was 12.5±2.8 seconds. We also evaluated eight ADL (walking, ascending stairs, feeding, dressing, toileting, bathing, grooming, and taking medicine) and rated them from 3 to 0 (score of 3=completely independent, 2=needs some help, 1=needs much help, and 0=completely dependent).¹² ADL was self-reported 1 month before the examination and confirmed by a physician when the subject was examined. The items were added to provide scores ranging from 0 to 24, with low scores indicating disability.

Brain MRI
MRI of the brain was conducted using a superconducting magnet with a main field strength of 0.5 T (G-50, Hitachi) on 15 subjects with PH, 15 with postural hypertension, and 30 with postural normotension. The brain was imaged in the axial plane in 10-mm-thick slices. T1-weighted images were obtained using a short spin-echo pause sequence with a repetition time of 600 ms and an echo time of 20 ms. Proton density and T2-weighted images were obtained using a long spin-echo pulse sequence with a repetition time of 2000 ms and echo times of 60 and 120 ms, respectively. Lacunes were defined as low-signal-intensity areas (3 mmdiameter10 mm) on T1-weighted images that were visible as hyperintense areas on T2-weighted images. Hyperintense punctate lesions on T2-weighted images were not counted as lacunes if they were not visible as low-intensity areas on T1-weighted images. Proton density images were evaluated for the extent of patchy or diffuse PVHs. The lesions were classified into four grades, as previously described.^{15 23 24} Specifically, grade 1 was defined as no white matter lesions, except for small triangular foci surrounding the frontal horns. Grade 2 was defined as caps in both anterior and posterior horns of the lateral ventricles or additional discrete patchy subcortical white matter lesions adjacent to or above the lateral ventricles. More extensive punctate periventricular white matter lesions and their early confluent stages were classified as grade 3. Marked areas of high signal intensity that reached confluence completely surrounding the lateral ventricles were defined as grade 4. The numbers of subjects with grade 1 or 2 and grade 3 or 4 in the postural hypotensive, hypertensive, and normotensive groups were compared. One author, a neurologist who was blinded to the clinical status of the subjects interpreted all MRI scans.

Statistical Analysis
Data are reported as mean±SD. ANOVA was used for 3-group comparison, and Fisher's PLSD was used for between-group comparison. ² tests were used to compare proportions of selected variables among the groups of individuals with postural hypotension, hypertension, or normotension. Student's t tests were used to compare scores of neurobehavioral function tests between postural normotension and postural dysregulation group. A probability value of .05 was considered statistically significant.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Twenty subjects (6.0%) had PH, defined as a postural drop in SBP of 20 mm Hg, and 29 subjects (8.7%) exhibited postural hypertension, defined as a postural elevation in SBP of 20 mm Hg. The other 285 subjects had postural normotension, defined as a postural change in SBP from -20 to 20 mm Hg. Only 2 subjects with postural hypotension, 1 with postural hypertension, and 2 with postural normotension complained of mild dizziness developed while standing. Table 1 shows the baseline characteristics among postural hypotension, hypertension, and normotension groups. There were no significant differences in age, gender, mean education, incidence of antihypertensive or other medications, or incidence of diabetes mellitus among three groups. Means of BP and pulse rate in sitting, supine, and standing position as well as postural changes in BP and pulse rate were compared among the three groups (Table 2). There were no significant differences in BP or pulse rate in sitting position among three groups. However, both systolic and diastolic supine BPs were significantly higher and standing BPs significantly lower in the PH group than in the postural hypertension or normotension group. Both systolic and diastolic standing BPs in the postural hypertension group were significantly higher than those in the other two groups. Table 3 shows the comparison of scores of neurobehavioral function tests and ADL as well as silent brain lesions on MRI among three groups. Scores in HDSR, VCPS, and ADL in the PH group were significantly lower than those in the postural normotension group. Scores in HDSR, VCPS, and UG test in the postural hypertension group were also lower than those in the postural normotension group. On MRI, more lacunes and more advanced PVH were revealed in the postural hypotension and hypertension groups than in the postural normotension group. Comparing the postural dysregulation group (postural hypotension and hypertension groups) and the postural normotension group, lacunar state and PVH and cognitive and neurobehavioral functions were significantly worse in the former.

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics Among Postural Hypotension, Hypertension, and Normotension Groups

View this table: [in this window] [in a new window]   Table 2. Orthostatic Changes in Blood Pressure and Pulse Rate Among the Three Study Groups

View this table: [in this window] [in a new window]   Table 3. Comparison of Scores of Neurobehavioral Function Tests and ADL, and Brain Lesions on MRI Among Postural Hypotension, Hypertension, and Normotension Groups

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The main objective of this study was to examine the association of exaggerated postural change in BP with cognitive and neurobehavioral function and with silent brain lesions in community-living older elderly individuals. Our cross-sectional data revealed that the prevalence rate of PH in community-dwelling older elderly aged 75 or older, at least in Japan, is not as high as previous studies have suggested.²⁵ Mader et al⁵ also reported a low prevalence rate of PH (10.7%) among community-dwelling elderly individuals and reported that healthy, normotensive elderly subjects without known risk factors for PH had a prevalence of PH of less than 7%. They concluded that PH was a relatively uncommon finding in the healthy elderly, its prevalence was significantly related to risk factors, and its association with falls or symptoms might be less than previously reported. The prevalence rate of PH in our study was 6.0%, which resembles the percentage of the population of healthy elderly in the study of Mader et al, although about a half of our study population took antihypertensive medications and not all were completely healthy. In contrast to PH, we found older subjects with an elevation in SBP of 20 mm Hg, called "postural hypertension" in our study. Although "orthostatic hypertension" was reported in several case studies, the definition of orthostatic hypertension remains to be established. Sapru et al¹⁰ defined orthostatic hypertension as marked hypertension at upright position with normal pressures at supine position. Streeten et al¹¹ also defined orthostatic hypertension as an increase in diastolic BP from below 90 to above 90 mm Hg after standing. In proportion to the definition of PH, we defined postural hypertension as an elevation of SBP 20 mm Hg at 1 to 2 minutes after standing. It may be noteworthy that there were not only 20 subjects (6.0%) with PH but also 29 (8.7%) with postural hypertension in our older elderly population.

Of particular note in our study is that our detailed and quantitative neurobehavioral function tests revealed significantly poorer neurobehavioral functioning not only in subjects with PH but also in those with postural hypertension compared with those functions in subjects with postural normotension. Scores in function tests in the postural dysregulation (postural hypotension and hypertension) group were significantly worse than those in the postural normotension group. This finding was independent of the effect of age, mean education, antihypertensive or other medications, or diabetes mellitus in our elderly population.

The association between postural dysregulation and poorer neurobehavioral functioning may have two possible explanations. The first is that postural dysregulation in SBP may be an indicator of "functional aging" as opposed to chronological age. More advanced functional aging of cerebral cortex resulted in worsening neurobehavioral function, and brain stem dysfunction resulted in changes altered BP regulatory mechanisms that led to poor maintenance of BP at upright posture and in exaggerated BP fluctuation. The second explanation is that long-standing, excessively altered changes in BP in the elderly may impair cerebral perfusion and bring changes, such as lacunes or leukoaraiosis, that cause neurobehavioral decline. The combined association of postural dysregulation in SBP, neurobehavioral function, and silent lesions on MRI in our study seems to support the latter hypothesis. Although PH associated with cerebral ischemia is controversial,²⁶ a few authors have reported primary orthostatic cerebral ischemia²⁷ or cerebral ischemic attacks caused by postprandial hypotension.²⁸ Recently, quantitative neurobehavioral function tests detected latent minor impairment of neurobehavioral functions in otherwise healthy older persons.^{14 29} Recent studies,^{29 30 31} including ours,¹⁵ have also revealed that leukoaraiosis in the apparently healthy elderly is associated with poorer scoring in neurobehavioral functions. In addition, there are several studies that report a significant association between leukoaraiosis and BP variation. Tohgi et al³² reported the importance of short-term variations in BP for the pathogenesis of Binswanger- and lacunar-type dementias in patients receiving antihypertensive medication. Ginanneschi et al³³ also reported the association between BP fluctuation and the pathogenesis of leukoaraiosis, and Raiha et al³⁴ reported the hemodynamic significance for the genesis of leukoaraiosis. Because reproducibility of PH is reported to be low even in symptomatic elderly individuals whose autonomic function is apparently normal,⁷ exaggerated postural change in SBP may be not always reproducible but sometimes latent. However, these potential BP dysregulatory mechanisms may be associated with latent neurobehavioral dysfunction as well as silent cerebrovascular disease. Further investigation is needed to determine whether these subjects with BP dysregulation and neurobehavioral dysfunction had unexplored risk factors, such as silent cerebrovascular occlusions.

In conclusion, asymptomatic subjects with postural hypotension as well as those with postural hypertension showed poorer scoring on neurobehavioral functions and more advanced leukoaraiosis than subjects without exaggerated postural changes in SBP in a sample of the community-dwelling elderly. A prospective study is needed to determine the prognostic significance of these findings.

	Selected Abbreviations and Acronyms

 

ADL = activities of daily living HDSR = Hasegawa Dementia Scale Revised MMSE = Mini-Mental State Exam PH = postural hypotension PVH = periventricular hyperintense lesion SBP = systolic blood pressure dSBP = difference between supine and standing measurements of SBP UG = "Up & Go" test VCPS = visuospatial cognitive performance score

	Acknowledgments

 
This work was supported by a grant-in-aid for scientific research of The Ministry of Education, Science, Sports and Culture, and a grant-in-aid for comprehensive research on aging and health of The Ministry of Welfare and Health, Tokyo, Japan. The authors express their deepest gratitude to the section of Community Health and Social Service in Kahoku town; Chizuko Nie, director of the section; and the staff of the Kahoku Study, without whose assistance this study would not have been possible.

Received April 18, 1997; revision received July 8, 1997; accepted July 8, 1997.

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