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Orthostatic Hypotension and Orthostatic Intolerance Symptoms in Geriatric Rehabilitation Inpatients, RESORT

  • Elena M. Christopoulos
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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  • Esmee M. Reijnierse
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

    Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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  • Peter W. Lange
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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  • Carel G.M. Meskers
    Affiliations
    Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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  • Andrea B. Maier
    Correspondence
    Address correspondence to Andrea B. Maier, MD, PhD, Department of Human Movement Sciences, VU University Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands.
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

    Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore
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Open AccessPublished:August 31, 2021DOI:https://doi.org/10.1016/j.jamda.2021.08.014

      Abstract

      Objectives

      Orthostatic hypotension (OH) and orthostatic intolerance symptoms are common in older community-dwelling adults and are associated with reduced quality of life and detrimental health outcomes. This study aimed to determine the prevalence, co-occurrence and determinants of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients.

      Design

      Observational, longitudinal cohort, “REStORing the health of acutely unwell adulTs” (RESORT).

      Setting and Participants

      Geriatric rehabilitation inpatients (n = 1505) of a tertiary teaching hospital in Melbourne, Australia.

      Methods

      OH was defined as a drop in systolic blood pressure by ≥20 mm Hg and/or diastolic blood pressure by ≥10 mm Hg within three 3 of moving from supine to a standing or sitting position. Symptoms were recorded following the 3 minutes. Determinants included sociodemographics, reason for admission, cognitive health, nutritional status, physical performance, frailty, morbidity, medication use, length of stay (LOS), and number of geriatric conditions. Independent t-tests, Mann-Whitney U tests or χ2 tests were used to analyze differences between inpatients with and without OH and symptoms. Logistic regression analyses were used to ascertain the determinants.

      Results

      OH and orthostatic intolerance symptoms were prevalent in 19.8% (standing: 21.4%, sitting: 18.2%) and 22.6% (standing: 25.0%, sitting: 20.2%) of inpatients, respectively. Symptoms were reported by 32.8% of inpatients with OH and 20.1% without OH. Higher number of comorbidities and geriatric conditions, low functional independence, and longer LOS were determinants of OH. Female gender, higher number of morbidities and geriatric conditions, low functional independence, depression risk, poor physical performance, musculoskeletal and “other” reasons for admission, and long LOS during geriatric rehabilitation were determinants of symptoms.

      Conclusions and Implications

      OH and orthostatic intolerance symptoms occur in one-fifth of geriatric rehabilitation inpatients, however, the co-occurrence is low and determinants differ. Poorer health in patients with orthostatic intolerance symptoms highlights the need to assess symptoms in clinical practice, independent of an OH diagnosis.

      Keywords

      Orthostatic hypotension (OH) is prevalent in 22.2% of community-dwelling older adults
      • Saedon N.I.
      • Pin Tan M.
      • Frith J.
      The prevalence of orthostatic hypotension: A systematic review and meta-analysis.
      and has been associated with lower cognition
      • Iseli R.
      • Nguyen V.T.V.
      • Sharmin S.
      • et al.
      Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis.
      and physical performance,
      • Mol A.
      • Reijnierse E.M.
      • Bui Hoang P.T.S.
      • et al.
      Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis.
      falls,
      • Mol A.
      • Bui Hoang P.T.S.
      • Sharmin S.
      • et al.
      Orthostatic hypotension and falls in older adults: A systematic review and meta-analysis.
      greater long-term risk of cardiovascular disease,
      • Ricci F.
      • Fedorowski A.
      • Radico F.
      • et al.
      Cardiovascular morbidity and mortality related to orthostatic hypotension: A meta-analysis of prospective observational studies.
      hospitalization,
      • Cohen E.
      • Grossman E.
      • Sapoznikov B.
      • et al.
      Assessment of orthostatic hypotension in the emergency room.
      and mortality
      • Ricci F.
      • Fedorowski A.
      • Radico F.
      • et al.
      Cardiovascular morbidity and mortality related to orthostatic hypotension: A meta-analysis of prospective observational studies.
      in various populations of older adults. OH is characterized by the inability to maintain blood pressure in an upright position after standing up and is defined by a drop in systolic blood pressure (SBP) by ≥20 mm Hg and/or a drop in diastolic blood pressure (DBP) by ≥10 mm Hg within 3 minutes of a postural change from supine to an upright position.
      • Freeman R.
      • Wieling W.
      • Axelrod F.B.
      • et al.
      Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
      The etiology of OH is multifactorial, and known risk factors for OH in older adults include chronological age,
      • Zhu Q.O.
      • Tan C.S.
      • Tan H.L.
      • et al.
      Orthostatic hypotension: Prevalence and associated risk factors among the ambulatory elderly in an Asian population.
      polypharmacy,
      • Rivasi G.
      • Rafanelli M.
      • Mossello E.
      • et al.
      Drug-related orthostatic hypotension: Beyond anti-hypertensive medications.
      frailty,
      • Kocyigit S.E.
      • Soysal P.
      • Bulut E.A.
      • et al.
      What is the relationship between frailty and orthostatic hypotension in older adults?.
      and multimorbidity.
      • Zhu Q.O.
      • Tan C.S.
      • Tan H.L.
      • et al.
      Orthostatic hypotension: Prevalence and associated risk factors among the ambulatory elderly in an Asian population.
      Symptoms of orthostatic intolerance are commonly associated with OH and may occur as a consequence of orthostasis-related cerebral hypoperfusion causing deprivation of cerebral oxygen.
      • Novak P.
      Orthostatic cerebral hypoperfusion syndrome.
      These symptoms most commonly encompass presyncope symptoms including dizziness, light-headedness, instability, blurred vision, and nausea upon orthostasis, which resolve on returning to recumbency. Symptoms of orthostatic intolerance are prevalent in up to 61% of acutely hospitalized geriatric inpatients
      • Vloet L.C.M.
      • Pel-Little R.E.
      • Jansen P.A.F.
      • et al.
      High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals.
      with OH and can be debilitating, resulting in decreased quality of life and poorer clinical outcomes.
      • Juraschek S.P.
      • Daya N.
      • Rawlings A.M.
      • et al.
      Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults.
      OH and orthostatic intolerance symptoms have not previously been studied in geriatric rehabilitation inpatients and may influence health and functional outcomes.
      This study aimed to investigate the prevalence, co-occurrence, and clinical determinants of OH and orthostatic intolerance symptoms and their co-occurrence in geriatric rehabilitation inpatients.

      Methods

       Study Design

      The REStORing health of acutely unwell adulTs (RESORT) study is a longitudinal, observational cohort of geriatric rehabilitation inpatients admitted to 1 of 4 subacute wards (total beds: 98) at the Royal Melbourne Hospital, a tertiary teaching hospital in Melbourne, Australia. Inpatients typically are admitted following an acute hospital stay with the aim to treat or stabilize chronic health conditions associated with aging, cognitive impairment, or disability and return to the community. Geriatric rehabilitation inpatients were assessed using a comprehensive geriatric assessment (CGA) to assess physical, cognitive, and physiological status. Inpatients underwent the CGA within 48 hours of admission, conducted by a multidisciplinary team of 12 geriatricians, nurses (am shift 1:5, pm 1:6, night 1:10 nurse-to-patient ratio plus one in-charge nurse), aligned with physiotherapists, occupational therapists, dietitians, and researchers. Inpatients admitted from October 16, 2017, until March 18, 2020, were included in the analysis. This study was approved by the Melbourne Health Human Research Ethics Committee (number: HREC/17/MH/103) and follows national and international ethical guidelines in accordance with the Helsinki Declaration,
      World Medical Association
      World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects.
      the National Statement on Ethical Conduct in Human Research, 2007,
      National Health and Medical Research Council
      National Statement on Ethical Conduct in Human Research 2007 (Updated 2018). 2018.
      and the Guidelines for Good Clinical Research Practice.
      Therapeutic Goods Administration
      Australian clinical trial handbook - guidance on conducting clincial trials in Australia using ‘unapproved’ therapuetic goods. 2018.
      Written and informed consent was provided for each inpatient or through a nominated proxy. Inpatients were excluded if they were unable to provide consent and had no legal proxy to consent, or if inpatients were receiving palliative care at admission.

       Patient Characteristics and Clinical Determinants

      Patient characteristics were collected on admission into the geriatric rehabilitation wards. Age and sex were extracted from medical records and a questionnaire regarding patient characteristics and health status was completed by the patient, next of kin, carers, or a researcher together with the patient to obtain marital status and country of birth. Body mass index was obtained by nurses who measured standing height (cm) without footwear if patients were able to stand, or knee height (cm) was measured in inpatients unable to stand using a sliding calliper, seated with knees at 90 degrees.
      • Chumlea W.C.
      • Roche A.F.
      • Steinbaugh M.L.
      Estimating stature from knee height for persons 60 to 90 years of age.
      Weight was measured to the nearest 0.1 kg on a calibrated weighing scale (standing), weighing chair (sitting), or hoist if the patient was unable to stand, without shoes or heavy clothing. Body mass index was calculated using the equation of body weight in kg, divided by height in meters squared (kg/m2). A physician assessed morbidity level using the 56-point Cumulative Illness Rating Score (CIRS).
      • Miller M.D.
      • Paradis C.F.
      • Houck P.R.
      • et al.
      Rating chronic medical illness burden in geropsychiatric practice and research: Application of the Cumulative Illness Rating Scale.
      Diseases of high severity scored higher and a higher total score indicated higher morbidity level. Number of medications were extracted from medical records and included prescribed, over-the-counter, or complementary medications. Medications that may affect blood pressure and therefore OH and orthostatic intolerance symptoms were grouped into cardiovascular medication (cardiac therapy, antihypertensives, diuretics, vasoprotectives, beta-blocking agents, calcium channel blockers, and agents acting on the renin angiotensin system) and psychotropic medication (psycholeptics and psychoanaleptics). A physician measured frailty using the clinical frailty scale (CFS),
      • Rockwood K.
      • Song X.
      • MacKnight C.
      • et al.
      A global clinical measure of fitness and frailty in elderly people.
      ranging from 1 (very fit) to 9 (terminally ill) and an occupational therapist assessed functional dependence using the Katz Activities of Daily Living (KADL)
      • Katz S.
      • Downs T.D.
      • Cash H.R.
      • et al.
      Progress in development of the index of ADL1.
      with scores ranging from 0 to 8 and higher scores indicating higher independence. Self-rated health ranging from 0 to 100 using the European quality of life-5 dimension-5 level (EuroQoL-5D-5L)
      • Herdman M.
      • Gudex C.
      • Lloyd A.
      • et al.
      Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
      was obtained via the patient questionnaire. Cognitive impairment was defined as a dementia diagnosis in medical records, the CIRS, or Charlson Comorbidity index (CCI),
      • Charlson M.E.
      • Pompei P.
      • Ales K.L.
      • et al.
      A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
      a score of <24 points in the standardized Mini-Mental-State-Examination (sMMSE),
      • Folstein M.F.
      • Folstein S.E.
      • McHugh P.R.
      “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician.
      <26 points in the Montreal Cognitive Assessment,
      • Nasreddine Z.S.
      • Phillips N.A.
      • Bédirian V.
      • et al.
      The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment.
      or <23 points in the Rowland Universal Dementia Assessment.
      • Storey J.E.
      • Rowland J.T.
      • Basic D.
      • et al.
      The Rowland Universal Dementia Assessment Scale (RUDAS): A multicultural cognitive assessment scale.
      Delirium was defined as an abnormal short Confusion Assessment Method score
      • Inouye S.K.
      • van Dyck C.H.
      • Alessi C.A.
      • et al.
      Clarifying confusion: The confusion assessment method. A new method for detection of delirium.
      or a delirium diagnosis in the CIRS. Anxiety and depression symptoms were self-reported via the patient questionnaire using the Hospital Anxiety and Depression Scale (HADS)
      • Snaith R.P.
      The Hospital Anxiety and Depression Scale.
      and higher scores indicated greater severity of symptoms. A nurse assessed the risk of malnutrition using the Malnutrition Screening Tool (MST)
      • Ferguson M.
      • Capra S.
      • Bauer J.
      • et al.
      Development of a valid and reliable malnutrition screening tool for adult acute hospital patients.
      ranging from 0 to 5 points and scores ≥2 points indicated malnutrition risk. Assessment by a physiotherapist encompassed the Short Physical Performance Battery (SPPB) including a balance test, a 4-m walk test (to measure gait speed), and the timed chair stand test, scored out of 4 points each,
      • Guralnik J.M.
      • Simonsick E.M.
      • Ferrucci L.
      • et al.
      A Short Physical Performance Battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.
      with a total score of 12 points and higher scores indicating higher levels of physical function. Maximal handgrip strength (kg) was measured using a hand-held dynamometer (JAMAR; Sammons Preston, Inc., Bolingbrook, IL) with 3 trials attempted on both hands, alternating between the right and left hand on each attempt.
      • Reijnierse E.M.
      • de Jong N.
      • Trappenburg M.C.
      • et al.
      Assessment of maximal handgrip strength: How many attempts are needed?.
      Surgical admissions
      • Jans Ø.
      • Kehlet H.
      Postoperative orthostatic intolerance: A common perioperative problem with few available solutions.
      and primary reasons for hospitalization were extracted from medical records including musculoskeletal, neurological, and cardiovascular conditions
      • Ricci F.
      • De Caterina R.
      • Fedorowski A.
      Orthostatic hypotension: Epidemiology, prognosis, and treatment.
      and other reasons for hospitalization. Length of stay (LOS) in both acute and geriatric rehabilitation admissions was extracted from medical records.

       Blood Pressure Measurements

      Blood pressure was measured by a nurse with a digital sphygmomanometer at rest following at least 5 minutes in a supine position and at 1 and 3 minutes after performing a postural change from supine to standing as quickly as possible (with assistance from a nurse if required). If inpatients were unable to stand or had a medical reason preventing them from standing, blood pressure was measured in a sitting position. OH was defined as a decrease of SBP by ≥20 mm Hg and/or DBP by ≥10 mm Hg within 3 minutes after the postural change.
      • Freeman R.
      • Wieling W.
      • Axelrod F.B.
      • et al.
      Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
      Directly after the last blood pressure measurement, inpatients were queried for any symptoms of orthostatic intolerance, including dizziness, light-headedness, blurred vision, instability, or any other symptoms experienced after the postural change during the upright position.

       Statistical Analysis

      Analyses were split by position of blood pressure measurement (standing or sitting) and inpatient characteristics were analyzed using descriptive statistics. Categorical variables were reported as numeric values (n) with percentages (%). Continuous variables were assessed for normality via a Shapiro-Wilk test and visual inspection of histograms and reported as mean and standard deviation (SD) or median and interquartile range [IQR]. Independent t-tests or Mann-Whitney U tests were used to test differences between continuous variables, and χ2 tests were used to analyze differences between categorical variables of inpatients with and without OH or orthostatic intolerance symptoms. Logistic regression analyses were performed and subsequently, variables with P values ≤.20 were included in multivariate analysis to ascertain the determinants of both OH and symptoms. Percentage of cumulative geriatric conditions were calculated by counting the number of abnormal conditions (based on the median values of the cohort) including number of medications ≥9, malnutrition risk (≥2 points using the MST), cognitive impairment diagnosis, total SPPB score <1, KADL score <2, CFS >6, CIRS score >12, and geriatric rehabilitation LOS >20 days. A percentage of the maximum of 8 geriatric conditions was calculated. P values ≤0.05 were considered statistically significant. Data analyses were performed using the Statistical Package for the Social Sciences (SPSS) (IBM SPSS Advanced Statistics 27.0; IBM Corp, Armonk, NY).

      Results

       Patient Characteristics

      A total of 1890 inpatients were included in RESORT. OH prevalence and position of blood pressure data were not available in 278 (14.7%) and 107 (5.7%) inpatients, respectively, leaving a total of 1505 inpatients included in the analysis. Of these inpatients, 754 (50.1%) performed the blood pressure assessment while standing and 751 (49.9%) while sitting. In 19 inpatients (1.3%), orthostatic intolerance symptoms were missing. Overall, the mean age was 82.8 (8.0) SD years (56.1% women). Patients who were able to perform the blood pressure assessment in a standing position had a lower risk of malnutrition and depression, had better physical performance, fewer geriatric conditions, and had a shorter LOS compared with inpatients performing the test in a sitting position (Table 1).
      Table 1Patient Characteristics at Admission to Geriatric Rehabilitation, Stratified by Position of Blood Pressure Measurement
      CharacteristicsNTotal, N = 1505Standing, n = 754Sitting, n = 751P Value
      Sociodemographics
       Age, y, mean (SD)150582.8 (8.0)82.5 (7.9)83.2 (8.1).09
       Female, n (%)1505844 (56.1)398 (52.8)446 (59.4).010
       Married, n (%)1503578 (38.5)295 (39.1)283 (37.8).59
       Born in Australia, n (%)1501643 (42.8)309 (41.0)334 (44.7).16
      Health characteristics
       Body mass index (kg/m2), mean (SD)148426.8 (6.3)27.1 (6.2)26.6 (6.3).14
       CIRS score
      CIRS: ranges 0–56.
      150412 [9–16]12 [8–16]13 [9–17].007
       Number of medications, mean (SD)15059.5 (4.3)9.2 (4.4)9.8 (4.2).009
       Cardiovascular medication, n (%)15051099 (73.0)541 (71.8)558 (74.3).27
       Psychotropic medication, n (%)1505711 (47.2)354 (46.9)357 (47.5).82
       CFS
      CFS: ranges 1–9.
      , score
      13666 [5–7]6 [5–6]6 [6–7]<.001
       Malnutrition risk (MST
      MST: ranges 0–5 points.
      ), n (%)
      1501621 (41.4)260 (34.6)361 (48.2)<.001
       KADL, score14862 [1–3]2 [1–3]1 [0–2]<.001
       Self-rated health (EuroQoL-5D-5L
      EuroQoL-5D-5L: ranges 0–100.
      )
      96950 [35–70]58 [45–71]50 [30–70]<.001
      Cognitive health
       Cognitively impaired, n (%)1505989 (65.7)477 (63.3)512 (68.2).045
       Delirium, n (%)1505354 (23.5)159 (21.1)195 (26.0).026
       HADS
      HADS: ranges 0–21.
      depression, score
      10447 [3–11]6 [3–10]8 [4–12]<.001
       HADS
      HADS: ranges 0–21.
      anxiety, score
      10267 [3–10]6 [2–10]7 [3–11].010
      Physical performance
       SPPB
      SPPB ranges 0–12.
      , score
      14311 [0–4]3 [1–5]0 [0–2]<.001
       Balance test
      Balance test and chair stand test: ranges 0–4.
      , score
      14400 [0–2]1 [0–3]0 [0–1]<.001
       Gait speed (m/s), mean (SD)8890.5 (0.2)0.5 (0.2)0.4 (0.2)<.001
       Chair stand test
      Balance test and chair stand test: ranges 0–4.
      , score
      14520 [0–0]0 [0–1]0 [0–0]<.001
       Handgrip strength men (kg), mean (SD)61619.2 (9.5)21.2 (8.8)16.8 (9.9)<.001
       Handgrip strength women (kg), mean (SD)78112.2 (6.7)13.4 (6.1)11.1 (7.1)<.001
      Geriatric conditions
       Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      150571.4 [50.0–87.5]57.1 [37.5–75.0]75.0 [62.5–87.5]<.001
      Primary reason for hospital admission, n (%)
       Musculoskeletal1505696 (46.2)308 (40.8)388 (51.7)<.001
       Neurological1505224 (14.9)102 (13.5)122 (16.2).14
       Cardiac1505121 (8.0)84 (11.1)37 (4.9)<.001
       Other
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      1505464 (30.9)260 (34.6)204 (27.2).002
      Surgical admission1501238 (15.9)98 (13.0)140 (18.7).002
      LOS
       Acute, days14627.2 [4.1–12.6]6.9 [3.9–11.3]7.7 [4.2–13.5].011
       Geriatric rehabilitation, days150519.8 [13.0–30.3]15.9 [11.0–24.9]23.0 [15.7–37.1]<.001
      Data are presented as median [IQR] unless otherwise indicated. P values ≤ .05 are considered significant (bold).
      CIRS: ranges 0–56.
      CFS: ranges 1–9.
      MST: ranges 0–5 points.
      § EuroQoL-5D-5L: ranges 0–100.
      HADS: ranges 0–21.
      ∗∗ SPPB ranges 0–12.
      †† Balance test and chair stand test: ranges 0–4.
      ‡‡ Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      §§ Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.

       Prevalence of OH and Orthostatic Intolerance Symptoms

      OH prevalence was 19.8% (standing: 21.4%, sitting: 18.2%) and 22.6% experienced orthostatic intolerance symptoms (standing: 25.0%, sitting: 20.2%) (Figure 1A). Of the inpatients with OH, 32.8% experienced symptoms (standing: 35.4%, sitting: 29.6%) and 20.1% of inpatients without OH also experienced symptoms (standing: 22.2%, sitting: 18.1%) (Figure 1B). Resting supine SBP and DBP were significantly higher, and 1- and 3-minute SBP and DBP were significantly lower in both sitting and standing inpatients with OH compared with those without OH. Heart rate was not different between the groups.
      Figure thumbnail gr1
      Fig. 1Prevalence of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients. (A) OH and orthostatic intolerance symptoms prevalence, (B) co-occurence of OH and orthostatic intolerance symptoms, (C) types of orthostatic intolerance symptoms prevalence in symptomatic inpatients stratified by OH diagnosis. ∗Other symptoms included pain, palpitations, and headache on postural change. P values obtained via χ2 tests.
      Overall, symptomatic standing and sitting inpatients had larger decreases in SBP and DBP and higher heart rate compared with asymptomatic inpatients (Supplementary Table 1). Symptomatic standing inpatients with OH had significantly larger drops in SBP compared with asymptomatic inpatients, whereas other hemodynamic measures were similar. Symptomatic standing inpatients without OH had significantly larger increases in SBP at 3 minutes and a higher increase in heart rate at 1 and 3 minutes compared with asymptomatic inpatients. These trends were not observed in inpatients in a sitting position (Supplementary Table 2). Light-headedness, dizziness, and instability were more prevalent in inpatients with OH compared with those without OH (Figure 1C). Standing and sitting inpatients who reported symptoms both reported a median of 1 [1–2] symptoms.

       Clinical Determinants

      Inpatients with OH while standing had significantly lower KADL scores, higher numbers of geriatric conditions, and longer LOS during acute hospitalization, while sitting inpatients with OH had significantly higher CIRS scores in comparison with inpatients without OH. Symptomatic inpatients while standing had higher CIRS and HADS depression scores; lower KADL, total SPPB, balance, and chair stand test scores; a higher number of geriatric conditions; were less likely to have musculoskeletal reasons for admission; and have longer LOS in geriatric rehabilitation compared with asymptomatic inpatients. Symptomatic sitting inpatients were significantly more likely to be women; have lower total SPPB, chair stand, and balance test scores; and slower gait speed, and were less likely to have “other” reasons for hospital admission compared with asymptomatic inpatients (Table 2). Multivariate analyses showed that longer LOS during acute hospitalization in standing inpatients and higher CIRS scores in sitting inpatients were determinants of OH (Table 3). None of the determinants were independently associated with orthostatic intolerance symptoms (Table 3).
      Table 2Clinical Determinants of OH and Orthostatic Intolerance Symptoms at Admission in Geriatric Rehabilitation Inpatients, Stratified by Position of Blood Pressure Measurement (Logistic Regression Analyses)
      CharacteristicsOHOrthostatic Intolerance Symptoms
      YesNoOR 95% CIP ValueYesNoOR 95% CIP Value
      Standingn = 161n = 593n = 186n = 558
       Sociodemographics
      Age, y, mean (SD)82.5 (7.2)82.5 (8.2)1.00 [0.98–1.02].9482.3 (8.5)82.5 (7.8)0.99 [0.98–1.02].87
      Female, n (%)87 (54.0)311 (52.4)1.07 [0.75–1.51].72104 (55.9)289 (51.8)1.18 [0.85–1.65].33
       Health characteristics
      Body mass index (kg/m2), mean (SD)26.4 (6.3)27.3 (6.2)0.98 [0.95–1.01].1427.1 (6.4)27.1 (6.2)1.00 [0.97–1.03].99
      CIRS
      CIRS: ranges 0–56.
      , score
      13 [9–15]12 [8–16]1.01 [0.98–1.05].3213 [9–17]12 [8–15]1.03 [1.00–1.07].032
      Number of medications, mean (SD)9.2 (4.4)9.3 (4.4)0.99 [0.96–1.04].849.4 (4.2)9.1 (4.4)1.02 [0.98–1.06].35
      Cardiovascular medication, n (%)110 (68.3)431 (72.7)1.23 [0.85–1.80].28134 (72.0)401 (71.9)0.99 [0.69–1.43].96
      Psychotropic medication, n (%)75 (46.6)279 (47.0)1.02 [0.72–1.45].9296 (51.6)255 (45.7)0.79 [0.57–1.10].16
      CFS
      CFS: ranges 1–9.
      , score
      6 [5–6]6 [5–6]1.16 [0.99–1.35].066 [5–6]6 [5–6]1.14 [0.99–1.31].08
      Malnutrition risk (MST
      MST: ranges 0–5 points.
      ), n (%)
      63 (39.4)197 (33.3)0.77 [0.54–1.10].1575 (40.3)185 (33.2)0.74 [0.52–1.04].08
      KADL, score2 [1–3]2 [1–3]0.89 [0.79–0.99].0382 [1–3]2 [1–3]0.88 [0.79–0.98].019
      Self-rated health (EuroQoL-5D-5L
      EuroQoL-5D-5L: ranges 0–100.
      )
      50 [40–70]60 [40–73]1.00 [0.99–1.01].8850 [40–75]60 [50–72]0.99 [0.99–1.01].71
       Cognitive health
      Cognitively impaired, n (%)111 (68.9)366 (617)0.73 [0.50–1.05].09119 (64.0)351 (62.9)0.96 [0.68–1.35].79
      Delirium, n (%)31 (19.3)128 (21.6)1.15 [0.75–1.79].5240 (21.5)117 (21.0)0.97 [0.97–0.65].88
      HADS
      HADS: ranges 0–21.
      depression, score
      6 [3–10]6 [3–10]0.99 [0.95–1.04].897 [3–12]6 [3–9]1.06 [1.02–1.10].005
      HADS
      HADS: ranges 0–21.
      anxiety, score
      5 [2–9.5]6 [3–10]0.98 [0.93–1.02].286 [2–11.8]6 [2.5–9]1.03 [0.99–1.07].16
       Physical performance
      SPPB
      SPPB ranges 0–12.
      , score
      3 [1–5.5]3 [1–5]1.02 [0.96–1.08].572 [0–4]3 [1–5]0.92 [0.86–0.98].006
      Balance test
      Balance test and chair stand test: ranges 0–4.
      , score
      1 [0–3]1 [0–2]1.04 [0.92–1.18].531 [0–2]2 [0–3]0.87 [0.77–0.98].025
      Gait speed (m/s), mean (SD)0.5 (0.2)0.5 (0.2)1.17 [0.48–2.84].730.5 (0.2)0.5 (0.2)0.66 [0.27–1.60].35
      Chair stand test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–1]0 [0–1]0.98 [0.88–1.09].680 [0–1]0 [0–1]0.89 [0.80–0.99].040
      Handgrip strength (kg), mean (SD)17.6 (8.4)16.9 (8.4)1.15 [0.94–1.41].1716.4 (8.1)17.3 (8.5)0.93 [0.76–1.12].43
       Geriatric conditions
      Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      62.5 [50.0–75.0]57.1 [37.5–75.0]1.01 [1.00–1.02].04262.5 [50.0–77.7]50.0 [37.5–75.0]1.02 [1.01–1.03]<.001
       Primary reason for hospital admission, n (%)
      Musculoskeletal63 (39.1)240 (41.3)1.09 [0.77–1.56].6264 (34.4)240 (43.0)1.44 [1.02–2.03].039
      Cardiac16 (9.9)68 (11.5)1.17 [0.66–2.09].5925 (13.4)59 (10.6)0.76 [0.46–1.26].29
      Neurological22 (13.7)80 (13.5)0.99 [0.59–1.64].9526 (14.0)75 (13.4)0.96 [0.59–1.55].85
      Other
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      123 (76.4)445 (75.0)0.86 [0.59–1.23].40135 (72.6)424 (76.0)0.79 [0.57–1.13].19
       Surgical admission17 (10.6)81 (13.7)1.34 [0.77–2.34].2927 (14.6)68 (12.2)0.81 [0.50–1.31].39
       LOS
      Acute, d8.8 [3.9–13.5]6.7 [3.9–10.9]1.02 [1.00–1.04].0227.2 [3.9–12.4]6.7 [3.9–11.2]1.00 [0.98–1.02].74
      Geriatric rehabilitation, d15.9 [10.8–25.7]15.9 [11.1–24.0]1.00 [0.99–1.01].5818.0 [11.8–26.9]15.3 [10.9–23.1]1.01 [1.00–1.02].021
      Sittingn = 137n = 614n = 150n = 592
       Sociodemographics
      Age, y, mean (SD)83.6 (7.7)83.1 (8.2)1.00 [0.98–1.03].5383.9 (8.2)83.1 (7.9)1.01 [0.99–1.04].24
      Female, n (%)75 (54.7)371 (60.4)0.79 [0.55–1.15].22101 (67.3)340 (57.4)1.53 [1.05–2.23].028
       Health characteristics
      Body mass index (kg/m2), mean (SD)27.0 (6.5)26.5 (6.3)1.01 [0.98–1.04].3926.6 (6.6)26.5 (6.2)1.00 [0.97–1.03].88
      CIRS
      CIRS: ranges 0–56.
      , score
      13 [10–18]12.5 [9–16]1.04 [1.01–1.07].02213 [9–17]13 [9–17]1.01 [0.98–1.04].71
      Number of medications, mean (SD)10.1 (4.5)9.7 (4.1)1.02 [0.98–1.07].369.9 (4.3)9.8 (4.2)1.01 [0.97–1.05].77
      Cardiovascular medication, n (%)105 (76.6)453 (73.8)0.86 [0.56–1.32].49107 (71.3)445 (75.2)1.22 [0.82–1.82].34
      Psychotropic medication, n (%)70 (51.1)287 (46.7)0.84 [0.58–1.21].3677 (51.3)275 (46.5)0.82 [0.58–1.18].29
      CFS
      CFS: ranges 1–9.
      , score
      6 [6–7]6 [6–7]1.06 [0.89–1.25].496 [6–7]6 [6–7]1.11 [0.94–1.31].23
      Malnutrition risk (MST
      MST: ranges 0–5 points.
      ), n (%)
      68 (49.6)293 (47.9)0.93 [0.64–1.35].7176 (50.7)280 (47.5)0.88 [0.61–1.26].48
      KADL, score1 [0–2]1 [0–2]0.96 [0.82–1.12].591 [0–2]1 [0–2]0.98 [0.85–1.14].79
      Self-rated health (EuroQoL-5D-5L
      EuroQoL-5D-5L: ranges 0–100.
      )
      50 [30–60]50 [30–70]0.99 [0.99–1.00].2650 [30–60]50 [30–70]0.99 [0.99–1.01].59
       Cognitive health
      Cognitively impaired, n (%)90 (65.7)422 (68.7)1.15 [0.78–1.69].4999 (66.0)409 (69.1)1.15 [0.79–1.68].47
      Delirium, n (%)41 (29.9)154 (25.1)0.78 [0.52–1.18].2437 (24.7)155 (26.2)1.08 [0.72–1.64].71
      HADS
      HADS: ranges 0–21.
      depression, score
      6 [3–12]8 [4–12]0.96 [0.92–1.00].089 [4–12]8 [4–12]1.02 [0.97–1.06].48
      HADS
      HADS: ranges 0–21.
      anxiety, score
      7 [2–10.5]7 [3–11]0.98 [0.94–1.03].448 [4–11.5]7 [3–11]1.03 [0.99–1.08].14
       Physical performance
      SPPB
      SPPB ranges 0–12.
      , score
      0 [0–1]0 [0–2]0.99 [0.90–1.09].860 [0–1]0 [0–2]0.89 [0.80–0.99].037
      Balance test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–1]0 [0–1]0.99 [0.83–1.18].920 [0–0]0 [0–1]0.82 [0.68–0.99].049
      Gait speed (m/s), mean (SD)0.4 (0.2)0.4 (0.2)2.56 [0.56–11.72].230.3 (0.2)0.4 (0.2)0.09 [0.02–0.55].009
      Chair stand test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–0]0 [0–0]0.96 [0.79–1.17].670 [0–0]0 [0–0]0.75 [0.58–0.97].028
      Handgrip strength (kg), mean (SD)14.1 (9.0)13.4 (8.8)1.06 [0.87–1.28].5812.4 (7.8)13.7 (9.0)0.95 [0.78–1.14].55
       Geriatric conditions
      Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      75.0 [62.5–87.5]75.0 [62.5–87.5]1.00 [0.99–1.01].4975.0 [62.5–87.5]75.0 [62.5–87.5]1.01 [0.99–1.02].34
       Primary reason for hospital admission, n (%)
      Musculoskeletal71 (51.8)317 (51.6)0.99 [0.69–1.44].9788 (58.6)297 (50.2)0.71 [0.49–1.02].06
      Cardiac27 (19.7)95 (15.5)1.45 [0.56–3.79].457 (4.7)29 (4.9)1.05 [0.45–2.45].91
      Neurological5 (3.6)32 (5.2)0.75 [0.46–1.19].2325 (16.7)96 (16.2)0.97 [0.59–1.57].89
      Other
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      34 (24.8)170 (27.7)1.16 [0.76–1.78].4930 (20.0)170 (28.7)1.61 [1.04–2.49].033
       Surgical admission23 (16.8)117 (19.1)1.17 [0.72–1.92].5229 (19.5)109 (18.5)0.94 [0.59–1.48].78
       LOS
      Acute, d8.8 [5.1–15.7]7.5 [4.2–13.0]1.00 [0.99–1.02].597.2 [4.5–12.0]7.7 [4.1–13.7]0.99 [0.97–1.01].36
      Geriatric rehabilitation, d25.3 [15.8–36.0]22.8 [15.4–37.8]0.99 [0.99–1.00].5221.9 [15.6–33.5]23.7 [15.7–37.7]0.99 [0.99–1.01].68
      Data are presented as median [IQR] unless otherwise indicated. P values ≤0.05 are considered significant (bold).
      CI, confidence interval; OR, odds ratio.
      CIRS: ranges 0–56.
      CFS: ranges 1–9.
      MST: ranges 0–5 points.
      § EuroQoL-5D-5L: ranges 0–100.
      HADS: ranges 0–21.
      ∗∗ SPPB ranges 0–12.
      †† Balance test and chair stand test: ranges 0–4.
      ‡‡ Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      §§ Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      Table 3Clinical Determinants of OH and Orthostatic Intolerance Symptoms at Admission in Geriatric Rehabilitation Inpatients, Stratified by Position of Blood Pressure Measurement (Multivariate Logistic Analyses)
      CharacteristicsOHOrthostatic Intolerance Symptoms
      OR 95% CIP ValueOR 95% CIP Value
      Standingn = 754n = 744
       Body mass index0.98 [0.95–1.01].19
       Cumulative illness rating scale, score1.02 [0.98–1.07].35
       Psychotropic medication use0.86 [0.55–1.36].52
       CFS, score1.14 [0.94–1.38].191.07 [0.86–1.33].55
       Malnutrition risk (MST)1.13 [0.69–1.85].621.35 [0.77–2.36].29
       KADL, score0.92 [0.79–1.08].290.91 [0.76–1.09].33
       Cognitive impairment1.33 [0.84–2.12].23
       HADS depression, score1.05 [0.98–1.12].15
       HADS anxiety, score0.98 [0.93–1.05].61
       SPPB, score1.01 [0.92–1.11].87
       Handgrip strength1.25 [0.99–1.59].06
       Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days.
      1.00 [0.99–1.02].971.01 [0.98–1.03].62
       Musculoskeletal reason for admission0.93 [0.51–1.72].83
       “Other” reasons for admission
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry. LOS: Length of stay. P values ≤ .05 are considered significant (bold).
      1.37 [0.76–2.49].30
       LOS in acute hospitalization, d1.02 [1.00–1.05].042
       LOS in geriatric rehabilitation, d1.01 [0.99–1.02].19
      Sittingn = 751n = 742
       Female gender0.69 [0.42–1.12].13
       Cumulative illness rating scale, score1.04 [1.00–1.08].043
       HADS depression, score0.96 [0.92–1.01].06
       HADS anxiety, score1.03 [0.98–1.08].20
       SPPB, score0.92 [0.82–1.04].18
       Musculoskeletal reason for admission0.93 [0.52–1.66].81
       Other reasons for admission
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry. LOS: Length of stay. P values ≤ .05 are considered significant (bold).
      0.58 [0.29–1.18].13
      CI, confidence interval; OR, odds ratio.
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days.
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry. LOS: Length of stay. P values ≤ .05 are considered significant (bold).

       OH and Orthostatic Intolerance Symptoms Overlap

      Standing inpatients with OH and symptoms had higher HADS depression scores, lower total SPPB and balance test scores, and a higher number of geriatric conditions compared with asymptomatic inpatients with OH. Symptomatic standing inpatients without OH were significantly more likely to have lower KADL scores, a higher number of geriatric conditions, and were more likely to have musculoskeletal reasons for admission and have longer LOS in geriatric rehabilitation compared with asymptomatic inpatients without OH. Sitting inpatients with symptomatic OH were significantly more likely to have lower CFS scores and higher HADS anxiety scores, and less likely to be cognitively impaired than asymptomatic OH inpatients. Symptomatic sitting inpatients without OH were significantly older, had higher CFS scores, and slower gait speed compared with asymptomatic inpatients without OH (Table 4).
      Table 4Clinical Determinants Dependent on Orthostatic Intolerance Symptoms, Stratified by OH Diagnosis and Position of Blood Pressure Measurement in Geriatric Rehabilitation Inpatients
      CharacteristicsOHNo OH
      SymptomsNo SymptomsP ValueSymptomsNo SymptomsP Value
      Standingn = 56n = 102n = 130n = 456
       Sociodemographics
      Age, y, mean (SD)82.4 (7.3)82.3 (7.1).998.3 (9.0)82.5 (7.9).85
      Female, n (%)32 (57.1)54 (52.9).6172 (55.4)235 (51.5).44
       Health characteristics
      Body mass index, kg/m2, mean (SD)26.0 (6.9)26.7 (6.1).5427.5 (6.1)27.2 (6.3).55
      Cumulative illness rating scale
      CIRS: ranges 0–56.
      , score
      13 [9–18]12 [9–15].2112 [9–17]11 [8–15].11
      Number of medications, mean (SD)9.2 (4.1)9.3 (4.6).939.6 (4.3)9.1 (4.4).17
      Cardiovascular medication, n (%)40 (71.4)68 (66.7).5494 (72.3)333 (73.0).87
      Psychotropic medication, n (%)27 (48.2)48 (47.1).8969 (53.1)207 (45.4).12
      CFS
      CFS: ranges 1–9.
      , score
      6 [5–6]6 [5–6].696 [5–6.5]6 [4–6].09
      Malnutrition risk (MST
      MST: ranges 0–5 points.
      ), n (%)
      27 (48.2)36 (35.3).1148 (36.9)149 (32.7).37
      KADL, score2 [1–3]2 [1–3].372 [1–3.5]2 [1–3.5].016
      Self-rated health (EuroQoL-5D-5L
      EuroQoL-5D-5L: ranges 0–100.
      )
      50 [40–70]60 [50–75].2360 [42.5–75]60 [46.3–71.5].85
       Cognitive health
      Cognitively impaired, n (%)37 (66.1)71 (69.6).6582 (63.1)280 (61.4).73
      Delirium, n (%)13 (23.2)17 (16.7).3227 (20.8)100 (21.9).78
      HADS
      HADS: ranges 0–21.
      depression, score
      6 [3–13]5 [2–9].0357 [3–11]6 [3–9].25
      HADS
      HADS: ranges 0–21.
      anxiety, score
      8 [2–11.5]5 [2–8].196 [2–12]6 [3–9.3].67
       Physical performance
      SPPB
      SPPB ranges 0–12.
      , score
      2 [0–4]4 [2–6].0012.5 [0–5]3 [1–5].05
      Balance test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [1–2]2 [1–3].0031 [0–2]1 [0–2].34
      Gait speed, m/s, mean (SD)0.5 (0.2)0.5 (0.2).360.5 (0.2)0.5 (0.2).55
      Chair stand test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–0.5]0 [0–1].210 [0–1]0 [0–1].11
      Handgrip strength (kg), mean (SD)17.7 (8.3)18.8 (7.6).2617.0 (6.9)17.8 (8.0).68
       Geriatric conditions
      Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      71.4 [50.0–87.5]57.1 [37.5–75.0].01062.5 [50.0–75.0]50.0 [37.5–75.0].002
       Primary reason for hospital admission, n (%)
      Musculoskeletal20 (35.7)41 (40.2).5844 (33.8)199 (43.6).046
      Cardiac6 (10.7)10 (9.8).8619 (14.6)49 (10.7).22
      Neurological7 (12.5)15 (14.7).7019 (14.6)60 (13.2).67
      Other
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      23 (41.1)36 (35.3).4748 (37.0)148 (32.5).34
       Surgical admission5 (8.9)10 (9.8).8622 (17.1)58 (12.7).21
       LOS
      Acute, d9.1 [3.6–11.8]8.8 [4.2–14.9].556.9 [4.0–12.5]6.6 [3.9–10.7].23
      Geriatric rehabilitation, d17.9 [11.7–25.9]14.8 [10.0–24.9].1818.0 [11.8–27.4]15.7 [11.0–23.1].021
      Sittingn = 40n = 95n = 110n = 497
       Sociodemographics
      Age, y, mean (SD)81.6 (8.3)84.4 (7.4).0684.8 (8.1)82.8 (8.1).023
      Female, n (%)26 (65.0)48 (50.5).1275 (68.2)292 (58.8).07
       Health characteristics
      Body mass index, kg/m2, mean (SD)26.8 (7.0)26.9 (5.9).9626.6 (6.4)26.5 (6.3).90
      Cumulative illness rating scale
      CIRS: ranges 0–56.
      , score
      13 [8–18]14 [10–18].1913 [9–16]12 [9–17].55
      Number of medications, mean (SD)10.4 (4.9)9.9 (4.4).779.7 (4.1)9.8 (4.2).81
      Cardiovascular medication, n (%)28 (70.0)76 (80.0).2179 (71.8)369 (74.2).60
      Psychotropic medication, n (%)23 (57.5)45 (47.4).2854 (49.1)230 (46.3).59
      CFS
      CFS: ranges 1–9.
      , score
      6 [6–6]7 [6–7].0107 [6–7]6 [5–7].030
      Malnutrition risk (MST
      MST: ranges 0–5 points.
      ), n (%)
      18 (45.0)49 (51.6).4958 (52.7)231 (46.7).25
      KADL, score1 [1–2]1 [0–2].541 [0–2]1 [1–2].55
      Self-rated health (EuroQoL-5D-5L
      EuroQoL-5D-5L: ranges 0–100.
      )
      50.0 [30.0–70.0]47.5 [25.0–60.0].3250.0 [23.8–60.0]50.0 [30.0–70.0].37
       Cognitive health
      Cognitively impaired, n (%)19 (47.5)70 (73.7).00380 (72.7)339 (68.2).35
      Delirium, n (%)10 (25.0)30 (31.6).4527 (24.5)125 (25.2).89
      HADS
      HADS: ranges 0–21.
      depression, score
      7 [3.3–12]6 [3–12].499 [5–12.3]8 [4–12].42
      HADS
      HADS: ranges 0–21.
      anxiety, score
      9 [4.8–12.8]6 [2–9].0167.5 [3.8–11]7 [3–11].58
       Physical performance
      SPPB
      SPPB ranges 0–12.
      , score
      0 [0–1]0 [0–2].250 [0–1]0 [0–2].29
      Balance test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–0]0 [0–1].390 [0–0]0 [0–1].09
      Gait speed, m/s, mean (SD)0.4 (0.1)0.4 (0.2).310.3 (0.2)0.4 (0.2).009
      Chair stand test
      Balance test and chair stand test: ranges 0–4.
      , score
      0 [0–0]0 [0–0].260 [0–0]0 [0–0].09
      Handgrip strength (kg), mean (SD)16.8 (5.7)16.5 (7.9).0713.3 (6.8)16.1 (7.4).08
       Geriatric conditions
      Percentage of geriatric conditions
      Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      75.0 [62.5–87.5]75.0 [62.5–87.5].2975.0 [62.5–87.5]75.0 [62.5–87.5].11
       Primary reason for hospital admission, n (%)
      Musculoskeletal25 (62.5)46 (48.4).1463 (57.3)251 (50.5).19
      Cardiac0 (0.0)5 (5.3).147 (6.4)24 (4.8).51
      Neurological8 (20.0)18 (18.9).8917 (15.5)78 (15.7).95
      Other
      Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.
      7 (17.5)26 (27.4).2223 (20.8)144 (29.0).09
       Surgical admission6 (15.0)17 (17.9).6823 (21.1)92 (18.6).55
       LOS
      Acute, d7.9 [5.4–13.7]9.2 [4.2–16.6].557.2 [4.2–11.7]7.5 [4.1–13.4].44
      Geriatric rehabilitation, d25.7 [16.9–35.1]24.8 [15.7–36.8].7121.0 [15.3–33.1]23.4 [15.5–37.8].24
      Data are presented as median [IQR] unless otherwise indicated. P values ≤ .05 are considered significant (bold).
      CIRS: ranges 0–56.
      CFS: ranges 1–9.
      MST: ranges 0–5 points.
      § EuroQoL-5D-5L: ranges 0–100.
      HADS: ranges 0–21.
      ∗∗ SPPB ranges 0–12.
      †† Balance test and chair stand test: ranges 0–4.
      ‡‡ Geriatric conditions include number of medications ≥ 9, malnutrition risk ≥ 2 points on the MST, cognitive impairment diagnosis, SPPB score ≤ 1, KADL score ≤ 2, CFS score ≥ 6, CIRS score ≥ 12, and LOS in geriatric rehabilitation ≥ 20 days (ranges 0%–100%).
      §§ Other reasons include infection, metabolic disorders, gastrointestinal, respiratory, urology, hematology, cancer, ophthalmology, vascular and psychiatry.

      Discussion

      Both OH and orthostatic intolerance symptoms were experienced by approximately one-fifth of geriatric rehabilitation inpatients. One-third of inpatients with OH experienced co-occurrence of symptoms and one-fifth of inpatients without OH were also symptomatic. Clinical determinants differed between inpatients with and without OH and orthostatic intolerance symptoms, with the exception of low KADL scores, higher CIRS scores, and number of geriatric conditions that were associated with both OH and symptoms. Determinants of OH and symptoms were similar between inpatients in standing and sitting positions, but more pronounced in the standing position.
      The prevalence of OH observed was lower compared with community-dwelling and acutely hospitalized individuals and older adults in a long-term care setting,
      • Saedon N.I.
      • Pin Tan M.
      • Frith J.
      The prevalence of orthostatic hypotension: A systematic review and meta-analysis.
      ,
      • Weiss A.
      • Grossman E.
      • Beloosesky Y.
      • et al.
      Orthostatic hypotension in acute geriatric ward: Is it a consistent finding?.
      ,
      • Pasina L.
      • Casati M.
      • Cortesi L.
      • et al.
      Orthostatic hypotension among elderly patients in Italian internal medicine wards: An observational study.
      which could be attributed to the high proportion of inpatients unable to stand. Standing leads to larger drops in blood pressure and potentially more symptoms compared with sitting,
      • Eşer I.
      • Khorshid L.
      • Güneş U.Y.
      • et al.
      The effect of different body positions on blood pressure.
      and the alternative of tilt table test involving passive standing is not feasible in this population. Orthostatic intolerance symptom prevalence varies widely between varying populations of older adults
      • Vloet L.C.M.
      • Pel-Little R.E.
      • Jansen P.A.F.
      • et al.
      High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals.
      ,
      • Freeman R.
      • Illigens B.M.W.
      • Lapusca R.
      • et al.
      Symptom recognition is impaired in patients with orthostatic hypotension.
      ,
      • Christopoulos E.M.
      • Tran J.
      • Hillebrand S.L.
      • et al.
      Initial orthostatic hypotension and orthostatic intolerance symptom prevalence in older adults: A systematic review.
      and may be attributed to heterogeneity between populations or differences in symptom assessment methods. Factors including physical inactivity and peripheral vascular disease predisposing to peripheral venous pooling in addition to dehydration as a result of recent acute illness or medication such as diuretics may influence symptom prevalence in geriatric rehabilitation inpatients.
      • Rivasi G.
      • Rafanelli M.
      • Mossello E.
      • et al.
      Drug-related orthostatic hypotension: Beyond anti-hypertensive medications.
      ,
      • Ricci F.
      • De Caterina R.
      • Fedorowski A.
      Orthostatic hypotension: Epidemiology, prognosis, and treatment.
      ,
      • Brown C.J.
      • Redden D.T.
      • Flood K.L.
      • et al.
      The underrecognized epidemic of low mobility during hospitalization of older adults.
      Conversely, asymptomatic OH may be indicative of adequate cerebral perfusion autoregulation on change in posture
      • Novak P.
      Orthostatic cerebral hypoperfusion syndrome.
      ,
      • Mol A.
      • Maier A.B.
      • van Wezel R.J.A.
      • et al.
      Multimodal monitoring of cardiovascular responses to postural changes.
      or habituation to orthostatic intolerance symptoms.
      • Arbogast S.D.
      • Alshekhlee A.
      • Hussain Z.
      • et al.
      Hypotension unawareness in profound orthostatic hypotension.
      Moreover, symptoms experienced by inpatients without OH may have corresponded with initial OH or rapid changes in blood pressure,
      • Mol A.
      • Reijnierse E.M.
      • Trappenburg M.C.
      • et al.
      Rapid systolic blood pressure changes after standing up associate with impaired physical performance in geriatric outpatients.
      which can be accurately detected only by continuous blood pressure monitoring.
      • Freeman R.
      • Wieling W.
      • Axelrod F.B.
      • et al.
      Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
      The importance of active stand is further demonstrated by the higher number and more pronounced clinical determinants in inpatients with OH and/or symptoms when standing. Female individuals have higher cerebral blood flow in comparison to male individuals,
      • Rodriguez G.
      • Warkentin S.
      • Risberg J.
      • et al.
      Sex differences in regional cerebral blood flow.
      therefore the same reduction in cerebral perfusion may have caused women to experience orthostatic intolerance symptoms more frequently than men while sitting. In community-dwelling older women,
      • Kamaruzzaman S.
      • Watt H.
      • Carson C.
      • et al.
      The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study.
      OH has been associated with increased number of comorbidities, therefore symptoms may occur due to effects on cerebral perfusion as a consequence of multimorbidity in standing inpatients. Longer LOS in geriatric rehabilitation associated with both OH and symptoms may have also been related to complications of multimorbidity that require longer recovery times.
      • Okamoto L.E.
      • Sharma P.
      • Massey L.
      • et al.
      Abstract P104: Impact of orthostatic hypotension in inpatient rehabilitation.
      Hospitalized inpatients typically take a higher number of medications, contributing to OH and symptoms.
      • Rivasi G.
      • Rafanelli M.
      • Mossello E.
      • et al.
      Drug-related orthostatic hypotension: Beyond anti-hypertensive medications.
      Frequently prescribed cardiovascular and psychotropic medications in older adults commonly cause side effects of OH and orthostatic intolerance symptoms to prevail.
      • Kamaruzzaman S.
      • Watt H.
      • Carson C.
      • et al.
      The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study.
      ,
      • Naschitz J.E.
      • Slobodin G.
      • Elias N.
      • et al.
      The patient with supine hypertension and orthostatic hypotension: A clinical dilemma.
      Lack of association between cardiovascular and psychotropic medication and OH or symptoms may indicate adequate blood pressure management of inpatients.
      • Naschitz J.E.
      • Slobodin G.
      • Elias N.
      • et al.
      The patient with supine hypertension and orthostatic hypotension: A clinical dilemma.
      In addition, the experience of orthostatic intolerance symptoms can induce anxiety and depression,
      • Anderson J.W.
      • Lambert E.A.
      • Sari C.I.
      • et al.
      Cognitive function, health-related quality of life, and symptoms of depression and anxiety sensitivity are impaired in patients with the postural orthostatic tachycardia syndrome (POTS).
      explaining the higher risk of depression in symptomatic patients. OH has been associated with impaired cognition
      • Iseli R.
      • Nguyen V.T.V.
      • Sharmin S.
      • et al.
      Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis.
      and cognitive impairment may have led to an inaccurate representation of symptom prevalence, giving rise to the higher prevalence of asymptomatic patients with OH when sitting and the lack of association between impaired cognition and symptoms.
      Poorer physical performance associated with OH
      • Mol A.
      • Reijnierse E.M.
      • Bui Hoang P.T.S.
      • et al.
      Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis.
      via deconditioning as a result of bedrest and inactivity during acute hospitalization may contribute to the poor physical performance associated with both OH and orthostatic intolerance symptoms.
      • Brown C.J.
      • Redden D.T.
      • Flood K.L.
      • et al.
      The underrecognized epidemic of low mobility during hospitalization of older adults.
      Alternatively, the experience of symptoms can prevent patients from exercising and result in lower physical performance. Similarly, frailty has been linked with a higher prevalence of OH and symptoms of orthostatic intolerance in both inpatient and community-dwelling older adults
      • Kocyigit S.E.
      • Soysal P.
      • Bulut E.A.
      • et al.
      What is the relationship between frailty and orthostatic hypotension in older adults?.
      ,
      • O’Connell M.D.L.
      • Savva G.M.
      • Fan C.W.
      • et al.
      Orthostatic hypotension, orthostatic intolerance and frailty: The Irish Longitudinal Study on Aging-TILDA.
      ; however, in this population, frailty was only a predictor of OH and symptoms in a sitting position likely due to these inpatients being relatively more frail with more comorbidities and geriatric conditions. Functional independence has been observed to be lower in older adults with OH
      • Mol A.
      • Reijnierse E.M.
      • Bui Hoang P.T.S.
      • et al.
      Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis.
      and low KADL scores as a predictor of OH and symptoms in standing but not in sitting inpatients may be explained by a smaller drop in blood pressure in the sitting position despite even lower functional independence.
      • Eşer I.
      • Khorshid L.
      • Güneş U.Y.
      • et al.
      The effect of different body positions on blood pressure.
      In addition, higher numbers of geriatric conditions that are associated with OH and symptoms in those who were standing may indicate underlying health deficits that lower both blood pressure and cerebral perfusion that may not be detected when sitting.
      • O’Connell M.D.L.
      • Savva G.M.
      • Fan C.W.
      • et al.
      Orthostatic hypotension, orthostatic intolerance and frailty: The Irish Longitudinal Study on Aging-TILDA.
      The multivariate analyses revealed LOS in standing patients and the CIRS score in sitting inpatients to be independently associated with OH, which highlights its association with the severity of disease leading to hospitalization.

       Strengths and Limitations

      The strengths of this study include the large population observed, with a wide variety of clinical characteristics available, being the first study to observe the determinants of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients. It cannot be disregarded that self-reported symptoms are influenced by cognitive impairment, delirium, or non–English-speaking backgrounds. Despite the large sample size for a geriatric rehabilitation cohort, the sample size was limited for multivariate analyses. Blood pressure was taken at various times throughout the day, therefore circadian fluctuations in blood pressure, medication dosage timing and interactions, food and fluid intake, and the time taken to change postures may have affected the prevalence of OH and symptoms. In addition, digital sphygmomanometers are less accurate in comparison with manual sphygmomanometers
      • Shahbabu B.
      • Dasgupta A.
      • Sarkar K.
      • et al.
      Which is more accurate in measuring the blood pressure? A digital or an aneroid sphygmomanometer.
      and continuous blood pressure monitoring devices.
      • Freeman R.
      • Wieling W.
      • Axelrod F.B.
      • et al.
      Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.

      Conclusions and Implications

      OH and orthostatic intolerance symptoms occur in one-fifth of geriatric rehabilitation inpatients and their co-occurrence is low. Overall, inpatients with OH or symptoms show poorer physical performance, functional independence, and cognitive health, have more comorbidities and geriatric conditions, and longer LOS. Therefore, it is imperative to assess all geriatric rehabilitation inpatients on admission for OH and the presence of orthostatic intolerance symptoms, preferably through active standing.

      Acknowledgments

      The authors thank the multidisciplinary team members of the Royal Melbourne Hospital, Royal Park Campus, involved in the RESORT cohort and the @AgeMelbourne team for their role in the data collection.

      Supplementary Data

      Supplementary Table 1Hemodynamic Characteristics of Geriatric Rehabilitation Inpatients, Stratified by OH Diagnosis or Orthostatic Intolerance Symptoms and Position of Blood Pressure Measurement
      CharacteristicsOHOrthostatic Intolerance Symptoms
      YesNoP ValueYesNoP Value
      Standingn = 161n = 593n = 186n = 558
       SBP (mm Hg), mean (SD)
      Supine139.3 (22.7)128.4 (17.7)<.001131.5 (20.8)130.3 (18.8).47
      1 min122.4 (21.7)128.7 (18.9)<.001125.6 (22.1)127.9 (18.9).18
      3 min124.8 (22.9)131.9 (19.3)<.001129.8 (22.7)130.8 (19.4).58
      Delta SBP (resting-1 min)−17.0 (16.5)0.3 (10.8)<.001−5.9 (17.6)−2.5 (12.7).004
      Delta SBP (resting-3 min)−14.8 (17.1)3.6 (12.2)<.001−1.9 (19.7)0.5 (13.5).07
       DBP (mm Hg), mean (SD)
      Supine75.8 (10.9)69.6 (8.9)<.00171.3 (10.2)70.9 (9.6).63
      1 min68.4 (12.2)71.2 (9.1).00269.7 (10.5)70.9 (9.6).15
      3 min69.1 (11.9)72.1 (9.4).00170.6 (10.6)71.9 (9.9).13
      Delta DBP (resting-1 min)−7.4 (10.3)1.6 (5.7)<.001−1.5 (9.0)0.1 (7.5).017
      Delta DBP (resting-3 min)−6.8 (9.8)2.5 (6.7)<.001−2.1 (9.0)1.1 (8.1).009
       Heart rate (beats/minute), mean (SD)
      Supine76.4 (14.5)74.6 (10.8).0975.4 (11.7)74.9 (11.7).65
      1 min80.2 (13.9)77.9 (12.5).0580.2 (12.9)77.9 (12.8).040
      3 min80.4 (14.2)78.4 (12.1).0980.9 (12.5)78.3 (12.6).015
      Delta heart rate (resting-1 min)4.3 (8.6)3.4 (8.5).265.2 (9.4)3.0 (8.2).004
      Delta heart rate (resting-3 min)4.2 (8.5)3.9 (7.4).634.4 (8.7)3.4 (7.1)<.001
      Sittingn = 137n = 614n = 150n = 592
       SBP (mm Hg), mean (SD)
      Supine137.9 (22.4)129.6 (18.5)<.001130.4 (20.5)131.5 (19.3).56
      1 min128.6 (22.5)131.0 (19.7).20127.9 (23.1)131.4 (19.3).06
      3 min126.2 (21.9)131.1 (19.5).011127.1 (22.5)131.2 (19.2).024
      Delta SBP (resting-1 min)−9.4 (16.3)1.42 (9.4)<.001−2.5 (12.8)−0.1 (11.4).024
      Delta SBP (resting-3 min)−10.8 (16.1)1.46 (9.9)<.001−3.1 (12.9)−0.1 (11.9).006
       DBP (mm Hg), mean (SD)
      Supine76.3 (9.7)70.7 (9.2)<.00170.7 (10.5)71.9 (9.3).17
      1 min69.3 (11.0)71.9 (9.7).00669.7 (11.4)71.9 (9.6).014
      3 min67.3 (10.7)71.9 (9.4)<.00169.3 (11.3)71.6 (9.4).010
      Delta DBP (resting-1 min)−7.0 (8.7)1.3 (6.2)<.001−1.1 (7.8)−0.1 (7.4).12
      Delta DBP (resting-3 min)−8.9 (9.7)1.3 (6.2)<.001−1.3 (9.0)−0.3 (7.8).16
       Heart rate (beats/minute), mean (SD)
      Supine76.7 (13.1)76.2 (10.9).6577.3 (11.9)75.9 (11.0).20
      1 min77.1 (13.9)77.2 (11.3).9678.9 (12.7)76.6 (11.4).037
      3 min78.1 (14.1)76.8 (11.1).2978.9 (12.8)76.6 (11.3).040
      Delta heart rate (resting-1 min)0.3 (10.0)1.0 (6.6).331.5 (8.4)0.7 (6.9).22
      Delta heart rate (resting-3 min)1.2 (10.4)0.8 (6.5).621.4 (8.3)0.8 (7.0).36
      BP, blood pressure. P values ≤ .05 are considered significant (bold).
      Supplementary Table 2Hemodynamic Characteristics of Geriatric Rehabilitation Inpatients, Stratified by OH Diagnosis, Orthostatic Intolerance Symptoms and Position of Blood Pressure Measurement
      CharacteristicsOHNo OH
      SymptomsNo SymptomsP ValueSymptomsNo SymptomsP Value
      Standingn = 56n = 102n = 130n = 456
       SBP (mm Hg), mean (SD)
      Supine142.5 (24.0)137.5 (22.1).19126.9 (17.5)128.8 (17.7).29
      1 min120.6 (24.0)123.3 (20.7).46127.7 (20.9)128.9 (18.3).52
      3 min122.7 (23.6)126.2 (22.9).36132.8 (21.8)131.8 (18.4).62
      Delta SBP (resting-1 min)−22.1 (16.1)−14.1 (16.2).0040.8 (13.3)0.1 (10.1).55
      Delta SBP (resting-3 min)−20.8 (17.1)−11.2 (16.2).0015.9 (14.9)3.1 (11.3).021
       DBP (mm Hg), mean (SD)
      Supine76.7 (11.5)75.3 (10.7).4568.9 (8.6)69.9 (9.0).28
      1 min68.8 (13.5)68.2 (11.6).7770.1 (9.0)71.6 (9.0).11
      3 min69.2 (12.0)69.2 (12.0).9971.2 (9.9)72.5 (9.2).16
      Delta DBP (resting-1 min)−8.0 (10.9)−7.1 (10.2).621.2 (6.4)1.7 (5.6).41
      Delta DBP (resting-3 min)−8.1 (9.5)−5.9 (9.9).192.2 (6.8)2.6 (6.7).57
       Heart rate, (beats/minute), mean (SD)
      Supine77.0 (13.5)76.0 (15.1).6974.7 (10.8)74.7 (10.8).99
      1 min81.5 (11.5)79.6 (15.1).4479.7 (13.6)77.5 (12.1).09
      3 min82.3 (12.2)79.6 (15.1).2880.4 (12.6)77.9 (11.9).05
      Delta heart rate (resting-1 min)5.6 (8.8)3.6 (8.5).185.0 (9.7)2.9 (8.2).015
      Delta heart rate (resting-3 min)6.0 (9.7)3.5 (7.8).095.6 (8.3)3.4 (7.0).003
      Sittingn = 40n = 95n = 110n = 497
       SBP (mm Hg), mean (SD)
      Supine134.8 (21.6)139.5 (22.8).27128.8 (19.9)129.9 (18.2).58
      1 min125.8 (24.6)130.2 (21.4).29128.7 (22.6)131.6 (18.9).16
      3 min121.9 (24.2)128.6 (20.5).11128.9 (21.8)131.7 (18.9).18
      Delta SBP (resting-1 min)−9.0 (17.9)−9.3 (15.7).92−0.1 (9.4)1.7 (9.4).06
      Delta SBP (resting-3 min)−12.2 (16.4)−9.9 (15.9).460.1 (9.6)1.77 (10.0).11
       DBP (mm Hg), mean (SD)
      Supine74.3 (11.7)77.2 (8.8).1169.4 (9.7)70.9 (9.1).13
      1 min68.4 (12.4)69.8 (10.5).4970.2 (10.9)72.3 (9.4).033
      3 min65.2 (11.0)68.3 (10.6).1470.8 (11.0)72.3 (9.1).14
      Delta DBP (resting-1 min)−5.9 (9.8)−7.4 (8.3).350.7 (6.1)1.4 (6.2).28
      Delta DBP (resting-3 min)−8.8 (9.4)−8.9 (10.0).931.4 (7.2)1.4 (6.0).99
       Heart rate, (beats/minute), mean (SD)
      Supine78.3 (12.7)76.2 (13.2).4176.9 (11.6)75.9 (10.6).38
      1 min80.3 (15.9)75.9 (12.8).1178.5 (11.5)76.8 (11.1).16
      3 min81.3 (15.5)77.1 (13.3).1478.2 (11.7)76.6 (10.9).19
      Delta heart rate (resting-1 min)1.5 (12.8)−0.2 (8.7).391.6 (6.2)0.9 (6.5).34
      Delta heart rate (resting-3 min)2.1 (12.3)0.9 (9.7).571.2 (6.5)0.7 (6.4).54
      BP, blood pressure. P values ≤ .05 are considered significant (bold).

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