Recurrent syncope in elderly patients and tilt test table outcome: the role of comorbidities.

Syncope is a common disorder that can lead to serious consequences in the elderly. Tilt-test is a safe, useful specific tool to investigate recurrent syncope also in the elderly. Comorbidities and medication use, widely present in elderly patients, affecting the hemodynamic response, can influence the tilt-test outcome. The aim of this study was to evaluate the influence of these confounding factors on tilt-test results in elderly patients with recurrent syncope. We included in this study a consecutive group of 87 patients>75 years (82.1+/-4.3 years) with unexplained syncope. They underwent passive upright tilt-test. Heart rate an blood pressure were recorded using non-invasive devices. The patients were classified according to the modified Vasovagal Syncope International Study (VASIS). Comorbidities were measured with the geriatric index of comorbidities (GIC), which is a composite score taking into account both the number of diseases and their severity as measured by Greenfield's IDS. The tilt-test was positive in 22 patients. There were no significant differences in clinical characteristics, and medication use between the tilt-test negative and positive patients, except for the GIC score (1.12+/-0.5 vs. 2.42+/-0.48; p=0.001) and for a reduced number of medications in the former group (5.7+/-3.1 vs. 8.2+/-2.4; p=0.001). This study suggests that comorbidities and the number of medications could influence tilt test outcome.

Influence of sex and age on blood pressure variability.

The aim of this study has been to identify changes of 24-h blood pressure variability, as related to age and sex in hypertensive subjects. As regards this point several international studies have shown the increase of morbidity and mortality caused by cardiovascular diseases in postmenopausal women produced by a lack of sex hormones, which had protected the women until this period. Each hypertensive subject was submitted to an ambulatory blood pressure monitoring (ABPM) and two variability indexes were obtained: S.D. and coefficient of variation (CV). The results have shown a strict correlation between blood pressure variability and age, without significant sex-related differences. A decrease of blood pressure variability and mean blood pressure (BP) values have also been found, in the night-time with respect to the day-time data; it was more pronounced in females than in males but this would not seem an age-related difference. Despite the fact that the correlation between blood pressure variability and age is very significant in every considered period in males, it has been found that women have statistical differences only in the day-time and in the nocturnal diastolic blood pressure (DBP) fluctuations. This might be caused by other independent factors, such as a postmenopausal lack of sex hormones.

The impact of malnutrition on the quality of life in the elderly.

Malnutrition is a frequent condition, both widely represented in geriatric population and underestimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people. The unexpected weight loss is a pathological condition, recently classified in three different ways (sarcopenia, wasting and cachexia) according to criteria of nutritional intake, functional abilities and age-related body composition modifications, that is caused by social psychological and medical factors. In this review, the authors highlight the ways that, through malnutrition, could lead to an impairment of quality of life in elderly people. Notwithstanding the great impreciseness and confusion that surrounds the term 'quality of life', the authors focus their attention on the correlation existing with the recently occurring changes to patients' health status and life-style, analysing the relationship with frailty, failure to thrive and homeostatic balance failure syndrome. With the latter term, the authors introduce a pathological condition widely represented in the late stages of malnutrition that often evolves in multiple organ failure and lastly in the death.

Heart rate and blood pressure variability in obese normotensive subjects.

OBJECTIVE: To assess autonomic modulation of cardiovascular activity in massively obese subjects. DESIGN: Cross-sectional clinical study. SUBJECTS: 43 age-matched normotensive subjects: 15 moderately obese (body mass index (BMI) < 40); 14 massively obese (BMI > 40) and 14 nonobese controls (BMI < 26). MEASUREMENTS: Using power spectral analysis, heart rate and arterial pressure variability were determined at rest and after sympathetic stress (tilt). Two spectral components were analysed: a low-frequency (LF) component at around 0.1 Hz, predominantly reflecting sympathetic modulation and a high-frequency (HF) component at around 0.26 Hz, reflecting parasympathetic modulation. RESULTS: Spectral data for heart rate showed that the massively obese subjects had lower LF [mean +/- s.e.m.] normalized units (NUs) at rest (35.1 +/- 0.9) and after tilt (56.1 +/- 2.1), than the moderately obese subjects (LF NUs at rest 53.9 +/- 4.2, P < 0.001; LF NUs tilt: 66.8 +/- 5.6, P < 0.001) and nonobese control subjects (LF NUs at rest, 56.6 +/- 3.0, P < 0.001); (LF NUs tilt: 81.7 +/- 1.7, P < 0.001). Data for systolic arterial pressure variability measured at rest exhibited the inverse pattern, the massively obese group having higher mean LF values (LF mm Hg2 rest: 15.0 +/- 1.4; LF mm Hg2 tilt: 15.7 +/- 1.5) than the moderately obese group (LF mm Hg2 rest 3.2 +/- 0.7, P < 0.001; LF mm Hg2 tilt: 7.2 +/- 2.0, P < 0.001) and than the nonobese control subjects (LF mm Hg2 rest 3.5 +/- 0.5, LF mm Hg2 tilt 8.5 +/- 0.8, P < 0.001). Regression detected a significant association between BMI and LF of systolic pressure (beta = 0.364; P = 0.0007), In LF of heart rate (beta = -5.555; P = 0.00001) and very low frequency (VLF) of diastolic pressure (beta = -3.305; P = 0.0020). CONCLUSION: Obesity seems to increase sympathetic modulation of arterial pressure, but diminishes modulation of heart rate. Because our obese subjects had high plasma noradrenaline levels, their low LF power of heart rate could reflect diminished adrenoceptor responsiveness.

Hyperinsulinaemia, regional adipose tissue distribution and left ventricular mass in normotensive, elderly, obese subjects.

Obesity is a metabolic condition, related to abnormalities of the glyco-insulinaemic metabolism, and plays a substantial role in the development of cardiovascular disease. The aim of this study was to establish a correlation among left ventricular mass, evaluated echocardiographically according to Penn Convention criteria, blood pressure, evaluated by ambulatory blood pressure monitoring, anthropometric indices for evaluation of body mass index and waist to hip ratio circumference, regional adipose tissue distribution, evaluated by ultrasound measurements of visceral adipose tissue, and insulin resistance, evaluated by hyperinsulinaemia by oral glucose tolerance test. We selected two groups of elderly male subjects well matched for age (68.5 +/- 6.4 years): 29 obese and 20 lean, with a body mass index, respectively, of 34.6 +/- 2.9 and 23.4 +/- 2.3. Statistical analysis was carried out by Student's t-test and linear regression analysis. In spite of the fact that statistical analysis showed a higher, though not statistically significant, systolic and diastolic mean blood pressure in the lean subjects, we found an increased left ventricular mass in obese subjects (P < 0.0001). The area under the insulin curve was higher in obese than in lean subjects (P < 0.0001) while the area under the glucose curve was not significantly different in the two groups. Furthermore, linear regression analysis showed that in obese subjects left ventricular mass was strictly correlated with visceral adipose tissue (r = 0.607; P < 0.0001) and hyperinsulinaemia (r = 0.615; P < 0.0001). In conclusion, our data suggest that centripetal adipose tissue distribution and hyperinsulinaemia, independent of blood pressure values, are closely correlated with left ventricular mass.

Baroreflex sensitivity in the elderly with silent myocardial ischemia.

In order to assess high-pressure baroceptor sensitivity and parasympathetic function in elderly patients with silent myocardial ischemia, we selected 45 inpatients in our geriatric unit for a prospective cohort study of patients with coronary heart disease. All patients were over 65 years of age (37 men and 8 women) and had coronary heart disease, documented by an angiographic study and electrocardiographic evidence of myocardial ischemia during exercise stress testing, performed according to the Bruce protocol. The subjects were divided in three subgroups: group 1 (22 patients) with electrocardiographic and echocardiographic history of myocardial infarction but no angina chest pain during exercise testing; group 2 (13 patients) with no exercise induced chest pain; and group 3 (10 patients) with exercise-induced chest pain. Baroceptor sensitivity was assessed in all subjects, by evaluating heart rate changes expressed in RR interval on the basis of changes in the mean arterial pressure during intravenous infusion of stepwise doses (50-100 and 150 microg) of phenylephrine hydrochloride. Heart rate changes were also evaluated during overshoot of the Valsalva maneuver (Valsalva max.), providing an index of parasympathetic activity. Our results showed that group two patients (only silent ischemia) had significantly (P>0.001) greater baroceptor sensitivity than the other two groups (group 2; 15.2+/-1.9 ms/mmHg; group 1: 10.0+/-1.7 ms/mmHg; and group 3: 9.8+/-1.7 ms/mmHg). Group two also showed a significant positive correlation (r=0.58; P<0.05) between baroceptor sensitivity and end-diastolic pressure and a significant inverse correlation (r=-0.672; P<0.05) between baroceptor sensitivity and the ejection fraction. Group 2 patients had a significantly longer RR interval than group 1 (P<0.05) and group 3 (P<0.05); a significant positive correlation (r=0.620; P<0.05) between Valsalva max. and end-diastolic pressure; and a significant inverse correlation (r=0.694; P<0.05) between Valsalva max. and the ejection fraction. Valsalva max. and baroceptor sensitivity correlated significantly in all three groups (group 1, r=0.707; P<0.001; group 2, r=0.94; P<0.001; and group 3; r=0.833; P<0.05). In conclusion our data suggest that elderly patients with silent ischemia appear to have an increased capacity for evoking parasympathetic reflexes that could inhibit pain perception.

Power spectral analysis of heart rate variability in obese subjects: evidence of decreased cardiac sympathetic responsiveness.

OBJECTIVE: To investigate changes in sympathetic nervous system function in obesity. DESIGN: Cross-sectional clinical study. SUBJECTS: 18 middle-aged obese patients (43-55 years, BMI > 33 kg/m2) and 26 age- and sex-matched normal-weight controls (44-56 years, BMI < 26 kg/m2). MEASUREMENTS: Post-synaptic sympathetic response studied by power spectral analysis of heart rate variability at rest and during sympathetic stimulus obtained through passive head-up tilt. Spectral analysis comprised two frequency domain components: high-frequency power (HF), reflecting parasympathetic activity and low-frequency power (LF), in particular the LF: HF ratio, reflecting sympathetic function. Pre-synaptic sympatho-adrenal function was assessed by measurement of 8.00 am plasma noradrenaline. RESULTS: Obese patients had significantly lower spectral indexes of sympathetic response and higher spectral markers of parasympathetic activity than nonobese subjects both at rest (25.9 +/- 3.5 vs 38.6 +/- 1.7 LF NUs, P < 0.001) and after tilt (0.98 +/- 0.40 vs 2.30 +/- 0.39 LF: HF, P < 0.05; 62.7 +/- 6.9 vs 41.1 +/- 4.9 HF NUs, P < 0.05). By contrast, the obese subjects had higher noradrenaline levels (289.32 +/- 27.40 vs 159.80 +/- 19.20 pg/ml, P < 0.001). No relation was found between these neuroautonomic indexes and body mass index. CONCLUSION: Obese subjects seem to have increased pre-synaptic sympatho-adrenal function but a depressed end-organ cardiovascular response.

White-coat hypertension and cardiac organ damage in elderly subjects.

PURPOSE: The aim of this study was comparing the cardiac mass in elderly normotensive subjects and elderly white-coat hypertensive patients by examining in perspective, in consecutive patients, office blood pressure (BP), ambulatory BP, and echocardiographically determined left ventricular mass. PATIENTS AND METHODS: We studied 42 elderly patients attending a hypertension unit: of these, 22 (mean age 68.7 +/- 3.2 years) had persistent > 90 mm Hg office diastolic blood pressure (DBP), > 140 mm Hg systolic blood pressure (SBP) and < 142/90 mm Hg daytime ambulatory BP (white-coat positives); the remaining 20 (mean age 67.4 +/- 2.2 years) had < 90 mm Hg office DBP, < 140 mm Hg SBP and < 142/90 mm Hg daytime ambulatory BP (normotensives). White coat-patients (n = 22) were selected from a series of 75 consecutive newly diagnosed and never treated patients with mild hypertension (casual DBP constantly between 90 mm Hg and 105 mm Hg). RESULTS: Neither left ventricular mass index (89.9 +/- 23.1 vs 91.8 +/-25.4 P = NS and +/- 25.4 P = NS) and left ventricular mass/height, (115.4 +/- 17.1 vs 119.6 +/- 18.3 P = NS), nor relative wall thickness (0.31 +/- 0.44 vs 0.33 +/- 0.05 P = NS) were significantly higher in white-coat hypertensives as against normotensives. Neither did we find a relevant difference between left atrial diameters in the above considered groups (3.28 +/- 0.41 vs 3.32 +/- 0.37). In fact 81.8% of white-coat hypertensives had left ventricular normal geometry; whilst 13.6% only had concentric remodeling. Age and sex were associated with left ventricular mass index, left ventricular mass/height and relative wall thickness. Multiple regression analysis revealed that it is ambulatory, not office BP that carries independent information about relative wall thickness and left ventricular mass indices. CONCLUSIONS: Since elderly white-coat hypertensive subjects did not display a greater cardiac involvement than age-matched normotensives, they should be treated as such.

Effect of aerobic training on the cognitive performance of elderly patients with senile dementia of Alzheimer type.

The importance of physical activity to maintain a healthy psychological functions is widely known. The present study involved 15 males affected by senile dementia of Alzheimer type (SDAT) and assessed their functional capabilities by means of the following neuropsychological tests: test of attentional matrix, verbal span test, supraverbal span test, mini mental state examination. After an exercise training program of 3 months, patients were assessed again by the same psychological tests which demonstrated a significant improvement.

Influence of obesity on cardiac mass and blood pressure in the elderly.

Obesity is a physical condition, related to abnormalities of glucose and insulin metabolism; it plays a substantial role in development of cardiovascular disease. The aim of this study was to establish the correlations among cardiac mass determined by echography according to the PENN Convention criteria (Devereux Index), blood pressure measured by ambulatory blood pressure monitoring (ABPM), and anthropometric indexes such as body mass index (BMI) and local adipose tissue distribution expressed as the waist to hip ratio (WHR). Two groups of subjects were selected, matched for age (67 +/- 2.5 years): 10 obese subjects with BMI = 34.5 +/- 2.8 and WHR = 1.02 +/- 0.004; and 10 non-obese subjects with BMI = 26.8 +/- 2.1 and WHR = 0.088 +/- 0.003. Statistical analysis was carried out by the Mann-Whitney U-Test, and linear regression analysis. The statistical analysis revealed a higher mean blood pressure (MBP) in the nonobese group (138.5 +/- 16.9 / 82.2 +/- 5.09 mmHg) compared to the obese subjects (131 +/- 15.3 / 84.29 +/- 11.72 mmHg), the difference was not significant (p > 0.05). Nevertheless, a significant difference was found in the left ventricular mass (LVM) and the LVM index (LVMI) of the two groups (p < 0.005) as follows: LVM(norm) = 224.55 +/- 50.59; LVM(ob) = 295.02 +/- 43.54; LVMI(norm) = 127.56 +/- 18.58; LVMI(ob) = 172.48 +/- 15.44. These results represent an evidence showing that obesity and blood pressure are two independent risk factors in the determination of the ventricular cardiac mass.

A case report on the effect of training and low caloric diet in hypertension, obesity and hyperinsulinemia.

In an obese hypertensive woman affected by angina-like chest pain, a physical training program and a low caloric diet resulted in a notable improvement of the anthropometric indexes, hyperinsulinemia, myocardial perfusion and left ventricular mass.

Role of aging in malnutrition and in restitution of nutritional parameters by tube feeding.

Aging and malnutrition are connected by social and pathological factors; many studies show that 60-80% of hospitalized elderly patients are malnourished. The aim of this study was to establish a correlation between age and nutritional parameters in malnourished, hospitalized, elderly patients before and after restitution by tube feeding (using Clintec chemicals) for 45 days, with a mean caloric contribution of 2670 +/- 235 Kcal/day. Twenty-three patients were examined, matched for age (80.59 + 8.35 years) and sex (11 females and 12 males). Patients affected by malignant, chronic or acute diseases that could directly increase cytokine production (TNF-alpha, IL-1, etc.) were excluded. Anthropometric measurements were carried out always by the same operator using a fiberglass tape measure and a Harpenden skinfold caliper. Statistical analysis was carried out by ANOVA test and linear regression analysis. The main observations before and after tube feeding were the following: (i) Significant increases were found in serum albumin, triglyceride and cholesterol levels, whereas slightly increasing tendencies occurred, without reaching statistical significance, in serum transferrin levels, in triceps skinfold (TSF) and mid arm muscle circumference (MAMC) values. In malnourished patients close correlations were found between the age and serum albumin (r = 0.486; p = 0.022), as well as between age and MAMC (r = 0.576; p = 0.005), however, these correlations disappeared after tube feeding. These data show that age itself does not represent an important impediment for nutritional restitution; the possibilities of the latter appear to be dependent on the self-sufficiency and cognitive faculty of the patient, as measured by the activity of daily living (ADL), instrumental activity of daily living (IADL) and mini mental state evaluation (MMSE) scores (p < 0.005).