Series: Concepts in end-of-life care: palliative care medicine.

The goals of palliative care are to provide the best quality of life for the patient and family at a critical time in the patient's life. Ethical principles of patient autonomy, beneficence, and justice are very important at this time. Good communication is paramount in respecting patients' values and preferences. Appropriate surrogates, as directed by the patient, should be included in discussions and decisions. Physical, social, emotional, and spiritual suffering must be addressed.

Falls and Orthostatic Hypotension in Older Adults: Re-examining Limits.

Background: Orthostatic hypotension (OH) is defined using substantial thresholds of blood pressure (BP) drops with standing, which may be insufficient for identifying falls risk. Objective: To assess associations between falls risk and (1) consensus-defined OH (cOH), (2) standing BP levels, (3) BP changes with standing, (4) combined standing BP levels and BP changes with standing. Design: Observational study of normative aging. Setting: Baltimore Longitudinal Study of Aging. Participants: Participants ≥65 years with first visits evaluating OH and self-reported falls (2004-2010). Measurements: BP was measured supine and 3 minutes after standing. A drop in systolic BP (SBP) ≥20mmHg or a drop in diastolic BP (DBP) ≥10mmHg upon standing defined cOH. Participants self-reported the number of falls experienced in the previous 12 months. Results: Among 400 participants (45% women; 30% black; mean age 74.8 years), 113 (28%) reported ≥1 fall; 19 (4.8%) had cOH. In adjusted models, cOH (OR=2.77, 95% CI: 1.00-7.71 p=0.051) and continuous SBP-drops per 5mmHg (OR=1.21, 1.00-1.47 p=0.046) were associated with having any fall and multiple falls (cOH: OR=3.94, 1.04-14.96 p=0.044; SBP 5mmHg drops: OR=1.34, 1.00-2.15 p=0.020). Attained SBP with standing was not associated with falls either alone (OR=1.01, 0.99-1.02 p=0.369) or in combination with SBP-drops (interaction OR=1.03, 0.96-1.09 p=0.414). Limitations: Cross-sectional design, prohibiting conclusions about causal relationships. Conclusions: Findings suggest that postural SBP-drops that are much lower than current OH definition thresholds indicate increased falls risk in older adults, regardless of absolute SBP level. This has implications for standard clinical falls risk assessment and communication of falls risk to patients.

Pathophysiology of hypertension in the elderly.

The importance of hypertension as a cardiovascular risk factor increases progressively with aging, but diastolic blood pressure plateaus at age 50, which leads to a rise in pulse pressure in the elderly. Thus, isolated systolic hypertension with a widened pulse pressure is the most common type of hypertension seen in persons older than 65 years of age. Pulse pressure is the most robust blood pressure measurement in predicting cardiovascular disease. This rise in systolic blood pressure and pulse pressure with aging is a consequence of arterial stiffness. With aging, both structural and functional changes occur that result in a less compliant aorta and large vessels. Investigators who use pulse-wave velocity and augmentation index as measures of large artery stiffness have repeatedly shown an increase in arterial stiffness with aging. Early return of the reflected pulse wave to the aorta during systole has been shown to be the primary mechanism accounting for the rise in systolic and decline in diastolic pressure that occurs with arterial stiffness. Several factors have been shown to decrease arterial stiffness including aerobic exercise, decreased sodium intake, n-3 fatty acids, estrogen replacement therapy, nitrates, and ACE inhibitors. Drugs that specifically lower systolic blood pressure but not diastolic pressure, such as vasopeptidase inhibitors, are under investigation in treating isolated systolic hypertension.