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Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis

BMC Family Practice volume 22, Article number: 1 (2021) Cite this article

Abstract

Background

Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.

Methods

Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.

Results

One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14–20%; I2 = 99%) for 34 community cohorts, 19% (15–25%; I2 = 98%) for 23 primary care cohorts and 31% (15–50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16–23%; I2 = 98%) with hypertension (20 cohorts), 21% (16–26%; I2 = 92%) with diabetes (4 cohorts), 25% (18–33%; I2 = 88%) with Parkinson’s disease (7 cohorts) and 29% (25–33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12–17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04).

Conclusions

PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.

PROSPERO:CRD42017075423.

Peer Review reports

Background

Postural, or orthostatic, hypotension (PH), is the fall in blood pressure (BP) when rising from seated or supine to standing [1]. It is associated with an increased risk of falls, cognitive decline, reduced quality of life and mortality [2,3,4,5].

Current National Institute for Health and Care Excellence (NICE) hypertension guidelines advise testing for PH in the presence of type 2 diabetes, postural symptoms or aged 80 or over [6]; European guidelines also suggest checking in older people and those with diabetes [7]. Whilst PH is routinely tested for in primary care when symptoms are reported, we have found that it is only considered one third of the time for older people and rarely with diabetes, in the absence of symptoms [8]. Since the majority of people with PH are asymptomatic, they are likely to go undetected under current practices, placing them at avoidable risk of sequelae [5, 9].

In 2011, a consensus definition for PH: a sustained reduction in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 min of rising to a standing position, was proposed [1]. However, many other definitions of PH exist; reported prevalence estimates are likely dependent on the definition used, making this a source of variance and uncertainty around diagnosis of PH. Prevalence may also vary depending on the method of BP measurement, population and care setting under investigation. The prevalence of PH has been reported as ranging from 2 to 57% in community settings, primary care and institutional care cohorts [4, 10, 11]; increasing prevalences have been associated with older age, diabetes and hypertension [9, 12,13,14].

The large variation of reported prevalences may create uncertainty for clinicians as to who should be assessed for PH [15]. By describing the prevalences of PH in settings and conditions relevant to primary care, and identifying factors associated with greater prevalences, we aim to raise awareness of those patients most likely to have asymptomatic PH. Such evidence could counteract clinical inertia and facilitate rational choices, in the face of rising workload, as to when to invest time in testing for PH [16, 17]. Increased recognition of PH would permit appropriate interventions, such as review of medications, to reduce risks of falls and other sequelae [18]. We undertook the following systematic review, meta-analyses and meta-regression to address these questions.

Methods

Literature searches

A systematic review was undertaken to determine the prevalence of postural hypotension across care settings. This study was prospectively registered with PROSPERO: CRD42017075423. We searched Medline (including Medline in Process and Old Medline) and Embase from their respective commencement dates until 1st October 2019, using a broad search strategy based on key search terms (Appendix 1). Further studies were identified from the authors’ archives and from reference lists of included studies and review articles. Study titles and abstracts were screened independently by two authors. Disagreements were discussed to reach consensus, with provision for adjudication by a third author, if needed. Two authors assessed and agreed full texts for inclusion, undertook data extraction and assessed study quality; the review process was managed using Covidence (Veritas Health Innovation, Melbourne, Australia).

Inclusion and exclusion criteria

Studies were eligible for inclusion if BP was measured in a lying or seated position followed by standing and using either a manual or automated sphygmomanometer. Eligible study settings were primary care, community or residential/nursing home populations. We identified 78 distinct definitions of PH in scoping studies for this review. To minimise heterogeneity of findings due to definitions, we restricted inclusion to studies which either reported using the consensus definition or adopted a definition encompassed within the consensus definition [1]. Exclusion criteria are summarised in Table 1.

Table 1 Exclusion criteria for review
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Data extraction

Study level demographics were extracted for care setting, mean age, BP measurement device, resting position (seated or supine) and medical history of hypertension, diabetes, Parkinson’s disease or dementia. Where a range of health status existed within a study population, if more than 50% of the total cohort included individuals with a particular condition, hypertension, for example, we applied the appropriate disease classification, i.e. the cohort would be classed as a hypertensive cohort. Populations were included within the community category, unless specifically selected from a primary care or institutional care setting. The Newcastle-Ottawa Scale (NOS), with questions adapted to PH specific context, was used to assess study quality (Appendix 2). Where multiple reports for a cohort were retrieved, extraction was primarily taken from the main publication, with addition of detail from subsidiary reports where needed.

Statistical analysis

Pooled estimates of mean prevalences for PH were calculated and compared between settings and populations using meta-analysis of proportions, undertaken in Stata v16 (Statacorp, Texas, USA) [19]. Random effects models were used throughout due to anticipated heterogeneity between included studies. Statistical heterogeneity was assessed using the I2 statistic, and explored with sensitivity analyses, using meta-analysis, based on care setting, disease status or BP measurement method. We also conducted sensitivity analyses according to the definition of PH, i.e. whether PH was reported using the consensus definition or a definition that fell within the consensus definition parameters but did not fully meet them (e.g. by measuring BP over less than three minutes of standing). Univariable meta-regression analyses were undertaken to examine association between study level factors [mean age, percentage of females, mean absolute resting systolic BP, care setting, BP measurement method (auscultatory or oscillometric) or position (seated or supine), disease status (hypertension, diabetes, Parkinson’s disease or dementia)] and prevalence of PH [20]. Factors suggesting univariable associations with PH (using P < 0.1) were entered into multivariable models, with a priori inclusion of age, care setting and presence of diabetes and hypertension. Publication bias was assessed visually using funnel plots and quantified with the Egger test [21].

Results

Searches identified 1816 unique citations; 356 full texts were reviewed; 92 studies met inclusion criteria, but only 61 fell within the consensus definition of PH, thus contributing to the meta-analyses. Reasons for the exclusion of studies are summarised in Fig. 1.

Fig. 1
figure 1

Flow chart illustrating the process of inclusion or exclusion in this prevalence of postural hypotension systematic review

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Description of studies

All included studies were cross-sectional or cohort studies, with cohort size ranging from 40 to 32,797 participants (Table 2). On quality assessment, areas of low quality (defined as falling below the median NOS total score of 8; range: 3–10) were notable in categories relating to the response rates of participants and in comparability between respondents and non-respondents (usually due to lack of information provided), and the use of non-validated methods for BP measurement (Table 3.).

Table 2 Studies included in meta-analysis for consensus definition of postural hypotension
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Table 3 Newcastle-Ottawa Scale quality assessment of included studies
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Reported prevalences

Overall, PH prevalence using the consensus definition was 18% (95% confidence interval, 16–21%, I2 = 99%). Pooled prevalences of PH were 17% (14–20%; I2 = 99%) for 34 community cohorts, 19% (15–25%; I2 = 98%) for 23 primary care cohorts and 31% (15–50%; I2 = 0%) for three nursing/residential care home cohorts (P = 0.16 for between group differences, see Fig. 2). When low quality studies were omitted from analyses, pooled prevalences of PH were 18% (15–23%; I2 = 99%) for 20 community cohorts, 22% (18–26%; I2 = 93%) for 10 primary care cohorts and 20% (17–22%; I2 = 0%) for two nursing/residential care home cohorts (P = 0.38 for between group differences).

Fig. 2
figure 2

Summary of the prevalence of postural hypotension according to the consensus definition across care settings

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For disease subgroups, pooled prevalences of PH were 19% (16–23%; I2 = 98%) in hypertension (20 cohorts), 21% (16–26%; I2 = 92%) in diabetes (four cohorts), 25% (18–33%; I2 = 88%) in Parkinson’s disease (seven cohorts) and 29% (25–33%; I2 = 0%) in dementia (three cohorts), compared with 14% (12–17%; I2 = 99%) for those without these conditions (26 cohorts; P < 0.01 for between group differences; Fig. 3.). When low quality studies were omitted from analyses, pooled prevalences of PH were 21% (17–26%; I2 = 98%) in hypertension (10 cohorts), 21% (16–26%; I2 = 92%) in diabetes (four cohorts), 29% (16–44%; I2 = 91%) in Parkinson’s disease (four cohorts) and 29% (27–31%; I2 = 0%) in dementia (one cohort), compared with 17% (13–21%; I2 = 99%) for those without these conditions (13 cohorts; P < 0.01 for between group differences).

Fig. 3
figure 3

Prevalence of postural hypotension according to the consensus definition across disease subgroups. ‘Control’ group represents those individuals with no co-morbidity

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Where the consensus definition of PH was reported at study level, prevalence estimates were higher (23%; 19–27%) than those definitions of PH that were not reported as the consensus definition, but fell within the scope of the definition at study level (16%; 14–19%; P = 0.01); this finding persisted on exclusion of low quality studies (P = 0.04). Sensitivity analyses revealed that the overall PH prevalence was not significantly affected by the type of BP measurement device [auscultatory, 17% (13–21%) or oscillometric, 18% (15–21%); P = 0.65, see Fig. 4.], or when measured from a seated (15%; 9–22%) rather than supine (19%; 16–22%) resting position (P = 0.24, see Fig. 5.). When low quality studies were omitted, there remained no difference in PH prevalence between seated (22%; 13–34%) and supine (20; 16–24%) BP measurement methods (P = 0.67). Heterogeneity remained high across all subgroups (e.g. setting, disease, PH definition and measurement method) and was not explained by the sensitivity analyses according to study quality. Egger tests (P < 0.01) and visual inspection of funnel plots suggested possible publication bias against low prevalence small studies (Fig. 6).

Fig. 4
figure 4

Summary of the prevalence of postural hypotension according to the consensus definition across different measurement methods (auscultatory vs. oscillometric techniques)

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Fig. 5
figure 5

Summary of the prevalence of postural hypotension according to the consensus definition across different resting positions (supine vs. seated techniques)

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Fig. 6
figure 6

Funnel plot for prevalence of postural hypotension (defined as a drop in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within three minutes of rising to a standing position). Egger test (P < 0.01)

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Univariable meta-regression showed three study level factors to be associated with mean prevalence of PH: age (P < 0.01), history of falls and disease status (all P < 0.05, see Table 4). For multivariable analysis, age (Fig. 7.) and presence of diabetes remained as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%).

Table 4 Univariable regression-analyses
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Fig. 7
figure 7

Bubble plot of study level association between mean age and prevalence of postural hypotension according to the consensus definition (systolic ≥20 mmHg or diastolic ≥10 mmHg within three minutes of standing). Circles represent estimates from each study, sized according to precision of estimate

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Discussiones

Summary

This is, to our knowledge, the first systematic review and meta-analysis to present estimates of PH prevalence in populations regularly encountered in primary care, including general practices and related outpatient clinics, care or nursing homes and community settings. Our findings confirm that PH, when tested for, is a common finding across care settings and disease subgroups, with the highest prevalences observed in people residing in care/nursing homes (and primary care, when low quality studies were omitted from analyses), and in those with dementia; age itself appears to be the key predictor of prevalence. The definition of PH used can impact prevalence estimates and therefore must be considered carefully in clinical practice. The type of BP measurement device and resting position does not appear to systematically impact PH prevalence estimates.

Strengths and limitations

This study provides insight into PH prevalences across a variety of care settings and disease cohorts. Our search terms were intentionally broad, thus it is unlikely that substantial numbers of relevant publications were overlooked. Data extraction was limited to English language papers and published records, although non English language and Grey literature data generally have been shown to make limited impact on review findings where a substantial body of published evidence exists [81]. We found some evidence for publication bias against low prevalence small studies; overall, there was considerable heterogeneity of PH prevalence estimates across different care settings, disease cohorts, PH definitions and BP measurement methods that was not accounted for in our sensitivity analyses. The utility of the NOS for assessing study quality has previously shown poor agreement between reviewers, with calls for more specific guidance in its use [82]. We adapted the generic guidance to give context specific to this PH review (Appendix 2), however, we did not find any substantial impact on heterogeneity in subgroup analyses according to quality assessment of studies. High residual levels of heterogeneity limit our ability to draw firm conclusions from the data. PH prevalence varied widely across studies (2.0–56.8%) and residual heterogeneity probably reflects cumulative effects of non-systematic variations in population size and health status, limitations in classifying cohorts by condition at study level, and the discrepancy in PH definitions and measurement methods employed across studies.

Our univariable meta-regression showed that the presence of disease was associated with increasing PH prevalence, according to condition. This association did not persist when multivariable regression was undertaken, but there was co-linearity of disease status with diabetes, which was included a priori in the multivariable model. Increasing BP per se, a known risk factor for orthostatic hypotension [83], was not associated with increasing PH incidence; however, data for baseline BP were, surprisingly, only reported in 13 studies, limiting our ability to explore this association. The relationship of PH with hypertension is complex; PH is associated with both uncontrolled hypertension and the number of antihypertensive drugs used in managing high BP [25, 38, 84, 85], but effective treatment of high BP in elderly persons is associated with reduced PH prevalence [41, 86]. Consequently, a non-linear or ‘U’ shaped relationship of prevalence to absolute BP might be expected, with interaction in analyses between a diagnosis of hypertension (indicating treatment) and absolute BP values. Exploration of such a relationship was not possible in the current analyses.

Current guidelines for postural hypotension management recommend clinicians undertake a comprehensive medication review if systolic BP falls by 20 mmHg on standing [6]. The de-escalation of antihypertensive medication is a common treatment method and may increase the probability of recovery from postural hypotension with no increased risk of adverse cardiovascular events [87], however, further work in this area is required.

Comparison with existing literature

This review builds on existing reviews that have summarised prevalence of PH in specific cohorts, such as those with diabetes or Parkinson’s disease and individuals over 60 years of age [13, 88,89,90,91]. Here, we report that PH affects 18% of individuals across care settings and disease cohorts. Our data show that PH incidence rises from community care settings to those attending primary care and residing in institutions. These findings reflect the likelihood that multimorbidity, and the subsequent risk of PH, is more common in care/nursing home settings than general practices or in the community [92]. We also found that individuals with chronic disease have increased prevalence estimates of PH compared to groups without such diseases present. This may be due to a number of factors, including medication (e.g. diuretics, antihypertensives), development of peripheral and/or autonomic neuropathy (associated with diabetes mellitus and dementia) or physical deconditioning (due to age-related changes or continued bed rest) [4].

There appears to have been an exponential rise in interest in PH, with ~ 70% of the studies reported in this review published in the last decade and ~ 50% in the last 5 years. This may reflect interest in rising longevity, multimorbidity and rates of diabetes (risk markers for PH) [93, 94]. Recent reporting of improved cardiovascular outcomes with intensive lowering of BP is also relevant [95, 96], given the risks of adverse events such as PH and falls, associated with lower BP targets [97].

Our findings are consistent with studies that have reported high prevalences of PH in individuals with diabetes (type 1, 19% and type 2, 20%) [88], and in the aged [98]. Prevalences approaching 50% have been reported in Parkinson’s disease with low prevalence of orthostatic symptoms, making the case for routine postural BP testing when reviewing all sufferers [99].

On subgroup analyses, we found no significant difference in PH prevalence when measuring BP in the sitting position rather than supine, prior to standing, and this finding remained on exclusion of low quality studies. This approach may therefore be justified as an alternative to the gold-standard supine-to-stand approach, if undertaken with rigid methodology. Shaw et al. have previously suggested that the sit-to-stand method is a good alternative for busy clinicians when the supine-to-standing method cannot be achieved; they proposed reducing diagnostic thresholds for PH to a systolic drop ≥15 mmHg or a diastolic drop ≥7 mmHg to maximise the sensitivity and specificity of the test and to reflect the reduced orthostatic stress of moving from sitting to standing, compared with lying supine [100]. We found no evidence to support a change in diagnostic threshold in this review, but suggest future studies should directly compare supine versus seated followed by standing PH measurement methods. We also found that adopting auscultatory or oscillometric methods of measuring BP did not impact prevalence estimates. Further work is required across larger cohorts to determine the most appropriate diagnostic criteria for PH in primary care if the pragmatic sit-to-stand method is to be adopted.

When the definition of PH did not fulfil the consensus description, but fell within its parameters, we found that prevalence was underestimated irrespective of study quality. This highlights the importance of adopting the consensus definition to minimise under-detection of PH whenever possible [1].

Implications for research and/or practice

Our univariable regression analyses confirmed that an increasing PH prevalence is strongly associated with increasing age, with age-related chronic diseases and with previous falls. Multivariable analyses revealed that increasing age and presence of diabetes were particularly associated with increased PH prevalence; such individuals may benefit from routine checking for postural hypotension. The population is aging [101], and people are living for longer periods in older age with levels of dependency, or in care settings [102]. European hypertension guidelines, recommend checking for PH in older people, and this will include greater numbers, with attendant workload pressures, over time [7, 16]. By describing the commonly encountered disease states and care settings associated with higher than background prevalences of PH, we provide evidence to encourage improved recognition of this condition through targeted testing. Ideally, BP should ideally be measured from supine to standing using auscultatory methods and our results support the use of the consensus definition [1, 80]. Pragmatically, however, the sit-to-stand method may also be employed as an alternative to the gold standard if the methods are rigorous [100]. However, further work comparing supine versus seated followed by standing measurement methods should be undertaken to clarify the most approach resting positions and thresholds for accurate PH diagnosis.

Conclusion

Overall, these findings demonstrate the substantial prevalence of PH across a range of populations and care settings relevant to primary care. Our prevalence findings suggest that checking for the presence of PH should be routinely considered when treating chronic conditions, such as diabetes, particularly in older persons. Failure to follow the consensus definition of PH appears to underestimate prevalence, therefore we advocate adoption of the consensus as a standard whenever checking for PH. Further work is needed to confirm the diagnostic thresholds for postural hypotension when BP is measured in the seated rather than supine position.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding authors on reasonable request.

Abbreviations

PH:

Postural hypotension

BP:

Blood pressure

NOS:

Newcastle-Ottawa Scale

References

  1. Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69–72.

    Article  PubMed  Google Scholar 

  2. Juraschek SP, Daya N, Appel LJ, Miller IIIER, Windham BG, Pompeii L, et al. Orthostatic hypotension in middle-age and risk of falls. Am J Hypertens. 2017;30(2):188–95.

    Article  PubMed  Google Scholar 

  3. Mehrabian S, Duron E, Labouree F, Rollot F, Bune A, Traykov L, et al. Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci. 2010;299(1–2):45–8.

    Article  PubMed  Google Scholar 

  4. Biaggioni I, Norcliffe-Kaufmann, L., & Kaufmann, H Orthostatic hypotension 2016. Available from: http://bestpractice.bmj.com/best-practice/monograph/972.html. Accessed 14 Aug 2017.

    Google Scholar 

  5. Benvenuto LJ, Krakoff LR. Morbidity and mortality of orthostatic hypotension: implications for management of cardiovascular disease. [review]. Am J Hypertens. 2011;24(2):135–44.

    Article  PubMed  Google Scholar 

  6. National Institute for Health and Care Excellence; Hypertension in adults: diagnosis and management (CG127). 2011.

    Google Scholar 

  7. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104.

    Article  PubMed  Google Scholar 

  8. Mejzner N, Clark CE, Smith LF, Campbell JL. Trends in the diagnosis and management of hypertension: repeated primary care survey in south West England. Br J Gen Pract. 2017;67(658):e306–e13.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. Orthostatic hypotension in older adults. The cardiovascular health study. CHS collaborative research group. Hypertension. 1992;19(6 Pt 1):508–19.

    Article  CAS  PubMed  Google Scholar 

  10. Clara JG, De Macedo ME, Pego M. Prevalence of isolated systolic hypertension in the population over 55 years old. Results from a national study. Rev Port Cardiol. 2007;26(1):11–8.

    PubMed  Google Scholar 

  11. Cohen G, Zalomonson S, Press Y. Prevalence of orthostatic hypotension in the unselected ambulatory population of persons aged 65 years old and above. Blood Press. 2015;24(5):03.

    Article  Google Scholar 

  12. Naschitz JE, Slobodin G, Elias N, Rosner I. The patient with supine hypertension and orthostatic hypotension: a clinical dilemma. Postgrad Med J. 2006;82(966):246–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Winkler AS, Bosman DR. Symptomatic postural hypotension in diabetes: Aetiology and management. Pract Diabetes Int. 2003;20(6):219–25.

    Article  Google Scholar 

  14. Clark CE, Thomas D, Warren FC, Llewellyn DJ, Ferrucci L, Campbell JL. Detecting risk of postural hypotension (DROP): derivation and validation of a prediction score for primary care. BMJ Open. 2018;8(4):e020740.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Hale WA, Chambliss ML. Should primary care patients be screened for orthostatic hypotension? J Fam Pract. 1999;48(7):547–52.

    CAS  PubMed  Google Scholar 

  16. Hobbs FD, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. Lancet. 2016;387(10035):2323–30.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Phillips LS, Branch WT, Cook CB, Doyle JP, El Kebbi IM, Gallina DL, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825–34.

    Article  CAS  PubMed  Google Scholar 

  18. Excellence NIfHaC. Falls in older people: assessing risk and prevention clinical guideline (CG161). 2013.

    Google Scholar 

  19. Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014;72(1):39.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Harbord R, Higgins JPT. Meta-regression in Stata. Stata J. 2008;8(4):493–519.

    Article  Google Scholar 

  21. Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Hommel A, Faber M, Weerkamp N, van Dijk J, Bloem B, Koopmans R. Prevalence and prescribed treatments of orthostatic hypotension in institutionalized patients with Parkinson’s disease. J Parkinsons Dis. 2016;6(4):805–10.

    Article  CAS  PubMed  Google Scholar 

  23. Enrique AL, Andrea AC, Maria de los Angeles C, Mendoza CKL, Nava DPE, Ana Lilia RC, et al. Prevalence of orthostatic hypotension in a series of elderly Mexican institutionalized patients. Cardiol J. 2011;18(3):2011.

  24. Valbusa F, Labat C, Salvi P, Vivian ME, Hanon O, Benetos A. Orthostatic hypotension in very old individuals living in nursing homes: The PARTAGE study. J Hypertens. 2012;30(1):53–60.

  25. Bouhanick B, Meliani S, Doucet J, Bauduceau B, Verny C, Chamontin B, et al. Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusion. Ann Cardiol Angeiol. 2014;63(3):176–82.

  26. Fleg JL, Evans GW, Margolis KL, Barzilay J, Basile JN, Bigger JT, et al. Orthostatic hypotension in the ACCORD (action to control cardiovascular risk in diabetes) blood pressure trial: prevalence, incidence, and prognostic significance. Hypertension. 2016;68(4):888–95.

    Article  CAS  PubMed  Google Scholar 

  27. Hirai FE, Moss SE, Klein BE, Klein R. Postural blood pressure changes and associated factors in long-term type 1 diabetes: Wisconsin epidemiologic study of diabetic retinopathy. J Diabetes Complicat. 2009;23(2):83–8.

    Article  Google Scholar 

  28. Klanbut S, Phattanarudee S, Wongwiwatthananukit S, Suthisisang C, Bhidayasiri R. Symptomatic orthostatic hypotension in Parkinson's disease patients: prevalence, associated factors and its impact on balance confidence. J Neurol Sci. 2018;385:168–74.

    Article  PubMed  Google Scholar 

  29. Kleipool EEF, Trappenburg MC, Rhodius-Meester HFM, Lemstra AW, van der Flier WM, Peters MJL, et al. Orthostatic hypotension: an important risk factor for clinical progression to mild cognitive impairment or dementia. The Amsterdam dementia cohort. J Alzheimers Dis. 2019;71(1):317–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Merola A, Romagnolo A, Rosso M, Lopez-Castellanos JR, Wissel BD, Larkin S, et al. Orthostatic hypotension in Parkinson's disease: does it matter if asymptomatic? Parkinsonism Relat Disord. 2016;33:65–71.

    Article  PubMed  Google Scholar 

  31. Romagnolo A, Zibetti M, Merola A, Canova D, Sarchioto M, Montanaro E, et al. Cardiovascular autonomic neuropathy and falls in Parkinson disease: a prospective cohort study. J Neurol. 2019;266(1):85–91.

    Article  PubMed  Google Scholar 

  32. Sonnesyn H, Nilsen DW, Rongve A, Nore S, Ballard C, Tysnes OB, et al. High prevalence of orthostatic hypotension in mild dementia. Dement Geriatr Cogn Disord. 2009;28(4):307–13.

  33. Wecht JM, Weir JP, Martinez S, Eraifej M, Bauman WA. Orthostatic hypotension and orthostatic hypertension in American veterans. Clin Auton Res. 2016;26(1):49–58.

    Article  PubMed  Google Scholar 

  34. Alli C, Avanzini F, Bettelli G, Colombo F, Corso R, Di TM, et al. Prevalence and variability of orthostatic hypotension in the elderly. Results of the ‘Italian study on blood pressure in the elderly (SPAA)’. Eur Heart J. 1992;13(2):1992.

    Article  Google Scholar 

  35. Atli T, Keven K. Orthostatic hypotension in the healthy elderly. Arch Gerontol Geriatr. 2006;43(3):313–7.

  36. Bengtsson-Lindberg M, Larsson V, Minthon L, Wattmo C, Londos E. Lack of orthostatic symptoms in dementia patients with orthostatic hypotension. Clin Auton Res. 2015;25(2):87–94.

    Article  CAS  PubMed  Google Scholar 

  37. Hiorth YH, Pedersen KF, Dalen I, Tysnes OB, Alves G. Orthostatic hypotension in Parkinson disease: a 7-year prospective population-based study. Neurology. 2019;93(16):e1526–e34.

    Article  CAS  PubMed  Google Scholar 

  38. Kamaruzzaman S, Watt H, Carson C, Ebrahim S. The association between orthostatic hypotension and medication use in the British Women's Heart and Health Study. Age Ageing. 2010;39(1):afp192.

    Article  Google Scholar 

  39. Liepelt-Scarfone I, Pilotto A, Muller K, Bormann C, Gauss K, Wurster I, et al. Autonomic dysfunction in subjects at high risk for Parkinson's disease. J Neurol. 2015;262(12):2643–52.

    Article  CAS  PubMed  Google Scholar 

  40. Liu K, Wang S, Wan S, Zhou Y, Pan P, Wen B, et al. Arterial Stiffness, Central Pulsatile Hemodynamic Load, and Orthostatic Hypotension. J Clin Hypertens (Greenwich). 2016;18(7):655–62.

    Article  Google Scholar 

  41. Masuo K, Mikami H, Ogihara T, Tuck ML. Changes in frequency of orthostatic hypotension in elderly hypertensive patients under medications. Am J Hypertens. 1996;9(3):263–8.

  42. Oishi E, Sakata S, Tsuchihashi T, Tominaga M, Fujii K. Orthostatic Hypotension Predicts a Poor Prognosis in Elderly People with Dementia. Int Med. 2016;55(15):1947–52.

    Article  Google Scholar 

  43. Perez-Orcero A, Vinyoles-Bargallo E, Pujol-Ribera E, de la Figuera-von Wichmann M, Baena-Diez JM, Manjon-Villanueva R, et al. Prevalence of orthostatic hypotension in non-institutionalised elderly aged 80 and over. A diagnostic study using an oscillometric device. Hipertens y riesgo Vasc. 2016;33(3):93–102.

    Article  CAS  Google Scholar 

  44. van Hateren KJJ, Kleefstra N, Blanker MH, Ubink-Veltmaat LJ, Groenier KH, Houweling ST, et al. Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study. Br J Gen Pract. 2012;62(603):e696–702.

  45. Walczak M. The prevalence of orthostatic hypotension in high-risk ambulatory elders. J Gerontol Nurs. 1991;17(11):26–9.

  46. Zhu QO, Tan CS, Tan HL, Wong RG, Joshi CS, Cuttilan RA, et al. Orthostatic hypotension: prevalence and associated risk factors among the ambulatory elderly in an Asian population. Singap Med J. 2016;57(8):444–51.

    Article  Google Scholar 

  47. Cremer A, Soumare A, Berr C, Dartigues JF, Gabelle A, Gosse P, et al. Orthostatic hypotension and risk of incident dementia: results from a 12-year follow-up of the Three-City study cohort. Hypertension. 2017;70(1):44–9.

    Article  CAS  PubMed  Google Scholar 

  48. Drozdz T, Bilo G, Debicka-Dabrowska D, Klocek M, Malfatto G, Kielbasa G, et al. Blood pressure changes in patients with chronic heart failure undergoing slow breathing training. Blood Press. 2016;25(1):4–10.

    Article  PubMed  Google Scholar 

  49. Foster-Dingley JC, Moonen JEF, de Ruijter W, van der Mast RC, van der Grond J. Orthostatic hypotension in older persons is not associated with cognitive functioning, features of cerebral damage or cerebral blood flow. J Hypertens. 2018;36(5):1201–6.

    Article  CAS  PubMed  Google Scholar 

  50. Hiitola P, Enlund H, Kettunen R, Sulkava R, Hartikainen S. Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older. J Hum Hypertens. 2009;23(1):2009.

    Article  Google Scholar 

  51. Kartheek BR, Kumar G. Postural changes in blood pressure in an elderly population. Int J Pharm Sci Rev Res. 2011;11(2):109–14.

  52. Mendez AS, Melgarejo JD, Mena LJ, Chavez CA, Gonzalez AC, Boggia J, et al. Risk factors for orthostatic hypotension: differences between elderly men and women. Am J Hypertens. 2018;31(7):797–803.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Nguyen TTT, Nguyen Van T, Nguyen QT, Nguyen TLT. Determining the prevalence of orthostatic hypotension and its associations with hypertension and functional decline in the community-dwelling elderly in Vietnam. J Clin Gerontol Geriatr. 2017;8:88–92.

    Article  Google Scholar 

  54. Putnam HWI, Jones R, Rogathi J, Gray WK, Swai B, Dewhurst M, et al. Hypertension in a resource-limited setting: is it associated with end organ damage in older adults in rural Tanzania? J Clin Hypertens (Greenwich). 2018;20(2):217–24.

    Article  CAS  Google Scholar 

  55. Rockwood MR, Howlett SE, Rockwood K. Orthostatic hypotension (OH) and mortality in relation to age, blood pressure and frailty. Arch Gerontol Geriatr. 2012;54(3):e255–e60.

    Article  PubMed  Google Scholar 

  56. Veronese N, Bolzetta F, De RM, Zambon S, Corti MC, Musacchio E, et al. Serum 25-hydroxyvitamin D and orthostatic hypotension in old people: The Pro.V.A. study. Hypertension. 2014;64(3):481–6.

  57. Wolters FJ, Mattace-Raso FU, Koudstaal PJ, Hofman A, Ikram MA. Orthostatic hypotension and the long-term risk of dementia: a population-based study. PLoS Med. 2016;13(10):e1002143.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Assantachai P, Watanapa W, Chiempittayanuwat S, Thipanunt P. Hypertension in the elderly: a community study. J Med Assoc Thailand. 1998;81(4):243–9.

  59. Bell EJ, Agarwal SK, Cushman M, Heckbert SR, Lutsey PL, Folsom AR. Orthostatic hypotension and risk of venous thromboembolism in 2 cohort studies. Am J Hypertens. 2016;29(5):634–40.

    Article  PubMed  Google Scholar 

  60. Cilia R, Cereda E, Klersy C, Canesi M, Zecchinelli AL, Mariani CB, et al. Parkinson's disease beyond 20 years. J Neurol Neurosurg Psychiatry. 2015;86(8):849–55.

    Article  PubMed  Google Scholar 

  61. Curreri C, Giantin V, Veronese N, Trevisan C, Sartori L, Musacchio E, et al. Orthostatic changes in blood pressure and cognitive status in the elderly: the Progetto Veneto Anziani study. Hypertension. 2016;68(2):427–35.

    Article  CAS  PubMed  Google Scholar 

  62. Ensrud KE, Nevitt MC, Yunis C, Hulley SB, Grimm RH, Cummings SR. Postural hypotension and postural dizziness in elderly women: the study of osteoporotic fractures. Arch Intern Med. 1992;152(5):1992.

    Article  Google Scholar 

  63. Fan XH, Wang Y, Sun K, Zhang W, Wang H, Wu H, et al. Disorders of orthostatic blood pressure response are associated with cardiovascular disease and target organ damage in hypertensive patients. Am J Hypertens. 2010;23(8):829–37.

  64. Fedorowski A, Stavenow L, Hedblad B, Berglund G, Nilsson PM, Melander O. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (the Malmo preventive project). Eur Heart J. 2010;31(1):85–91.

    Article  PubMed  Google Scholar 

  65. Frewen J, Savva GM, Boyle G, Finucane C, Kenny RA. Cognitive performance in orthostatic hypotension: Findings from a nationally representative sample. J Am Geriatr Soc. 2014;62(1):117–22.

  66. Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. [erratum appears in J Am Geriatr Soc. 2011 May;59(5):960]. J Am Geriatr Soc. 2011;59(3):383–9.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Lampela P, Lavikainen P, Huupponen R, Leskinen E, Hartikainen S. Comprehensive geriatric assessment decreases prevalence of orthostatic hypotension in older persons. Scand J Public Health. 2013;41(4):351-8.

  68. Luukinen H, Koski K, Laippala P, Kivela SL. Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med. 1999;159(3):08.

    Article  Google Scholar 

  69. Luukkonen A, Tiihonen M, Rissanen T, Hartikainen S, Nykanen I. Orthostatic hypotension and associated factors among home care clients aged 75 years or older - a population-based study. J Nutr Health Aging. 2018;22(1):154–8.

    Article  CAS  PubMed  Google Scholar 

  70. Mader SL, Josephson KR, Rubenstein LZ. Low prevalence of postural hypotension among community-dwelling elderly. J Am Med Assoc. 1987;258(11):1987.

    Article  Google Scholar 

  71. Masaki KH, Schatz IJ, Burchfiel CM, Sharp DS, Chiu D, Foley D, et al. Orthostatic hypotension predicts mortality in elderly men: the Honolulu heart program. Circulation. 1998;98(21):24.

    Article  Google Scholar 

  72. O'Connell MDL, Savva GM, Fan CW, Kenny RA. Orthostatic hypotension, orthostatic intolerance and frailty: the Irish longitudinal study on aging-TILDA. Arch Gerontol Geriatr. 2015;60(3):01.

    Google Scholar 

  73. Ong HL, Abdin E, Seow E, Pang S, Sagayadevan V, Chang S, et al. Prevalence and associative factors of orthostatic hypotension in older adults: results from the well-being of the Singapore elderly (WiSE) study. Arch Gerontol Geriatr. 2017;72:146–52.

    Article  PubMed  Google Scholar 

  74. Shin C, Abbott RD, Lee H, Kim J, Kimm K. Prevalence and correlates of orthostatic hypotension in middle-aged men and women in Korea: The Korean Health and Genome Study. J Hum Hypertens. 2004;18(10):717–23.

  75. Vanhanen H, Thijs L, Birkenhager W, Bulpitt C, Tilvis R, Sarti C, et al. Prevalence and persistency of orthostatic blood pressure fall in older patients with isolated systolic hypertension. J Hum Hypertens. 1996;10(9):1996.

    Google Scholar 

  76. Velilla-Zancada SM, Escobar-Cervantes C, Manzano-Espinosa L, Prieto-Diaz MA, Ramalle-Gomara E, Vara-Gonzalez LA. Impact of variations in blood pressure with orthostatism on mortality: the HOMO study. Blood Press Monit. 2017;22(4):184–90.

    Article  PubMed  Google Scholar 

  77. Viramo P, Luukinen H, Koski K, Laippala P, Sulkava R, Kivela SL. Orthostatic hypotension and cognitive decline in older people. J Am Geriatr Soc. 1999;47(5):600–4.

  78. Wu JS, Yang YC, Lu FH, Wu CH, Wang RH, Chang CJ. Population-based study on the prevalence and risk factors of orthostatic hypotension in subjects with pre-diabetes and diabetes. Diabetes Care. 2009;32(1):69–74.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Yap PL, Niti M, Yap KB, Ng TP. Orthostatic hypotension, hypotension and cognitive status: early comorbid markers of primary dementia? Demen Geriatr Cogn Disord. 2008;26(3):239–46.

    Article  Google Scholar 

  80. Iqbal P, Fotherby MD, Potter JF. Differences in orthostatic blood pressure changes measured with an oscillometric blood pressure monitor and a mercury sphygmomanometer. Blood Press. 1996;5(4):222–6.

    Article  CAS  PubMed  Google Scholar 

  81. Hartling L, Featherstone R, Nuspl M, Shave K, Dryden DM, Vandermeer B. Grey literature in systematic reviews: a cross-sectional study of the contribution of non-English reports, unpublished studies and dissertations to the results of meta-analyses in child-relevant reviews. BMC Med Res Methodol. 2017;17(1):64.

    Article  PubMed  PubMed Central  Google Scholar 

  82. Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa scale showed low reliability between individual reviewers. J Clin Epidemiol. 2013;66(9):982–93.

    Article  PubMed  Google Scholar 

  83. Goldstein DS, Pechnik S, Holmes C, Eldadah B, Sharabi Y. Association between supine hypertension and orthostatic hypotension in autonomic failure. Hypertension. 2003;42(2):136–42.

    Article  CAS  PubMed  Google Scholar 

  84. Di SC, Milazzo V, Bruno G, Maule S, Veglio F. Prevalence of orthostatic hypotension in a cohort of patients under antihypertensive therapy. High Blood Pressure and Cardiovascular PreventionConference: 2013 National Congress of the Italian Society of Hypertension, SIIA 2013 Rome ItalyConference Start: 20131003 Conference End: 20131005Conference Publication: (varpagings). 2013;20:3.

  85. Barochiner J, Alfie J, Aparicio L, Rada M, Morales M, Cuffaro P, et al. Orthostatic hypotension in treated hypertensive patients. Rom J Int Med. 2012, 2012;50(3):203–9.

  86. Auseon A, Ooi WL, Hossain M, Lipsitz LA. Blood pressure behavior in the nursing home: Implications for diagnosis and treatment of hypertension. J Am Geriatr Soc. 1999;47(3):285–90.

  87. Moonen JEF, Foster-Dingley JC, de Ruijter W, van der Grond J, de Craen AJM, van der Mast RC. Effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment: the DANTE study Leiden. Age Ageing. 2016;45(2):249–55.

    Article  PubMed  Google Scholar 

  88. Zhou Y, Ke SJ, Qiu XP, Liu LB. Prevalence, risk factors, and prognosis of orthostatic hypotension in diabetic patients: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96(36):e8004.

    Article  Google Scholar 

  89. Velseboer DC, de Haan RJ, Wieling W, Goldstein DS, de Bie RM. Prevalence of orthostatic hypotension in Parkinson's disease: a systematic review and meta-analysis. Parkinsonism Relat Disord. 2011;17(10):724–9.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Low PA. Prevalence of orthostatic hypotension. Clin Auton Res. 2008;18(Suppl 1):8–13.

    Article  PubMed  Google Scholar 

  91. NIz S, Pin Tan M, Frith J. The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis; 2018.

    Google Scholar 

  92. Schram MT, Frijters D, van de Lisdonk EH, Ploemacher J, de Craen AJ, de Waal MW, et al. Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly. J Clin Epidemiol. 2008;61(11):1104–12.

    Article  PubMed  Google Scholar 

  93. Office for National Statistics. National Population Projections: 2016-based statistical bulletin 2016. Available from: www.ons.gov.uk.

    Google Scholar 

  94. Klonoff DC. The increasing incidence of diabetes in the 21st century. J Diabetes Sci Technol. 2009;3(1):1–2.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Leung AA, Nerenberg K, Daskalopoulou SS, McBrien K, Zarnke KB, Dasgupta K, et al. Hypertension Canada's 2016 Canadian hypertension education program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2016;32(5):569–88.

    Article  PubMed  Google Scholar 

  96. Gabb GM, Mangoni AA, Anderson CS, Cowley D, Dowden JS, Golledge J, et al. Guideline for the diagnosis and management of hypertension in adults - 2016. Med J Aust. 2016;205(2):85–9.

    Article  PubMed  Google Scholar 

  97. Clark CE, McManus R. The use of highly structured care to achieve blood pressure targets. BMJ. 2012;345:e7777.

    Article  PubMed  Google Scholar 

  98. Finucane C, O'Connell MD, Fan CW, Savva GM, Soraghan CJ, Nolan H, et al. Age-related normative changes in phasic orthostatic blood pressure in a large population study: findings from the Irish longitudinal study on ageing (TILDA). Circulation. 2014;130(20):11.

    Article  Google Scholar 

  99. Palma JA, Gomez-Esteban JC, Norcliffe-Kaufmann L, Martinez J, Tijero B, Berganzo K, et al. Orthostatic hypotension in Parkinson disease: how much you fall or how Low you go? Mov Disord. 2015;30(5):15.

    Article  Google Scholar 

  100. Shaw BH, Garland EM, Black BK, Paranjape SY, Shibao CA, Okamoto LE, et al. Optimal diagnostic thresholds for diagnosis of orthostatic hypotension with a ‘sit-to-stand test’. J Hypertens. 2017;35(5):1019–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  101. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (London). 2015;385(9963):117–71.

  102. Kingston A, Wohland P, Wittenberg R, Robinson L, Brayne C, Matthews FE, et al. Is late-life dependency increasing or not? A comparison of the cognitive function and ageing studies (CFAS). Lancet. 2017;390(10103):1676–84.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We thank Mrs. Ellie Kingsland for administrative support in retrieving many of the papers included in this review.

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England

    Sinead T. J. McDonagh, Natasha Mejzner & Christopher E. Clark

Authors
  1. Sinead T. J. McDonagh
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  2. Natasha Mejzner
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  3. Christopher E. Clark
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Contributions

CEC and SM conceived this study, undertook searching, study selection, data extractions, quality assessment, carried out the analysis and drafted the manuscript. NM undertook searching, study selection and data extractions. All authors contributed to and approved the final version of the manuscript for publication.

Corresponding author

Correspondence to Sinead T. J. McDonagh.

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Appendices

Appendix 1

Search strategy (Medline and Embase)

  • 1 postural hypotension.mp. [mp = ti, ab, hw, tn, ot, dm, mf, dv, kw, fx, nm, kf, px, rx, ui, sy]

  • 2 orthostatic hypotension.mp. [mp = ti, ab, hw, tn, ot, dm, mf, dv, kw, fx, nm, kf, px, rx, ui, sy]

  • 3 prevalence.mp. [mp = ti, ab, hw, tn, ot, dm, mf, dv, kw, fx, nm, kf, px, rx, ui, sy]

  • 1 or 2

  • 3 and 4

  • Limit 5 to human

Appendix 2

Newcastle-Ottawa Scale adapted for cross-sectional studies for review of postural hypotension prevalence

Selection: (Maximum 5 stars (5 points))

Covidence key: 0 stars = High ROB

1 or 2 stars = Low ROB

Cannot tell = Unclear ROB

  1. 1)

    Representativeness of the sample:

    1. a)

      Truly representative of the average in the target population. * (all subjects or random sampling)

    2. b)

      Somewhat representative of the average in the target population. * (non-random sampling)

    3. c)

      Selected group of users.

    4. d)

      No description of the sampling strategy.

  2. 2)

    Sample size:

    1. a)

      Justified and satisfactory (a subjective judgement). *

    2. b)

      Not justified (important mainly if low sample size e.g. < 100).

  3. 3)

    Non-participants:

    1. a)

      Comparability between respondents and non-respondents characteristics is established, and the response rate is satisfactory. *

    2. b)

      The response rate is unsatisfactory, or the comparability between respondents and non-respondents is unsatisfactory.

    3. c)

      No description of the response rate or the characteristics of the responders and the non-responders.

  4. 4)

    Ascertainment of the exposure (i.e. measurement of sitting/lying and standing blood pressure):

    1. a)

      Validated measurement tool. **

    2. b)

      Non-validated measurement tool, but the tool is available or described.*

    3. c)

      No description of the measurement tool.

Comparability: (Maximum 2 points)

  1. 1)

    The subjects in different outcome groups are comparable, based on the study design or analysis. Confounding factors are controlled. In this context it is controlling for co-variates.

Reported prevalence may be reported as unadjusted (usual) with logistic regressions or adjusted. Can indicate which in extraction. Go for unadjusted or adjusted?

  1. a)

    The study controls for the most important factor (systolic BP or Age probably both important). *

  2. b)

    The study control for any additional factor (candidates include BMI, BP, age, gender use of antihypertensive medication). *

Outcome: (Maximum 3 stars)

The outcome for this review is the prevalence of postural hypotension:

  1. 1)

    Assessment of the outcome:

    1. a)

      Independent blind assessment. **

    2. b)

      Record linkage. **

    3. c)

      Self report. *

    4. d)

      No description.

These descriptors are unhelpful so suggest re-classify as:

  1. a)

    presented as n/N or proportion for each relevant group in results. **

  2. b)

    Self report i.e. in some way reported by unblinded investigators. *

  3. c)

    No description

  1. 2)

    Statistical test:

In this review – the calculation of proportion(s) with postural hypotension, so should be clearly derived from n/N without unexpected or unexplained omissions from numerator or denominator.

  1. a)

    The statistical test used to analyze the data is clearly described and appropriate, and the measurement of the association is presented, including confidence intervals and the probability level (p value). *

  2. b)

    The statistical test is not appropriate, not described or incomplete.

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McDonagh, S.T.J., Mejzner, N. & Clark, C.E. Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis. BMC Fam Pract 22, 1 (2021). https://doi.org/10.1186/s12875-020-01313-8

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Keywords

BMC Primary Care

ISSN: 2731-4553

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