Nonpharmacologic Management of Orthostatic Hypotension in Older People: A Systematic Review. The SENATOR ONTOP Series

Selvarani Subbarayan (Corresponding Author), Phyo K. Myint, Kathryn R. Martin, Iosief Abraha, Sirjana Devkota, Denis O’Mahony, Alfonso J. Cruz-Jentoft, Antonio Cherubini, Roy L. Soiza

Research output: Contribution to journalArticle

Abstract

Objectives
Nonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.

Design
Systematic review of systematic reviews.

Setting and Participants
MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.

Results
Eleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) −12.56, −7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI –18.20, −6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.

Conclusions/Implications
There is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.
Original languageEnglish
Pages (from-to)1065-1073.e3
Number of pages12
JournalJournal of the American Medical Directors Association
Volume20
Issue number9
Early online date17 May 2019
DOIs
Publication statusPublished - Sep 2019

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Orthostatic Hypotension
Blood Pressure
Therapeutics
Lower Extremity
Confidence Intervals
Resistance Training
PubMed
Drinking Water
Meta-Analysis
Head
Databases

Keywords

  • Orthostatic hypotension
  • postural hypotension
  • orthostasis
  • non-pharmacological therapy
  • older people
  • nonpharmacologic therapy

ASJC Scopus subject areas

  • Geriatrics and Gerontology
  • Health Policy
  • Nursing(all)

Cite this

Nonpharmacologic Management of Orthostatic Hypotension in Older People : A Systematic Review. The SENATOR ONTOP Series. / Subbarayan, Selvarani (Corresponding Author); Myint, Phyo K.; Martin, Kathryn R.; Abraha, Iosief; Devkota, Sirjana; O’Mahony, Denis ; Cruz-Jentoft, Alfonso J. ; Cherubini, Antonio; Soiza, Roy L.

In: Journal of the American Medical Directors Association, Vol. 20, No. 9, 09.2019, p. 1065-1073.e3.

Research output: Contribution to journalArticle

Subbarayan, Selvarani ; Myint, Phyo K. ; Martin, Kathryn R. ; Abraha, Iosief ; Devkota, Sirjana ; O’Mahony, Denis ; Cruz-Jentoft, Alfonso J. ; Cherubini, Antonio ; Soiza, Roy L. / Nonpharmacologic Management of Orthostatic Hypotension in Older People : A Systematic Review. The SENATOR ONTOP Series. In: Journal of the American Medical Directors Association. 2019 ; Vol. 20, No. 9. pp. 1065-1073.e3.
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abstract = "ObjectivesNonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.DesignSystematic review of systematic reviews.Setting and ParticipantsMEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.ResultsEleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95{\%} confidence interval (CI) −12.56, −7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95{\%} CI –18.20, −6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.Conclusions/ImplicationsThere is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.",
keywords = "Orthostatic hypotension, postural hypotension, orthostasis, non-pharmacological therapy, older people, nonpharmacologic therapy",
author = "Selvarani Subbarayan and Myint, {Phyo K.} and Martin, {Kathryn R.} and Iosief Abraha and Sirjana Devkota and Denis O’Mahony and Cruz-Jentoft, {Alfonso J.} and Antonio Cherubini and Soiza, {Roy L.}",
note = "The research leading to these results was supported by the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 305930 (SENATOR project). The sponsor did not play any role in the study design, methods, data collection and analysis, and preparation of the article.",
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AU - O’Mahony, Denis

AU - Cruz-Jentoft, Alfonso J.

AU - Cherubini, Antonio

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N2 - ObjectivesNonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.DesignSystematic review of systematic reviews.Setting and ParticipantsMEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.ResultsEleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) −12.56, −7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI –18.20, −6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.Conclusions/ImplicationsThere is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.

AB - ObjectivesNonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.DesignSystematic review of systematic reviews.Setting and ParticipantsMEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.ResultsEleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) −12.56, −7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI –18.20, −6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.Conclusions/ImplicationsThere is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.

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