Postprandial Hypotension Is More Common Than Orthostatic Hypotension In Older Adults With Dementia With Lewy Bodies: A Cross-Sectional Study

doi:10.21203/rs.3.rs-3226191/v1

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Postprandial Hypotension Is More Common Than Orthostatic Hypotension In Older Adults With Dementia With Lewy Bodies: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-3226191/v1

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Purpose

Dysautonomia is one of the supportive clinical features in dementia with Lewy bodies (DLB). This study aimed to investigate the prevalence of postural and postprandial blood pressure changes as a sign of dysautonomia in DLB patients.

Methods

The study group comprised 125 patients with DLB (76 females; mean age 78.4 ± 7.1 years) and 126 controls (89 females; mean age 74.5 ± 6.8 years). Postprandial blood pressure changes were assessed by ambulatory 24-hour blood pressure monitorization. Postural blood pressure changes were assessed via the head-up tilt table test.

Results

The frequency of postprandial hypotension (PPH), orthostatic hypotension (OH), and delayed OH was higher in patients with DLB compared to controls (89.4% vs 50.8%; p < 0.001, 45.5% vs 28.6%; p = 0.006, and 13.3% vs 5.6%; p = 0.045, respectively); whereas the frequency of supine hypertension (HT), and orthostatic hypertension (OHT) was similar. However, supine HT in non-hypertensive participants was higher in DLB patients than in controls (n = 45, 48.9% vs n = 37, 27%; p = 0.043). PPH and OH were independently associated with DLB (odds ratio [OR]:10.52 confidence interval [CI]%95 3.11–35.61; p < 0.00, and OR:1.96 CI%95 1.05–3.69; p = 0.035, respectively) after adjustment for age, the number of drugs, anti-psychotics, antiparkinsonian drugs, angiotensin receptor blockers, and beta blockers.

Conclusion

The study demonstrated that PPH was the most common type of dysautonomia, followed by OH and supine HT in older patients with DLB Given the potential complications of postural blood pressure changes and PPH in such patients, autonomic dysfunction should be evaluated in the follow-up of DLB.

Dementia with Lewy Bodies

Postprandial Hypotension

Orthostatic Hypotension

Dysautonomia

Dysautonomia, a dysfunction of the autonomic nervous system (ANS) controlling many fundamental homeostatic mechanisms within our physiology, such as heart rate, blood pressure, body temperature, salivation, pupil size, gastrointestinal motility, and sphincter control, may accompany many disease processes.[1] There is growing evidence in the literature that dysautonomia, occurring at all the stages of the synucleinopathies, such as Parkinson Disease (PD), Dementia with Lewy Bodies (DLB), and Multiple-System Atrophy, sometimes may be the only clinical finding.[2] In contrast, the diagnosis of dementia increases the risk of dysautonomia, especially orthostatic hypotension (OH),[3] which is even further increased by the diagnosis of DLB.[4, 5] Dysautonomia, including urinary incontinence, OH, and constipation, is suggested to be an early and prominent marker of DLB, [6–9] one of the most common clinical syndromes of synucleinopathies.[10]

The hallmark of the pathology is accounted for by the aggregation of α-synuclein in neurons and glia, identified as Lewy bodies found in the post-synaptic peripheral autonomic neurons. DLB is also associated with under activity of the cholinergic nervous system [6], including parasympathetic and pre-ganglionic sympathetic neurotransmission.[11] In addition, neuronal loss in DLB is variable in most cases, commonly ensuing in the nigrostriatal dopaminergic pathway, olfactory bulb, locus coeruleus, amygdala, limbic and superior temporal cortices, and peripheral nervous system.[10] Therefore, the clinical picture is characterized by colorful findings, such as parkinsonism, fluctuating cognition, visual hallucinations, REM sleep behavior disorder (RBD) as well as dysautonomia.

It is worth noting at this point that OH, a well-known type of dysautonomia, is also shown to be associated with cognitive impairment, incident falls, and reduced survival in patients diagnosed with DLB.[12] It is not only one of the supportive clinical features of the DLB but also leads to complexity in the management of patients and increases disease burden.[13] Although there is much evidence of how important OH is in DLB patients clinically,[14] other postprandial and postural blood pressure changes in DLB, such as, postprandial hypotension (PPH), orthostatic hypertension (OHT) and supine hypertension (HT), in such patients have not been studied in detail yet. Therefore, the study aimed to show the prevalence of blood pressure changes in DLB patients.

Participants

Between December 2017 and April 2023, a total of 125 patients with probable DLB were included in the study, whereas a total of 126 cognitively healthy individuals were admitted to our geriatrics outpatient clinic for prevention programs due to forgetfulness or other medical problems despite normal CGA normal cognitive assessment, normal physical and neurological examinations, including as controls. The diagnosis of probable DLB was made according to the fourth consortium of DLB consensus.[8] The study was approved by the local ethics committee of the University and was conducted in accordance with the Helsinki Declaration.

All the patients underwent comprehensive geriatric assessment, including a complete medical history evaluation, neurological and neuropsychological assessment[15, 16], and routine blood ests. Additionally, with the consent of the patients, cerebrospinal fluid (CSF) analysis was performed, and brain imaging was carried out in all the demented patients.

Exclusion Criteria

The patients with infection, peripheral neuropathy, stroke, other types of dementia except DLB, malignancy, major depression, acute or chronic inflammatory/autoimmune disease, decompensated heart failure, were excluded.

Comprehensive Geriatric Assessment (CGA)

All the data, including demographic characteristics (age, gender), concomitant diseases, number of drugs, antihypertensive drugs, antipsychotics, antidepressants and antiparkinsonian drugs usage, Barthel Index for Basic Activities of Daily Living (BADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Tinetti Performance and Mobility Assessment (POMA) and laboratory results were also recorded.[17] Global cognitive functions were tested with the Montreal Cognitive Assessment (MOCA) in those with 11 or more years of education and with the Mini-Mental State Examination (MMSE) in those with less than 11 years of education[18].

Evaluation of Postural and postprandial blood pressure changes

Postural blood pressure changes were evaluated using the head up TILT table (HUT) test. HUT was conducted using the Tilt Table (Gemesan1 Tilt TableG-71, Turkey). Monitoring throughout the HUT was conducted using the Biolight1 BIOM69. After the patients were allowed to rest in the supine position for at least 10 minutes in a quiet room at 20–24°C, the Tilt Table was raised to an angle of 60–80°. The patients were monitored for blood pressure during HUT.[18] OH was defined as a decrease of at least 20 mmHg in systolic blood pressure and/or 10 mmHg in diastolic blood pressure within 3 minutes in the HUT test in an upright position of at least 60 degrees.[3] Delayed OH was also defined as OH in the HUT test after 3 minutes cut off.[19] OHT was defined as an increase in systolic blood pressure of 20 mmHg for normotensive individuals.[20] Supine HT was defined as a systolic blood pressure of at least 140 mmHg or a diastolic blood pressure of at least 90 mmHg after staying in the supine position for at least five minutes.[21] Schiller Br-102 Plus Ambulatory Blood Pressure Monitor (Schiller AG, Baar, Switzerland) was used to record 24-hour blood pressure changes. Meal time was also recorded, and PPH was defined as a decrease in systolic blood pressure of at least 20 mm Hg within two hours of a meal.[22]

Statistical analysis

The patients were divided into two groups: cognitively healthy participants and patients with probable DLB. The variables were investigated using the Kolmogorov-Smirnov test to determine whether they were normally distributed. Descriptive analysis was presented using means and standard deviations (SD). Continuous variables with normal distribution were analyzed via the independent samples t-test and those with non-normal distribution via the Mann-Whitney U test. Differences between categorical variables were assessed with Pearson's chi-square test or Fisher's exact test. Binary logistic regression analysis was performed for the factors that were likely to affect OH, delayed OH, and PPH postprandial OH in patients with DLB. Adjusted model was established according to age, number of drugs, usage of antipsychotics, antiparkinsonian drugs, Angiotensin receptor blockers (ARRB), and beta-blockers. Probability (p) value of < 0.05 was considered significant. All statistical analyses were performed using the SPSS 22.0 (SPSS Inc.) package program.

Demographics and clinical features of participants

165 (%65.70) participants were female and the mean age was 76.44 ± 7.24. The mean age of the DLB group was 78.42 ± 7.13, and that of the cognitively healthy patients was 74.49 ± 6.85, and the difference was statistically significant (p < 0.001). The frequency of comorbidities was not statistically different between the groups. The number of drugs and use of ARB and BB were higher in the cognitively healthy group. (p = 0.001, p = 0.035 and 0.005 respectively) The frequency of antipsychotics and antiparkinsonian drugs was higher in the DLB group (p < 0.001 and p < 0.001). As expected, MMSE scores, MOCA scores, POMA scores, BADL and IADL scores were higher in the cognitively healthy group. (p < 0.001). Constipation, one of the dysautonomia forms, has a higher prevalence in the DLB group (22.8% vs 37.2%). (p < 0.016). The demographic characteristics of the patients, comprehensive geriatric assessment tests, laboratory parameters, comorbid conditions and postural and postprandial blood pressure changes are summarized in Table 1.

Table 1

Characteristics of Participants
	Control n:126	DLB n:125	p
Demographics
Age	74.49 ± 6.85	78.42 ± 7.13	0.000
Sex - Female (%)	70.6	60.8	0.101
Comorbidities
Hypertension(%)	70.6	64	0.262
Diabetes Mellitus(%)	31	29.9	0.861
CHF(%)	3.2	6.8	0.188
CAD(%)	28.6	21.4	0.196
SVD(%)	5.6	9.4	0.253
Hyperlipidemia(%)	16.7	18.8	0.661
Depression(%)	43.7	40.5	0.622
Drugs
Number of Drugs	5.40 ± 3.79	6.59 ± 3.07	0.001
ACEi (%)	14.3	13.7	0.891
ARB (%)	42.1	29.1	0.035
CCB (%)	26.2	27.4	0.838
BB (%)	38.9	22.2	0.005
Diuretics (%)	35.7	35	0.913
Alpha blockers(%)	7.1	4.3	0.337
Antidepressant(%)	35.7	48.1	0.054
Antipsychotic(%)	5.6	23.1	0.000
Anti-parkinson(%)	3.2	21.3	0.000
Labaratory
eGFR mL/min 1.73 m2	73.23 ± 17.60	70.36 ± 20.61	0.254
Comprehensive Geriatric Assessment
MMSE	25.42 ± 3.95	16.10 ± 5.44	0.000
MOCA	23.68 ± 3.69	17.83 ± 5.83	0.000
POMA	25.19 ± 3.85	21.33 ± 7.26	0.000
BADL	91.33 ± 10.66	78.45 ± 22.57	0.000
IADL	19.92 ± 4.04	10.18 ± 6.58	0.000
Postural and Postprandial Blood Pressure - Heart Rate Changes
Postprandial Hypotension (%)	50.8	89.4	0.000
Supine Hypertension (%)	38.1	46.4	0.183
POTS (%)	0	3.1	0.081
OHT (%)	1.6	6.5	0.058
OH (%)	28.6	45.5	0.006
Delayed OH (%)	5.6	13.3	0.045
ACEi: Angiotension Converting Enzyme inhibitor; ARB: Angiotensin Receptor Blocker; BADL: Barthel Basic Activity of Daily Living; BB: Beta Blocker; CAD: Coronary Artery Disease; CCB: Calcium Channel Blocker; CHF: Congestive Heart Failure; DLB: Dementia with Lewy Bodies; IADL: Lawton-Brody Instrumental Activity of Daily Living; MMSE: Mini Mental State Examination; MOCA: Montreal Cognitive Assessment, OH: Orthostatic Hypotension; OHT: Orthostatic Hypertension; POMA: Tinetti Performance Oriented Mobility Assessment; SVD: Serebrovascular Disease
Statistically significant p values (p < 0 0.05) are shown in bold characters.

Postural and postprandial blood pressure and changes

PPH, OH, and delayed OH were more frequent in the DLB group (p < 0.001, p = 0.006 and 0.045, respectively), whereas the frequency of supine HT, and OHT was similar between the groups (Table 1). However, supine HT in non-hypertensive participants was higher in DLB patients than in controls (n = 45; 48.9% vs n = 37, 27%; p = 0.043). After adjustments according to age, the number of drugs, anti-psychotic, antiparkinsonian drugs ARB (angiotensin receptor blocker) and BB (beta blocker); PPH and OH were associated with DLB (OR 10.524% 95 CI 3.110-35.614 p < 0.001and OR 1.965% 95 CI 1.048–3.686 p = 0.035 respectively). (Table 2.)

Table 2

The association with dysautonomia and DLB after adjusted for age, number of drugs, antipsychotic drugs, antiparkinsonian drugs, angiotensin receptor blockers, beta blockers
	Cognitively Normal	DLB
	OR(95% CI)	OR	OR(95% CI)	p
Postprandial hypotension (%)	Reference	10.524	3.110-35.614	< 0.001
OH (%)		1.965	1.048–3.686	0.035
Delayed OH(%)		2.274	0.753–6.863	0.145
CI: Confidence Interval; DLB: Dementia with Lewy Bodies, OH: Orthostatic Hypotension OR: Odds Ratio
Statistically significant p values (p < 0.05) are shown in bold characters.

This cross-sectional-single center study demonstrates that OH and PPH are more common in elderly patients with DLB than in cognitively healthy controls. Furthermore, to the best of our knowledge, this is the first report to show PPH as an autonomic manifestation of DLB other than constipation, salivation, incontinence, hyperhidrosis, and sexual dysfunction, in older adults in a memory clinic.

When it comes to dysautonomia, which is likely to be an early marker of DLB, OH is often the first to come to mind. A recent meta-analysis has reported OH in 50.8% of DLB patients,[14] which is considerably higher than both patients with AD (28%)[3] and non-demented older adults (17.9%).[5] Many studies in patients with DLB have reported that OH may be closely related to cognitive impairment, even an important predictor of cognitive outcomes, and chronic hypoxia may link to neurodegenerative mechanisms.[4, 12, 23] Increased α-synuclein cortical and subcortical pathology has been reported in DLB patients with OH,[24] which may worsen by acute and chronic cerebral hypoperfusion.[21, 25] Additionally, recurrent hyperperfusion due to supine HT, which usually accompanies OH, may also play a role in cognitive impairment in these patients. It was reported that these patients may also have baroreflex failure and peripheral noradrenergic deficiency.[26] Also, OH is likely to be severe in DLB patients due to the involvement of the rostral ventrolateral medulla and medullary raphe control of sympathetic outflow.[23] Considering these pathophysiological changes in OH as well as DLB, other dysautonomia findings such as supine HT, OH, delayed OH, and PPH also seem to be associated with DLB. Nevertheless, these conditions, especially PPH in DLB patients, have not yet been evaluated in detail.

Unlike others, PPH is characterized by inadequate cardiovascular compensation to meal-induced splanchnic blood pooling resulting from complex interactions between ingested nutrients and the gastrointestinal tract.[27] Besides dysautonomia, several potential mechanisms are involved in the development of PPH: Increased splanchnic blood pooling, age or HT-related decreased baroreflex function, inadequate sympathetic nerve firing or vascular responsiveness to norepinephrine, upregulation of vasoactive intestinal peptides, and insulin-mediated vasodilation.[27] In addition, PPH is also associated with an increased risk for cerebrovascular disease, transient ischemic attack, syncope, falls, and coronary events,[22] just like OH.

The fact that half of the healthy controls in the study had PPH confirms that older adults are prone to PPH. This may be related to an age-related selective decrease in the number of cholinergic neurons in the enteric nervous system and parallel progressive loss of Cajal interstitial cells in the stomach and colon throughout life.[28] Additionally, the very high frequency of PPH in DLB patients, nearly 9 out of 10 patients, is of paramount importance for clinical practice, indicating that an older patient with PPH should be investigated for DLB or carefully monitored for an early/upcoming feature of DLB. On the contrary, DLB patients who report worsening in their clinical condition, especially after meals, should be evaluated for PPH, and all adverse health outcomes related to PPH, such as falls, stroke, and coronary events, should be prevented in those with PPH.

This study showed that DLB increased the risk of OH and PPH by approximately 2 and 10-fold, respectively, compared to healthy controls. This increased OH risk in DLB patients is a well-known issue and consistent with our previous studies. [8, 9, 14] However, to the best of our knowledge, this is the first study to report the increased risk of PPH in DLB patients. Considering both DLB-related negative health outcomes, [9, 13, 21, 29] and adverse events and complications related to OH and PPH, as signs of dysautonomia, it is clear that the prevention of such outcomes is indispensable to ensure better management of DLB.[8, 9, 14]

Although delayed OH was significantly higher in DLB patients than in control, this difference between the groups disappeared after the adjustment. Indeed, a higher frequency is an expected outcome, as delayed OH is likely to be an early and milder form of OH in such patients. Within this context, Gibbons et al reported that delayed OH seems to be associated with progression to OH and 10-year mortality in patients with α-synucleinopathies.[14, 19]

The frequency of supine HT was similar to the control in the study. However, when supine HT was evaluated according to the presence of HT in each group in order to eliminate the effect of HT, it was shown that supine HT was higher in DLB patients without HT than in those of controls, which is consistent with previous studies.[21]

Given the adverse health outcomes associated with DLB, as well as the fact that dysautonomia such as OH, supine HT, and PPH alone cause a variety of serious adverse health outcomes in older adults, including cardiovascular events, cerebrovascular disease, syncope, falls, fractures, cognitive impairment and mortality,[3, 5, 14, 22] the prevention of such conditions is crucial to ensure better management of DLB and alleviate caregiver burden. The study has several strengths. To start with, all the participants underwent a comprehensive geriatric assessment, and CSF biomarkers, if possible, were used to support the diagnosis. In addition, as far as we are concerned, this is the first study to evaluate blood pressure changes as an indication of dysautonomia, especially PPH, in older patients with DLB. Finally, the blood pressure changes were assessed by HUT with 24-hour ambulatory blood pressure measurement and adequate sample size. On the other hand, the study has some limitations: One is the study’s cross-sectional design which limits the establishment of a cause-and-effect relationship. Another is that postural blood pressure changes cannot be evaluated beat-to-beat monitorization in HUT. Apart from these, although the diagnosis of PPH without a standard meal seems to be a limitation, 24-hour blood pressure monitoring with the patient's routine daily diet to diagnose PPH may be more important in terms of reflecting real-life naturalistic data. As cardiovascular medications are vital in older adults and it is considered unethical to discontinue them.[30] All patients continued to take them during the tests, which was taken into account in the regression analysis. The other is DLB diagnosis without confirmation neuropathologically.

In conclusion, this study shows that OH, supine HT and PPH, dysautonomia symptoms appear higher in DLB patients. Therefore, considering the potential complications of postural blood pressure changes and PPH, it would be appropriate to evaluate dysautonomia in the follow-up of DLB for which there is no cure yet.

ACKNOWLEDGEMENTS

The investigation was approved by the local ethics committee and conformed to the Declaration of Helsinki of 1975. All authors declare no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. There are no financial conflicts of interest to disclose. All authors agreed on submission.

ROLE OF AUTHORS

The authors confirm contribution to the paper as follows: study conception and design: Ahmet Turan ISIK; data collection: Mehmet Selman ONTAN, Feyza MUTLAY, Alev CAM MAHSER, Acelya GOKDENIZ YILDIRIM, Derya KAYA; analysis and interpretation of results: Fatma Sena DOST, Mehmet Selman ONTAN; draft manuscript preparation: Ahmet Turan ISIK, Derya KAYA, Fatma Sena DOST, Mehmet Selman ONTAN; critical revision: Ahmet Turan ISIK. All authors reviewed the results and approved the final version of the manuscript.

ACKNOWLEDGEMENTS

All authors declare no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. There are no financial conflicts of interest to disclose. All authors agreed on submission.

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Postprandial Hypotension Is More Common Than Orthostatic Hypotension In Older Adults With Dementia With Lewy Bodies: A Cross-Sectional Study

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Abstract

Purpose

Methods

Results

Conclusion

INTRODUCTION

METHODS

Participants

Exclusion Criteria

Comprehensive Geriatric Assessment (CGA)

Evaluation of Postural and postprandial blood pressure changes

Statistical analysis

RESULTS

Demographics and clinical features of participants

Postural and postprandial blood pressure and changes

DISCUSSION

Declarations

References

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