Journal of Gerontological Nursing

POSTPRANDIAL BLOOD PRESSURE CHANGES IN THE ELDERLY

Mary D Lilley, MSN, APRN

Abstract

ABSTRACT

Postprandial blood pressure reductions have been observed in frail elderly individuals. This study evaluated blood pressure and heart rate changes in 10 healthy elderly subjects at intervals before and after a morning meal. Subjects did not exhibit significant reductions in systolic blood pressure or increases in heart rate over time, rather, such changes were due to variation within subjects. They did not exhibit significant changes in diastolic blood pressure. Age, health, and meal choice may have influenced results. Further research will determine which groups of elderly are most at risk for postprandial blood pressure reductions and consequently at risk for injury from falls due to dizziness and syncope.

Abstract

ABSTRACT

Postprandial blood pressure reductions have been observed in frail elderly individuals. This study evaluated blood pressure and heart rate changes in 10 healthy elderly subjects at intervals before and after a morning meal. Subjects did not exhibit significant reductions in systolic blood pressure or increases in heart rate over time, rather, such changes were due to variation within subjects. They did not exhibit significant changes in diastolic blood pressure. Age, health, and meal choice may have influenced results. Further research will determine which groups of elderly are most at risk for postprandial blood pressure reductions and consequently at risk for injury from falls due to dizziness and syncope.

Compared with younger populations, older adults experience higher mortality rates and have higher rates of days of restricted activity and disability as a result of falling (Hogue, 1982). Hospitalization and long-term placement are common and expensive outcomes for elderly persons sustaining injury from falls. Inadequate blood pressure (BP) regulation resulting from the interaction of agerelated changes in the cardioregulatory system with one or more cardiovascular stressors such as eating, position changes, or elimination has the potential to decrease an elderly person's cardiac output thereby increasing the elderly person's risk of injury from falls due to dizziness or syncope.

Lipsitz, Nyquist, Rowe, and Wei (1983) and Vaitkevicius, Esserwein, Maynard, O'Connor, and Fleg (1991) observed significant postprandial reductions in BP in frail institutionalized elderly populations. Lipsitz and Fullerton (1986) reported similar findings in a noninstitutionalized group of elders. Subjects in these studies had multiple health problems, and the postprandial BP reductions may have reflected disease rather than the aging process. Few studies have targeted a healthy aging population, and those that evaluated this population have had discrepant results (Peitzman & Berger, 1989; Lipsitz et al., 1993).

Table

TABLE 1Age-Related Changes in the Cardioregulatory System

TABLE 1

Age-Related Changes in the Cardioregulatory System

The Orem Self-Care nursing model (1985) provides a conceptual framework to consider this problem. Prevention of hazards to human life, function, and well being is one universal aspect of the concept of selfcare. As people age they may become incapable of complete selfcare because of lack of knowledge, as well as physiological changes over which they have little or no apparent control. Postprandial reductions in blood pressure may represent a potential hazard to life or a potential self-care deficit.

REVIEW OF THE LITERATURE

Postprandial hemodynamic effects take place in both the gastrointestinal and systemic vascular systems as a result of the interaction of neural, hormonal, and meal characteristic influences. As individuals age, certain anatomical and physiological changes occur that can interfere with their ability to respond adequately to such common cardiovascular stressors as postural changes, the Valsalva maneuver, and eating, placing those individuals at increased risk for injury. The following review describes many of these effects and examines conflicting research findings concerning the phenomenon of postprandial BP reductions in both the frail and healthy elderly populations.

Gastrointestinal Hemodynamics

Food ingestion may be seen as a cardiovascular stressor because the process of digestion effects certain hemodynamic changes regulated by the sympathetic nervous system (produces gastrointestinal blood vessel constriction), parasympathetic nervous system (produces slight vasodilation), and humoral system (gastrin, secretin, glucagon, vasoactive intestinal polypeptide, substance P, neurotensin, and adenosine regulate intestinal blood flow and insulin increases mean arterial pressure as well as affects intestinal blood flow) (Jansen & Hoefnagels, 1991; Christensen, 1983).

Meal Composition and Gastrointestinal Blood Flow

Splanchnic and hepatic blood flow increase as much as 35% and 70%, respectively, following the ingestion of a high-protein meal, remain elevated at 90 minutes, and return gradually to baseline approximately 280 minutes after the meal (Svensson et al., 1983; Brandt et al., 1955). In contrast, high-carbohydrate and high-fat meals are not associated with any significant changes in hepatic blood flow (Orrega, Mena, Baroana, & Palma, 1965). Combination meals consisting of protein, fat, and carbohydrate result in an increase in splanchnic blood flow at 30 minutes after die beginning of the meal in young adults and a 14% to 30% increase in healthy elderly adults (Lipsitz et al, 1993).

Meal Composition and Systemic Hemodynamic Response

Ingestion of a combination meal resulted in no significant changes in heart rate (HR) or BP in healthy young adults (Lipsitz et al., 1983; Norryd, Dencker, Lunderquist, Olin, & Tylen, 1975; Ryan, Goldberger, Ruthazer, Mietus, & Lipsitz, 1992). Other studies have shown small but statistically significant HR increases (Lipsitz, Pluchino, Wei, Minaker, & Rowe, 1986; Lipsitz et al., 1993). Bagatell and Heymsfield (1984) noted a significant positive correlation between meal size and cardiac index, HR, stroke volume, index of myocardial oxygen consumption, and total body oxygen consumption reaching a peak at 30 to 60 minutes after the beginning of the meal in young adults.

Age-Related Changes in the Cardioregulatory System

Table 1 outlines several anatomical and physiological changes that occur with aging that can interfere with the individual's ability to respond adequately to a cardiovascular stressor such as eating.

Aging Cardiovascular Response to Food Ingestion. Lipsitz et al. (1983) investigated postprandial changes in BP and HR in institutionalized elderly persons. Elderly subjects with and without a history of syncope exhibited substantial postprandial reductions in BP which occurred without a compensatory rise in HR. Young subjects receiving the same meal did not exhibit any significant changes in BP and HR.

Lipsitz and Fullerton (1986) investigated this postprandial phenomenon in a frail, noninstitutionalized elderly population. They observed significant but less substantial BP reductions as well as HR increases following a noon-time meal in 21 community-dwelling elderly adults who attended a nutrition program.

Peitzman and Berger (1989) noted a mean systolic BP (SBP) decline of 16 mm Hg in a group of 16 healthy elderly individuals. These subjects experienced a compensatory rise in mean HR of 5 beats per minute.

A later study by Lipsitz's group, described in two journal articles, evaluated a healthier elderly population and did not find any significant postprandial BP declines (Jansen, Connelly, Kelley-Gagnon, Parker, & Lipsitz, 1995; Lipsitz et al., 1993). They hypothesized that meal choice and position of measurement (supine) may have yielded results that diverged from the earlier studies.

Potter et al. (1989) noted statistically significant declines in supine SBP and diastolic BP (DBP) for high-carbohydrate and high-protein meals compared with no change or a rise after normal (mixed) and high-fat meals in healthy elderly adults.

These studies indicate that some elderly individuals exhibit significant reductions in BP following the ingestion of certain meals. There has been no published nurse-initiated research to date addressing this issue. More research is needed to discern whether these BP reductions reflect age or disease processes. This study attempted to clarify this issue by targeting a group of healthy noninstitutionalized elderly.

RESEARCH HYPOTHESES

Healthy noninstitutionalized elderly subjects will exhibit significant postprandial changes in systolic blood pressure and diastolic blood pressure. They will exhibit significant changes in HR.

Table

TABLE 2Nutrient Value of Foods Comprising Test Meal Compared with Recommended Dietary Allowance for Adults Age 65 and Older

TABLE 2

Nutrient Value of Foods Comprising Test Meal Compared with Recommended Dietary Allowance for Adults Age 65 and Older

METHOD

Reference Population

A convenience sample of 10 noninstitutionalized elderly adults was located through two senior citizen organizations in Massachusetts communities. A statement of informed consent was obtained from each subject prior to participation. Subjects were selected according to the following criteria:

* Sixty-five years of age or older.

* English-speaking.

* Alert and oriented.

* Residing in a private home or apartment, senior housing, or retirement village.

Table

TABLE 3Clinical Characteristics of Subjects (N=0)

TABLE 3

Clinical Characteristics of Subjects (N=0)

* Not taking any of the following medications: beta blockers, calcium channel antagonists, diuretics, nitrates, tranquilizers, antidepressants, sedative hypnotics, centrally acting antihypertensives, and insulin or oral hypoglycemics.

* Not being medically treated for hypertension, diabetes mellitus, Parkinson's disease, congestive heart failure, or having a history of syncope.

Measurements

Heart rate. Heart rate was measured by palpation of the radial artery for 1 minute.

Blood pressure. Systolic blood pressure and DBP were measured indirecdy using a Norelco® Healthcare digital blood pressure meter (#HC3001). This meter uses the oscillometric method for BP determination with an accuracy of ± 3 mm Hg from 0 mm Hg to 250 mm Hg.

Standardized meal A solid/liquid meal providing approximately one third of the recommended dietary allowance for calories, protein, fat, and carbohydrate was provided for each subject (Table 2).

Protocol

Subjects were asked not to consume any food or fluids after midnight of the night before the test The researcher began each evaluation at 8 a.m. Each subject remained seated for the duration of the test. Four recordings of BP and HR were taken at 5minute intervals before the meal. Subjects consumed the meal during a 15-minute period. Five recordings of BP and HR were obtained at 15, 25, 35, 45, and 60 minutes after the start of the meal, a format used by Lipsitz et al. (1983). The influence of testing was minimized by disregarding the first BP and HR values for each subject which may have been elevated due to anxiety.

STATISTICAL ANALYSIS

Data were analyzed using paired t-tests and repeated measures analysis of variance. The level of significance was established at/» = .05. The last three of the four preprandial SBP, DBP, and HR values were averaged to obtain mean basal values. Postprandial measurements were compared with these baseline values using paired r-tests to evaluate the significance of postprandial changes in blood pressures and HR at each time period. Postprandial SBP, DBP, and HR changes over time were analyzed using repeated measures analysis of variance.

RESULTS

The 10 people meeting the selection criteria who agreed to participate in the study had a mean age of 74 ± 9 years. Six subjects were men. All subjects were in fairly good health without acute illness. Five subjects did not take any medications. Characteristics of the subjects are elaborated in Table 3.

Systolic Blood Pressure

Subjects exhibited statistically significant postprandial reductions in SBP due to individual differences (variation within subjects) (F[9, 36] = 4.13, ? < .001) and not to whole group changes between measurement periods (variation over time) (F[4, 36] = 0.44, ? > .05). Paired i-test analysis indicated there was a maximum, although insignificant, reduction in SBP from baseline of 3.0 ± 3.68 mm Hg at 35 minutes after the start of the meal. Table 4 compares individual subjects' SBP and DBP change from baseline over time.

Diastolic Blood Pressure

Subjects did not exhibit significant postprandial changes in DBP within subjects (F[9, 36] = 1.06, p > .05) or over time (F[4, 36] = 1.06, p > .05). There was a maximum reduction in DBP of 5.2 ± 1.87 mm Hg at 35 minutes after the start of the meal (*[9] = 2.78, p<.02).

Heart Rate

Subjects exhibited significant postprandial increases in HR due to variation within subjects (F[9, 36] = 10.30,/» < .0001) rather than to variation over time (F[4, 36] = 1.13, ? > .05). Heart rate increased significantly from baseline at each postprandial measurement period and reached a maximum increase of 6.4 ± 1.73 beats per minute (f[9] = 3.70, ? < .005) at 60 minutes after the start of the meal. Table 5 presents HR change from baseline over time. The data compares well with studies that find peak cardiac indices at 30 to 60 minutes after food ingestion.

Table

TABLE 4Postprandial Systolic and Diastolic Blood Pressure (SBP/DBP) Change from Baseline Over Time*

TABLE 4

Postprandial Systolic and Diastolic Blood Pressure (SBP/DBP) Change from Baseline Over Time*

DISCUSSION

Basal Values of Blood Pressure and Heart Rate

The mean basal SBP of 127 ± 21 mm Hg and mean basal HR of 65 ± 11 beats per minute for this study population compare with findings reported by Lipsitz et al. (1983), Lipsitz and Fullerton (1986), Peitzman and Berger (1989), and Jansen et al. (1995) summarized in Table 6. Subjects 6, 8, and 10 exhibited mild to moderate elevation of SBP which is a common age-related change of the cardiovascular system (Chobanian, 1983).

Systolic Blood Pressure

Group SBP reductions over time were not statistically or clinically significant (i.e., did not result in clinical hypotension). Potential explanations for these findings include several factors. Subjects had a mean age of 74 ± 9 years of age which is considerably younger than the elderly subjects participating in the study by Lipsitz et al. (1983) (Af = 87, SD ± 1). Aging is associated with impaired baroreflex functioning (Gribbin, Pickering, Sleight, & Peto, 1967).

Subjects in the present study were healthier than those in the 1983 and 1986 Lipsitz studies but comparable or less healthy than the 1995 Jansen et al. study. Five of the 10 subjects did not take any medications. Eight of the 21 subjects in the study by Lipsitz and Fullerton (1986) were being medically treated for hypertension, as well as other chronic illnesses excluded from the present study. Lipsitz and Fullerton (1986) found a significant inverse correlation between basal SBP and postprandial BP change at 60 minutes after the start of the meal, that is, the higher the basal SBP, the greater the postprandial decline. Hypertension and aging are independently associated with impaired baroreceptor function (Gribbin et al., 1967).

Meal choice may have influenced the degree of change in BP. The prior studies (Table 6) had substantially higher calorie, protein, and/or fat composition than this study. Highprotein meals are associated with larger increases in hepatic and splanchnic blood flow than highcarbohydrate and high-fat meals (Orrega et al., 1965). However, oral glucose loading may result in SBP declines compared with no changes from oral fructose loading as a result of insulin associated splanchnic vasodilation (Jansen, Penterman, van Lier, & Hoefnagels, 1987). Furthermore, the rate of digestion slows with increasing caloric density (Moore et al., 1984), and the rate of gastric emptying is slowest for fats and protein (McHugh & Moran, 1979). It is possible that the higher complex carbohydrate concentration but lower protein concentration provided to subjects in this study may have contributed to the insignificant BP changes for the group as a whole.

Table

TABLE 5Heart Rate Change from Baseline Over Time/Paired t-Test Results

TABLE 5

Heart Rate Change from Baseline Over Time/Paired t-Test Results

These results do not reconcile completely with data from Potter et al. (1989) which showed more pronounced SBP declines (range -3 to -19 mm Hg) after high-carbohydrate (72% carbohydrate, 21% protein, 7% fat) and high-protein (17% carbohydrate, 21% protein, 7% fat) meals but do compare with their mixed (49% carbohydrate, 24% protein, 27% fat) meal results (range -1 to -13 mm Hg). The four meals in the aforementioned study included chicken, vegetable, and potato. The latter items break down glucose relatively quickly, perhaps producing a more rapid splanchnic vasodilation.

These results compare very well with those of Jansen et al. (1995) whose subjects experienced only a maximum SBP decline of 4 mm Hg. They suggested the lack of significant declines might be related to the supine measurement of BP and HR and meal choice. However, Potter et al. (1989) and Peitzman and Berger (1989) noted no additional significant orthostatic changes at any of the postmeal measurement periods.

There are two substantial differences between this study and that by Jansen et al. (1995). The Jansen study used a liquid (Carnation® Instant Breakfast) meal served at 22°C. This study had a mixed liquid/solid meal at varied temperatures: hot cereal, cold milk, and juice. Kuipers, Jansen, Peeters, and Hoefnagels (1991) noted that ingested warm glucose solutions resulted in significant BP declines compared to increases in BP for cold solutions. They suggested the cold liquid may exert a pressor effect.

Subjects 2 and 6 (20% of the population) exhibited SBP reductions of greater than 10 mm Hg and as much as 28 mm Hg at 35, 45, and 60 minutes after the start of the meal. Neither of these people experienced dizziness or other symptoms of hypotension. These results were similar to those found in the frail institutionalized elderly studied by Lipsitz et al. (1983) and the community-dwelling elderly studied by Lipsitz and Fullerton (1986). A lack of symptoms in patients with unexplained syncope who experienced postprandial hypotension was also noted by Jansen et al. (1995). Researchers postulated that despite SBP declines of 25 mm Hg, no systolic pressures declined to a clinical hypotensive range (< 100 mm Hg).

Several hypotheses have been promoted to account for postprandial SBP changes found in certain groups of elderly:

* Impaired baroreflex response to a decrease in circulating blood volume occurring as a result of blood shunting to the gastrointestinal tract to facilitate digestion.

* Failure to maintain systematic vascular resistance in response to meal ingestion.

* Impairment in postprandial autonomic modulation of HR.

* Failure to maintain compensatory norepinephrine (NE) levels and cardioacceleratory responses (Lipsitz et al., 1993; Lipsitz et al., 1986).

Some of these changes may be attributed to cardiovascular diseases or processes affecting autonomic nervous system function such as Parkinson's disease and diabetes mellitus (Robertson, Wade, & Robertson, 1981; Micieli, Martignoni, Cavallini, Sandrini, & Nappi, 1987).

Table

TABLE 6Comparison of Five Studies Evaluating Postprandial Blood Pressure Changes in the Elderly

TABLE 6

Comparison of Five Studies Evaluating Postprandial Blood Pressure Changes in the Elderly

Diastolic Blood Pressure

There were significant postprandial DBP reductions from baseline which reached a maximum of 5.2 ± 1.9 at 35 minutes after the start of the meal. Fagan, Conrad, Mar, and Nelson (1986) report reductions in DBP of 3 to 7 mm Hg in both old and young subjects following the ingestion of a meal. This is believed to be related to the increase in splanchnic blood flow and consequent decrease in total peripheral resistance which occurs following the ingestion of food.

Heart Rate

Postprandial HR changed significantly from basal HR at each measurement period, reaching a maximum of 6.4 beats per minute at 60 minutes after the start of the meal. These findings contrast with those of Lipsitz et al. (1983) who found that frail institutionalized elderly persons failed to exhibit a significant rise in HR to compensate for BP reductions. However, Lipsitz and Fullerton (1986) found that community-dwelling elderly subjects exhibited HR increases of 8 beats per minute at 60 minutes after the start of the meal which compares with the findings of the present study. They suggested that observed BP declines may have reflected impaired baroreflex-mediated peripheral vasoconstriction rather than impaired cardioacceleration.

LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH

Nonrandomization and sample size have limited the generalizability of results to a population of healthy noninstitutionalized elderly. Each of these limitations has increased the probability of committing a type II error. The lack of random selection may have resulted in critical values of F which were too small. The small sample size reduced the degree of power of the statistical tests employed.

More sophisticated medical research has ensued since this study was conducted in 1986, including simultaneous measurements of multiple hemodynamic indices, splanchnic blood pooling, HR power spectrum analyses, and plasma NE levels (Ryan et al., 1992; Lipsitz et al., 1993). However, small sample size, differences in meal choice, subjects, and position of measurements (supine or sitting) make comparisons and interpretation of data challenging. The mechanism(s) by which it occurs is unclear but future research should clarify the process. The clinical significance of this phenomenon is incompletely understood and may only be realized when evaluating those patients with unexplained syncope or falls, or those in whom disease processes such as hypertension, Parkinson's disease, and diabetes mellitus are present. It will be difficult to ascertain how much such postprandial BP changes may be related to the disease processes or the medications used to manage the illness. Postprandial hypotension has clearly been associated with falls and syncope alone and in conjunction with other cardiovascular stressors such as medications, postural changes, and the Valsalva maneuver used during voiding or defecation (Lipsitz et al., 1986; Jonsson, Lipsitz, Kelley, & Koestner, 1990).

Recent studies have investigated interventions to reduce the severity of postprandial BP changes. Heseltine, Dakkak, Woodhouse, MacDonald, and Potter (1991) found that caffeine ingestion reduced or eliminated postprandial BP declines in the elderly, likely secondary to its adenosine receptor antagonism. Other studies have found that the somatostatin analog octreotide, which inhibits the secretion of all gastrointestinal hormones, prevents postprandial BP decline after oral glucose loading in the elderly (Jansen et al., 1989).

Future research should be directed toward investigating the effect of meal times and caloric value on BP changes. Medication timing in relation to meals and BP changes needs further investigation.

NURSING IMPLICATIONS

This study and the others reviewed suggest that a healthy elderly population may not be at as great a risk for postprandial BP reductions as a frail elderly population. However, it is noteworthy that 20% of the healthy elderly subjects in this study experienced moderate to substantial postprandial SBP reductions. Given this prevalence in a healthy elderly population, postprandial BP changes should be considered as a possible factor to consider in elderly patients who present with symptoms of dizziness or a history of falls or syncope. Nurses who care for the elderly population, especially those elders with cardiovascular or neurological disease, should consider evaluating their clients for this problem.

There is a dearth of published nursing research addressing the issue of postprandial BP in the elderly population. Nurses are in a strategic position to educate elders; to conduct trials and evaluate practical interventions to minimize the effect of this phenomenon. Such interventions might include having elderly persons who are at risk for postprandial hypotension lie down after meals, or avoid prolonged standing or bathing after eating, which might cause additional vasodilation and BP reductions. The efficacy of caffeine, cold drink, or change in meal size or content in minimizing BP reductions in the unique and vulnerable elderly populations can be evaluated. Nursing interventions derived from this research could be implemented to maximize the elderly individual's ability for self-care.

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TABLE 1

Age-Related Changes in the Cardioregulatory System

TABLE 2

Nutrient Value of Foods Comprising Test Meal Compared with Recommended Dietary Allowance for Adults Age 65 and Older

TABLE 3

Clinical Characteristics of Subjects (N=0)

TABLE 4

Postprandial Systolic and Diastolic Blood Pressure (SBP/DBP) Change from Baseline Over Time*

TABLE 5

Heart Rate Change from Baseline Over Time/Paired t-Test Results

TABLE 6

Comparison of Five Studies Evaluating Postprandial Blood Pressure Changes in the Elderly

10.3928/0098-9134-19971201-07

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