JAMDA xxx (2017) 1e6

JAMDA
journal homepage: www.jamda.com

Original Study

Frailty, Disability, and Ambulatory Blood Pressure in Older Adults

Teresa Gijón-Conde MD a, b, Auxiliadora Graciani MD a, Esther López-García PhD a,
Esther García-Esquinas MD a, Martin Laclaustra MD a, c, Luis M. Ruilope MD a,
Fernando Rodríguez-Artalejo MD a, José R. Banegas MD a, *
a
Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid ⁄ IdiPAZ CIBER in Epidemiology and Public
Health (CIBERESP), Madrid, Spain
b
Centro de Salud Universitario Cerro del Aire, Majadahonda, Madrid, Spain
c
Aragon Institute for Health Research (IIS Aragón), Translational Research Unit, Hospital Universitario Miguel Servet, CIBERCV, Universidad de Zaragoza,
Zaragoza, Spain

a b s t r a c t

Keywords: Background and objective: Frailty and disability are associated with cardiovascular risk factors, including
Ambulatory blood pressure hypertension, in older people; however, little is known about their association with ambulatory blood
elderly pressure (BP). Thus, we assessed the relationship of frailty and disability with ambulatory BP in older
frailty
adults.
disability
Design, setting, and participants: Cross-sectional study of 1047 community-living individuals aged

60 years in Spain.
Measurements: BP was determined with validated devices under standardized conditions during
24 hours. Frailty was defined as having 3 or more of the following criteria: weight loss, low grip strength,
low energy, slow gait speed, and low physical activity. Disability was assessed with the Lawton-Brodýs
questionnaire on instrumental activities of daily living. Associations with systolic BP (SBP) and dipping
(nocturnal SBP decline) were modeled and adjusted for sociodemographic variables, body mass index,
lifestyles, antihypertensive drug treatment, comorbidities, 24-hour heart rate, and conventional or
ambulatory SBP as appropriate.
Results: Participants’ mean age was 71.7 years (50.8% men); 6% were frail and 8.1% had disability.
Compared with nonfrail participants, those with frailty had 3.5 mm Hg lower daytime SBP (P ¼ .001),
3.3% less SBP dipping (P ¼ .003), and 3.6 mmHg higher nighttime SBP (P ¼ .016). Compared with par-
ticipants who are not disabled, those who are disabled had 2.5 mmHg lower daytime SBP (P ¼ .002), 2.5%
less SBP dipping (P ¼ .003), and 2.7 mmHg higher nighttime SBP (P ¼ .011).
Conclusions: In community-dwelling older adults, frailty and disability were independently associated
with lower diurnal SBP, blunted nocturnal decline of SBP, and higher nocturnal SBP. These findings may
help explain the higher mortality associated with low clinic SBP in frail older subjects observed in
epidemiologic studies.
Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Hypertension is highly prevalent among elderly persons and con-

This work was supported by Fondo de Investigación Sanitaria (FIS) grant no.
16/01460 (Instituto de Salud Carlos III and FEDER/FSE), CIBERESP, the FRAILOMIC
Initiative (FP7-HEALTH-2012-Proposal no. 305483-2) and the ATHLOS project (EU
H2020- Project ID: 635316). The funding agencies had no role in study design, data
analysis, interpretation of results, manuscript preparation or in the decision to
submit this manuscript for publication.
The authors declare no conflicts of interest.
* Address correspondence to José R. Banegas, MD, Department of Preventive
Medicine and Public Health, Universidad Autónoma de Madrid, Arzobispo Morcillo
4, Madrid 28029, Spain.
E-mail address: joseramon.banegas@uam.es (J.R. Banegas).
tributes substantially to poor physical function, and cardiovascular
and all-cause mortality.1e4 Ambulatory blood pressure monitoring
(ABPM) is a useful tool for the diagnosis and management of hyper-
tension because it predicts clinical outcomes better than conventional
blood pressure (BP) measurements.5e8 In particular, nighttime systolic
BP (SBP) is the strongest predictor of cardiovascular disease (CVD).9e11
Likewise, a blunted nocturnal decline of SBP (dipping) is also a risk
factor for CVD mortality.12,13 Night/day SBP ratio expresses the same
information as the dipping size,8 and independently predicts total
mortality.12 On the other hand, frailty and disability syndromes are

https://doi.org/10.1016/j.jamda.2017.11.014
1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
2 T. Gijón-Conde et al. / JAMDA xxx (2017) 1e6
associated with aging and chronic diseases, and also increase the risk
of falls, hospitalizations, and mortality.14,15
A significant association of BP, hypertension, and other CVD risk
factors with frailty and disability has been previously described.3,16e19
However, most studies on the relationship between BP and frailty/
disability focused on conventional BP measurements,3,16e19 and only a
few small, cross-sectional studies in older individuals have evaluated
this relationship using ABPM.20e22 In addition, these latter studies
were conducted in clinical settings or with voluntary patients, and
adjusted for only a few covariates, not including important con-
founders (eg, physical activity, diet, or comorbidities).
A better characterization of the relationship between ABPM and
frailty/disability could serve to identify the role of daytime and
nighttime BP in these entities and to shed light on the complex and
controversial relation between BP and mortality in older adults16,23; in
particular, it remains poorly understood why in older adults with
frailty or poor functional status, observational studies usually find
higher mortality associated with lower BP while clinical trials show
benefit from BP lowering even in the oldest old.16,24e31 Thus, this
study examines the relationship of frailty and disability with con-
ventional BP and daytime and nighttime ambulatory BP in a large
sample of community-dwelling older adults in Spain.32
Methods
Study Design and Population
Data were taken from the Seniors-ENRICA cohort, whose methods
have been previously reported.32,33 In brief, this cohort was estab-
lished in 2008e2010 with 2614 individuals selected through stratified
random sampling from the population aged
60 years in Spain.32 At
baseline, information on sociodemographic variables, lifestyle, health
status, and morbidity was collected by telephone interview; also a
home visit was conducted to collect blood samples, and another home
visit to perform a physical examination and to record habitual diet and
prescribed medication. Participants were followed-up until
2012e2013, when a second wave of data collection was performed
with the surviving 2519 participants, of which 2037 provided updated
information for the phone interview, the physical examination, diet,
and medication. In this second wave, and because of logistic and cost
reasons, ABPM was offered to 1698 individuals, and was performed in
1328 participants (response rate, 78.2%). Compared with participants
without ABPM, those who underwent it had similar age and sex dis-
tribution, education levels, obesity, diabetes, current smoking, and
previous history of CVD.
Personnel involved in data collection were trained and certified in
the study procedures. Study participants gave written informed con-
sent. The study was approved by the Clinical Research Ethics Com-
mittee of the “La Paz” University Hospital in Madrid.
Blood Pressure Measurement
BP was measured using standardized procedures and conditions,
with validated automatic devices (Omron M6; Omron Healthcare,
Lake Forest, IL) and appropriate-sized cuffs. BP was determined 3
times at 2-minute intervals, after resting 5 minutes in a seated posi-
tion. In the analyses, BP was calculated as the mean of the last 2 of 3
readings. Thereafter, 24-hour ABPM was performed using a validated
automated noninvasive oscillometric device (Microlife WatchBPO3
monitor; Microlife Corp, Widnau, Switzerland),34 programmed to
register BP at 20-minute intervals during the day and at 30-minute
during the nighttime for the 24-hour period. Appropriate cuff sizes
were used. The patients were instructed to maintain their usual ac-
tivities but keeping the arm extended and immobile at the time of cuff
inflation. Valid ABPM registries had to fulfill several pre-established
criteria, including 24-hour duration and at least 70% of systolic BP
(SBP) and diastolic BP (DBP) successful recordings during the daytime
and nighttime periods.7,8 Daytime and nighttime periods were
defined individually according to the patient’s self-reported time of
going-to-bed and getting-up.
Frailty Assessment
We used the operational definition of frailty developed by Fried
et al.35 in the Cardiovascular Health Study. Specifically, frailty was
defined as having at least 3 of the following 5 criteria: (1) exhaustion,
based on a response of “
3-4 days a week” to any of the following
questions from the Center for Epidemiologic Studies Depression Scale:
“I felt that anything I did was a big effort” or “I felt that I could not keep
on doing things”; (2) low physical activity, defined as walking 2.5 h/
wk in men and 2 h/wk in women; (3) slow walking speed, defined as
the lowest quintile in our study sample for the 3-m walking speed test,
adjusted for sex and height; (4) weight loss, defined as involuntary
loss of
4.5 kg in the preceding year; and (5) weakness (low grip
strength), defined as the lowest quintile in our study sample of
maximum strength on the dominant hand, adjusted for sex and body
mass index (BMI); strength was measured twice with a Jamar dyna-
mometer on the dominant hand.
Disability Assessment
Disability was assessed according to instrumental activities of daily
living (IADL) with the LawtoneBrody questionnaire.36 This scale eval-
uates the individual’s ability to use the telephone, go shopping, prepare
meals, do housework, do laundry, use different means of transportation,
take medication, and manage finances. Owing to cultural issues, meal
preparation, housework, and laundry were excluded in men; thus,
summary scores ranged from 0 to 5 in men, and from 0 to 8 in women.
Disability was defined as <5 points in men and <8 in women.36
Other Variables
Study participants reported their sociodemographic characteris-
tics: sex, age, educational level (primary; secondary; university),
marital status (single/separated/widowed; married), cohabitation
(living alone; living with the family, with flat mate, in an institution, or
accompanied in any other situation); smoking status (no; yes), and
alcohol consumption (no-drinker; drinker). Salt intake (g/d) was
assessed with a validated computerized diet history developed from
that used in the European Prospective Investigation into Cancer and
Nutrition cohort study in Spain.37,38 Adherence to the Mediterranean
diet was summarized with the Mediterranean diet adherence screener
(MEDAS).39 MEDAS consists of 12 items with targets on food con-
sumption and another 2 items with targets for food intake habits
characteristic of the Mediterranean diet in Spain. One point is given
for each target achieved. The total MEDAS score ranged from 0 to 14,
with a higher score indicating better Mediterranean adherence. For
the purpose of analysis, we excluded alcohol consumption from the
MEDAS as this variable is considered separately in this study. Infor-
mation on physical activity was also obtained with the validated Eu-
ropean Prospective Investigation into Cancer and Nutrition study
instrument, and individuals were classified as inactive or active.40
Participants also reported their usual sleep quality during the night
(very good/good; or bad/very bad).41 Medication use was collected by
a face-to-face interview and verified against drug packaging. Partici-
pants also reported if they suffered from any of the following
physician-diagnosed diseases: cardiovascular diseases (myocardial
infarction, stroke, and heart failure), diabetes mellitus, cancer at any
site, asthma or chronic bronchitis, osteomuscular disease (osteoar-
thritis, arthritis, hip fracture), or depression requiring drug treatment.
 T. Gijón-Conde et al. / JAMDA xxx (2017) 1e6 3

Table 1
Characteristics of the Study Participants According to Frailty and Disability Status

No Frailty Prefrailty Frailty No Disability Disability

N (%) 488 (46.6) 496 (47.4) 63 (6.0) 962 (91.9) 85 (8.1)

Age, y (SD) 70.0 (5.0) 72.6 (6.7) 77.0 (7.0)** 71.1 (5.8) 77.8 (7.5)**
Men, % 59.8 44.8 28.6** 51.7 41.2
Primary studies, % 55.3 65.3 77.8** 60.7 69.4
Married, % 77.3 67.4 57.1** 73.3 50.6**
Living alone, % 17.6 20.4 23.8 18.5 28.2*
Current smoking, % 10.5 12.1 7.9 10.9 12.9
Alcohol consumption, % 59.6 52.2 34.9** 56.5 32.9**
Salt intake, g/d (SD) 2.9 (1.3) 2.7 (1.2) 2.6 (1.3)* 2.8 (1.2) 2.5 (1.2)
MEDAS score (SD) 7.3 (1.8) 7.0 (1.7) 6.7 (1.7)* 7.2 (1.8) 6.8 (1.5)*
Physical inactivity, % 34.6 44.6 61.9** 38.4 70.6**
Poor sleep quality, (%) 23.0 27.4 42.9* 24.9 41.2**
BMI, kg/m2 (SD) 27.5 (4.3) 27.9 (4.7) 29.3 (5.7)* 27.6 (4.4) 29.7 (5.5)**
BP, mm Hg
Conventional SBP/DBP 138.7/74.8 137.1/73.5 136.3/71.3* 137.8/74.3 137.6/70.8*
24-h SBP/DBP 124.1/70.8 123.1/69.2 123.2/66.5* 123.5/70.1 123.8/66.9**
Daytime SBP/DBP 127.7/73.9 125.7/71.8 124.5*/68.7* 126.7/72.9 125.1/68.8**
Nighttime SBP/DBP 116.6/64.3 117.2/63.8 120.9*/62.8 116.8/64.1 121.1*/63.3
Systolic dipping, % 8.6 (7.3) 6.6 (7.1) 2.9 (6.6)** 7.7 (7.2) 2.9 (7.4)**
Systolic night/day ratio (SD) 0.92 (0.06) 0.93 (0.06) 0.96 (0.05)** 0.92 (0.06) 0.96 (0.06)**
Heart rate (bpm)
24-h heart rate (SD) 65.8 (8.7) 67.8 (9.1) 70.4 (8.1)** 66.9 (8.8) 69.4 (10.1)*
Antihypertensive drugs, n (SD) 0.6 (0.9) 0.7 (1.0) 0.8 (1.0) 0.6 (0.9) 0.9 (1.1)*
Comorbidity, n (SD) 1.4 (1.3) 1.6 (1.3) 2.7 (1.8)* 1.3 (1.3) 2.2 (1.8)**

SD, standard deviation.

Frailty, >3 criteria of Fried score; prefrail: 1e2 criteria; no frail: ¼ 0 criteria. No disability: Lawton-Brody score ¼ 8 in women/ ¼ 5 in men; disability: Lawton-Brody score <8 in
women/<5 in men.
*P < .05; **P < .001 compared with no frailty/no disability.

Lastly, BMI was calculated as measured weight in kilogram divided by
square height in meter.
Statistical Analyses
The analyses were conducted among 1047 individuals with at least
70% valid ABPM readings and complete information on study variables
(78.8% of all with available ABPM). We used the relative percentage of
systolic BP fall during the night [(daytime BP-nighttime BP)/daytime
BP] and the night/day ratio as estimates of nocturnal BP dipping, such
that the lower the ratio, the greater the dipping.7,8
To compare means across groups, we used the Student t-test or
analysis of variance, whereas for proportions we used the c2 test. We
examined the multivariable relationship of frailty and disability with
daytime and nighttime SBP as well as with systolic dipping and night/
day ratio, as only these BPs variables were significantly associated
with frailty/disability in bivariate analyses and given that the systolic
BP component is predominant in older people.7,33 We ran 4 multiple
linear regressions with daytime SBP, nighttime SBP, systolic dipping
and SBP night-to-day ratio modeled as continuous outcomes, and
frailty and disability as the main independent variables. Frailty score
was analyzed as a continuous variable but was classified into non-
frailty, prefrailty (1e2 Fried criteria), and frailty (
3 criteria) for a later
analysis; and disability was dichotomized (no/yes). The regression
models were adjusted for sociodemographic variables (age, sex,
educational level, marital status, and cohabitation), BMI, smoking,
alcohol consumption, salt intake, Mediterranean diet score, physical
activity, sleep quality, number of antihypertensive drugs, number of
comorbidities, conventional SBP, nighttime SBP (for daytime SBP
outcome), daytime SBP (for nighttime SBP outcome), 24-hour SBP (for
dipping and night/day ratio outcomes), and 24-hour heart rate. These
variables were coded as continuous/numerical (age, BMI, salt intake,
MEDAS, number of BP medication, number of comorbidities, BPs, and
heart rate) or categorical (the other variables) as defined above. Lastly,
we examined the adjusted mean daytime SBP, nighttime SBP, dipping,
and night/day ratio according to the frailty status (no/prefrail/frail)
and disability status (no/yes), using general linear models adjusted for
the same covariates as before.
Because we observed no significant interaction of the association
between frailty or disability and BPs with sex, we presented results for
all the study population. Statistical significance was set at P < .05, and
the Bonferroni correction was used for post-hoc multiple

Table 2 Table 3
Multivariate Association of Frailty With Daytime and Nighttime SBP, Systolic Dip- Multivariate Association of Disability With Daytime and Nighttime SBP, Systolic
ping, and Night/Day Ratio Dipping, and Night/Day Ratio

Beta Standard Error P Value Beta Standard Error P Value

Daytime SBP (mm Hg) 1.542 0.381 <.001 Daytime SBP (mm Hg) 2.464 0.809 .002
Nighttime SBP (mm Hg) 1.388 0.506 .006 Nighttime SBP (mm Hg) 2.762 1.069 .010
Systolic dipping (%) 1.334 0.388 .001 Systolic dipping (%) 2.599 0.823 .002
Systolic night/day ratio 0.012 0.003 .001 Systolic night/day ratio 0.019 0.007 .008

The relationships were modeled through multiple linear regressions adjusted for
sociodemographic variables (age, sex, educational level, marital status, and cohab-
itation), BMI, smoking, alcohol, salt intake, MEDAS, physical activity, sleep quality,
number of antihypertensive drugs, number of comorbidities, conventional SBP,
nighttime SBP (for daytime SBP), daytime SBP (for nighttime SBP), 24-hour SBP (for
dipping and night/day ratio), and 24-hour heart rate.
Beta is the change in the corresponding SBP parameter per 1 additional frailty
category (nonfrail, prefrail, frail).
The relationships were modeled through multiple linear regressions adjusted for
sociodemographic variables (age, sex, educational level, marital status, and cohab-
itation), BMI, smoking, alcohol, salt intake, MEDAS, physical activity, sleep quality,
number of antihypertensive drugs, number of comorbidities, conventional SBP,
nighttime SBP (for daytime SBP), daytime SBP (for nighttime SBP), 24-hour SBP (for
dipping and night/day ratio), and 24-hour heart rate.
Beta is the change in the corresponding SBP parameter in patients with Lawton-
Brody score <8 (vs 8) in women or <5 (vs 5) in men.
4 T. Gijón-Conde et al. / JAMDA xxx (2017) 1e6

Daytime systolic BP(mm Hg) Nighttime systolic BP(mm Hg)

P = .001 124 P = .016

129
128.0 122 122.3
128
127 127.4 126.6
126 126.8 126.0 125.6
120 120.0
125
118.2
118
125.4 117.2 117.5 117.7
124 123.9
123 116 116.4 116.7
122 122.2 115.6
121 114
120
119 112

No frailty Prefrailty Frailty No frailty Prefrailty Frailty

SBP Dipping(%) SBP night/day ratio

P = .003 0.97 P = .016

10
9 8.7 0.96 0.96
7.6
8 8.1% 0.95
7
7.4 6.9% 6.6
0.94 0.94 0.94
0.93
6 0.93 0.93 0.93
6.3
5
4.8% 0.92 0.92 0.93
4 0.91
3 3.1 0.91
0.9
2
0.89
1
0 0.88

No frailty Prefrailty Frailty No frailty Prefrailty Frailty

Fig. 1. Daytime and nighttime systolic blood pressure, dipping, and night/day ratio, according to frailty status. Data are presented as mean with 95% confidence interval, and were
obtained from general linear models adjusted for sociodemographic variables (age, sex, educational level, marital status, and cohabitation), BMI, smoking, alcohol, and salt intake,
MEDAS, physical activity, sleep quality, number of antihypertensive drugs, number of comorbidities, conventional SBP, daytime SBP (for nighttime SBP), nighttime SBP (for daytime
SBP), 24-hour SBP (for dipping and night/day ratio), and 24-hour heart rate.

comparisons. The analyses were performed with the SPSS v 21 (IBM,
Armonk, New York).
Results
Among the 1047 participants, mean age was 71.7 years, 50.8% were
men, 6% were frail, 47.4% prefrail, and 8.1% had disability. Mean con-
ventional, 24-hour, daytime, and nighttime SBP were 137.8, 123.6,
126.6, and 117.1 mm Hg, respectively. Compared with individuals
without frailty or disability, those with these conditions were older,
more frequently women, less frequently married and alcohol drinkers,
less adherent to the Mediterranean diet, more physically inactive,
with worse sleep quality and higher BMI and comorbidity (Table 1).
Those with frailty (and prefrailty) or disability had not significantly
different mean conventional and 24- hour SBP, but they had lower
daytime SBP and less systolic dipping, and higher nighttime SBP,
systolic night/day ratio, and 24-hour heart rate than their nonfrail
counterparts who are not disabled (Table 1).
After full adjustment for potential confounders, 1 additional frailty
category (nonfrail, prefrail, frail) was significantly associated with a
1.542-mm Hg lower daytime SBP (P < .001), a 1.388-mm Hg higher
nighttime SBP (P ¼ .006), a 1.334% less SBP dipping (P ¼ .001), and a
0.012 higher systolic night/day ratio (P ¼ .001) (Table 2). Compared
with participants who are not disabled, those who are disabled had
2.464-mm Hg lower daytime SBP (P ¼ .002), 2.762-mm Hg higher
nighttime SBP (P ¼ .010), 2.599% less systolic dipping (P ¼ .002), and
0.019 higher systolic night/day ratio (P ¼ .008) (Table 3).
Lastly, adjusted mean daytime and nighttime systolic BPs, dip-
ping, and night/day ratio according to frailty and disability status
are shown in Figures 1 and 2. There was a statistical significant
trend toward lower daytime SBP, higher nighttime SBP, lower
nocturnal SBP decline, and higher night/day ratio values across the
increasing frailty categories (Figure 1), and also in those with vs
without disability (Figure 2). Specifically, daytime SBP was 3.5 mm
Hg lower in frail patients (vs nonfrail) and 2.5 mm Hg lower in
patients who are disabled (vs not disabled), and nighttime SBP was
3.6 mm Hg higher in frail patients and 2.7 mm Hg higher in those
disabled.
Discussion
This study shows that nocturnal systolic BP was greater and dip-
ping and daytime systolic BP were smaller in older adults with frailty
or disability. These findings may be important because both higher
nocturnal BP and blunted SBP decline have been associated with a
worse CVD risk profile and an increased risk of CVD and all-cause
mortality; also, the coexistence of these 2 BP conditions is associ-
ated with the worst risk profile.9e13,42 Interestingly, moderate re-
ductions of nocturnal BP can be achieved with simple lifestyle
measures.43
There is great variability in the prevalence of frailty depending on
the measurement tool used but, as an average, 10% of people aged

65 years and 25% to 30% of those aged
85 years have frailty.44,45 The
frequency of frailty in our study (6%) is similar to the 7% reported in
community-dwelling participants aged >65 years in the Cardiovas-
cular Health Study.15,35 Further, in the general US population, 10.3% of
individuals with hypertension and 6.6% of nonhypertensive partici-
pants reported IADL disability.17 However, the direct cross-country
 T. Gijón-Conde et al. / JAMDA xxx (2017) 1e6 5

Daytime systolic BP(mm Hg) Nighttime systolic BP(mm Hg)

P = .002
P = .011
122
128 127.2 121.6
121
127
126.8 120
126
125.8 119
119.6
125 126.3
118 117.5 117.7
124 124.3
123 117 116.9
122 122.7 116
115 116.3
121
120 114
119 113

No disability Disability No disability Disability

SBP Dipping(%) SBP night/day ratio

P = .003
0.97 P = .011
9
7.9
8 0.96 0.96
7
7.5
6.6 0.95 0.95
6 7.1
0.94
5 5.0 0.93
4 0.93 0.93 0.93
3 3.4 0.92 0.92
2
0.91
1
0.9
0
No disability Disability No disability Disability

Fig. 2. Daytime and nighttime SBP, dipping, and night/day ratio, according to disability status. Data are presented as mean with 95% confidence interval, and were obtained from
general linear models adjusted for sociodemographic variables (age, sex, educational level, marital status, and cohabitation), BMI, smoking, alcohol, salt intake, MEDAS, physical
activity, sleep quality, number of antihypertensive drugs, number of comorbidities, conventional SBP, daytime SBP (for nighttime SBP), nighttime SBP (for daytime SBP), 24-hour SBP
(for dipping and night/day ratio), and 24-hour heart rate.

comparisons of disability prevalence could be difficult due to meth-
odological differences among studies.46,47
Our results are in agreement with those reported by Yano et al20 in
a smaller, cross-sectional study of 148 treated elderly hypertensive
patients, where slower walking speed was associated with high
nocturnal SBP level and with diminished nocturnal SBP dipping
independently of the 24-hour BP levels. This association has also been
reported in a small sample of 77 elderly individuals in Brazil where the
frail group showed higher 24-hour and sleep SBP and DBP values than
the nonfrail group.21 Our results are also consistent with those by
Hajjar et al22 on 80 older adults with and without stroke, where less
dipping magnitude in SBP was associated with slower gait speed and
worse IADL.
Regarding potential mechanisms of the associations found, poor
physical (and cognitive) function have been associated with brain
lesions that could influence the BP dipping pattern.22 Also, reduced
mobility during the day in patients who are frail or disabled may
lower physical activity, which may alter the daytime BP profile and
diminish nocturnal BP dipping.48 Moreover, functional disabilities
could result from high BP (including less nocturnal dipping),
possibly through the development of coronary disease, stroke, or
white matter lesions.22
Our results have clinical implications. Observational epidemiologic
studies,16,24,25 contrary to clinical trials,26e29 support the caution that
frail older adults may not benefit from, and may even be harmed, by
intensive BP lowering, which requires several medications.49 One
recent study has suggested that the association of low SBP with higher
mortality in the oldest individuals, even if frail, may be explained by
reverse causation because of the decline of SBP close to death.50
Although exploratory analyses in some major trials have found
benefit from lowering BP across frailty categories,29,31 frail older adults
may be underrepresented in trial samples, and the results of clinical
trials might not be generalizable to wider community-dwelling pop-
ulations. Further, the lower mortality with low BP found in clinical
trials in the short term is compatible with the higher mortality
observed in epidemiologic studies in the medium or long term.
Moreover, data interpretation should be cautious because most pre-
vious studies used BP only measured in the office, and not ABPM data
that includes nighttime BP and dipping values, which could be asso-
ciated with poor functional outcomes as our study shows. Interest-
ingly, the circadian BP alterations in older adults who are frail and
disabled remained after adjustment of comorbidities, BP levels, and
other covariates, suggesting that low daytime SBP and blunted dip-
ping might be a real marker of increased vascular frailty and disability.
Suggestively, our findings that, besides lower daytime SBP, a blunted
dipping and higher nighttime SBP occur in older adults who are frail
and disabled, might help explain why in observational studies, low
clinic BP was associated with higher mortality in older adults, espe-
cially with frailty or poor functional status.16,24,25
Compared with previous research on this subject, the main
strengths of this study are its large sample size, adjustment for a wide
range of important confounders (including sleep quality and antihy-
pertensive treatment), and its focus on a community-living older
population rather than on clinical setting. Given that this study was
not strictly representative of the general older population of Spain,
extrapolations should be interpreted with caution. Nevertheless, the
baseline sociodemographic and clinical characteristics of the partici-
pants were similar to those who did not participate. Also, antihyper-
tensive therapy was based on the participant’s declaration and,
therefore, may be imprecise; nevertheless, medication was checked
against prescription containers. Lastly, our study’s cross-sectional
design does not allow for drawing conclusions on the timing
sequence and causality of the relationship of frailty and disability with
ambulatory BP.
6 T. Gijón-Conde et al. / JAMDA xxx (2017) 1e6
Conclusions
In conclusion, in this relatively large sample of community-living
older individuals in Spain, frailty and disability were associated with
blunted systolic dipping, higher nocturnal SBP, and lower daytime SBP
regardless of conventional BP and a number of confounders. ABPM may
provide additional information over usual conventional BP measure-
ments in the clinical evaluation of older individuals with frailty or
disability, and may help explain the higher mortality risk with lower
clinic BP among frail older adults observed in nonrandomized studies.
However, longitudinal studies on the association between frailty,
disability, and ABPM are required to verify and extend our results.
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