Clinical and Experimental Hypertension

ISSN: 1064-1963 (Print) 1525-6006 (Online) Journal homepage: http://www.tandfonline.com/loi/iceh20

Poor sleep is responsible for the impaired

nocturnal blood pressure dipping in elderly
hypertensive: A cross-sectional study of elderly

Shaopan Zhao, Shihui Fu, Jiefeng Ren & Leiming Luo

To cite this article: Shaopan Zhao, Shihui Fu, Jiefeng Ren & Leiming Luo (2018):
Poor sleep is responsible for the impaired nocturnal blood pressure dipping in elderly
hypertensive: A cross-sectional study of elderly, Clinical and Experimental Hypertension, DOI:
10.1080/10641963.2017.1411495

To link to this article: https://doi.org/10.1080/10641963.2017.1411495

Published online: 08 Feb 2018.

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CLINICAL AND EXPERIMENTAL HYPERTENSION
https://doi.org/10.1080/10641963.2017.1411495

Poor sleep is responsible for the impaired nocturnal blood pressure dipping in
elderly hypertensive: A cross-sectional study of elderly
Shaopan Zhao, Shihui Fu, Jiefeng Ren, and Leiming Luo
Department of Geriatric Cardiology, Chinese People’s Liberation Army General Hospital, Beijing, China

ABSTRACT ARTICLE HISTORY

Objective: This study was aimed to assess whether sleep disorder was associated with an increased risk Received 23 September 2017
of less nocturnal blood pressure (BP) dipping in elderly patients with hypertension. Revised 19 November 2017
Methods: Cases were 1006 patients, aged >60 years, who were admitted to hospital with diagnosed Accepted 26 November 2017
hypertension during 2016–2017, and were divided into three groups with the systolic nocturnal BP KEYWORDS
dipping of 10%, and 0% as the cut-off value. The patients’ sleep was evaluated by Pittsburgh sleep Sleep quality; elderly;
quality index (PSQI). hypertension; blood
Results: Compared to non-dipper BP rhythm patients (n = 382) and dipper BP rhythm patients (n = 132), pressure rhythm; nocturnal
reverse dipper patients (n = 492) exhibited higher PSQI score and had higher scores on six components blood pressure dipping
with the exception of use sleep drug (p < 0.05). Multivariate logistic regression indicated that poor sleep,
which was defined as high score of PSQI or its seven components, was associated with prevalence of
reverse dipper in elderly hypertensive (odds ratio (OR) = 1.17, (95% confidence interval (CI), 1.13–1.21,
p < 0.05) after adjusting for risk factors of hypertension. Multiple linear regression analysis showed that
there was a significant negative correlation between PSQI score (include its seven components) and
nocturnal BP dipping value after adjusting for risk factors of hypertension (β = −0.584, p < 0.001).
Conclusions: In elderly patients with hypertension, poor sleep quality individuals were more prone to
reverse dipper BP rhythm. Even adjusting for the effect of known risk factors of hypertension, poor sleep
may contribute to attenuated BP dipping in elderly hypertensive.

Introduction conducted to assess the relationship between sleep disorders

More and more evidences show that (1 -4), regardless of 24-
Hour blood pressures (BPs), Nocturnal mean BP can better
predict the morbidity and mortality of non-fatal cardiovascu-
lar events (CVEs) in hypertensive compared with daytime
mean BP, which is an independent predictor of the prognosis
of hypertensive. Usually, the normal nocturnal BP was slightly
lower than daytime BP and decreased by 10–20%. If the
nocturnal BP decline is insufficient and even don’t fall,
which is a “non-dippers”, will significantly increase the risk
of target organ damage, including cerebrovascular disease,
renal disease, and cardiovascular morbidity and mortality
(1,5,6). The smaller the decline of nocturnal BP dipping, the
greater the risk of CVEs (1). With the increase of age, the
incidence of non-dippers also increased significantly (7). The
disappearance of nocturnal BP rhythm may also significantly
increase the incidence of target organ damage in elderly
hypertensive patients.
As one of the most important factors that affect the BP,
sleep has been paid more and more attention. Previous studies
have shown that there is a close correlation between sleep
disorders and non-dippers (8,9). However, whether sleep dis-
orders increase the risk of non-dipper BP pattern in elderly
hypertensive remains unclear. Therefore, this study was
and BP rhythm in elderly hypertensive.
Methods
Study design and population
A cross-sectional study design was performed. This study
enrolled 1006 hospitalized patients with hypertension at
least 60 years old in Chinese People’s Liberation Army
General Hospital between March 2016 and March 2017.
All subjects completed a structured questionnaire, which
included items to collect their demographic information,
medical history, medication history, lifestyle habits (cigar-
ette smoking, alcohol drinking, and regular exercise), and
Pittsburgh Sleep Quality Index (PSQI). Exclusion criteria
included those with a diagnosis of secondary hypertension,
severe uncorrected primary valvular disease, acute myocar-
dial infarction, heart failure, acute infectious diseases,
chronic obstructive pulmonary disease, malignant tumor,
serious liver or kidney dysfunction, and unable to complete
the questionnaire because of mental illness. This study was
approved by Ethics Committee of Chinese People’s
Liberation Army General Hospital and all patients gave
written informed consents.

CONTACT Leiming Luo lleim@sina.com Department of Geriatric Cardiology, Chinese People’s Liberation Army General Hospital, 100853, China
Shaopan Zhao and Shihui Fu are co-first authors.
© 2018 Taylor & Francis
2 S. ZHAO ET AL.
Anthropometric measurements
Doctors and nurses were trained in the standard protocol of
measurement before the survey. Anthropometrics were mea-
sured in the clinic, with participants wearing light clothing
and no shoes. Height was measured in centimeters using a
wall mounted measuring tape, and weight was measured in
kilograms using a digital scale. Body mass index (BMI) was
calculated as weight (kg) divided by height squared (m2).
Hypertension was defined as systolic blood pressure (SBP) ≥
140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg,
and/or taking an antihypertensive drugs.
Questionnaire
A structured questionnaire was administered face to face to
each subject and recorded on paper to obtain demographic,
and behavior-associated information, including age, gender,
smoking, drinking, exercise, and medication history. Cigarette
smoking was classified as current smoker (at least one pack
per month in the past half year) and noncurrent smoker.
Alcohol drinking was classified as current drinker (at least
175 grams per week in the past half year) and noncurrent
drinker. Regular exercise was defined as vigorous exercise at
least 30 minutes exercise for at least 3 days per week.
Self-reported sleep quality were assessed by the Chinese
version of the PSQI, which had been proven to exhibit excel-
lent overall reliability and test–retest reliability (10). PSQI
consists of 19 individual items that generate 7 component
scores (subjective sleep quality, sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbance, use of sleep med-
ication, and daytime dysfunction), and each of them consisted
of a four-grade system (0, 1, 2, 3). The total score of PSQI is
21 and was divided into 4 classifications: very good sleep with
a score < 5, good sleep with a score 6–10, general sleep with a
score 11–15 and poor sleep with a score ≥ 16.
Ambulatory blood pressure measurement
24h-ambulatory blood pressure monitoring (24h-ABPM) was
performed using ABPM-04 equipment (Meditech, USA). BP
measurements were automatically measured every 30 minutes
during the daytime (6:00–21:59) and every 60 minutes (22:00–
5:59) during the nighttime over a 24h period. Average systolic
and diastolic BPs were calculated for both daytime and night-
time periods. Nocturnal BP dipping values were calculated
according to the standard formula as: (average daytime BP—
average nighttime BP)/average daytime BP) × 100%. In addi-
tional, nocturnal BP dipping values was further categorized
into three groups, those with a nocturnal BP decrease of ≥10%
(dipper) vs.0%-10% (non-dipper) vs. < 0% (reverse dipper),
according to the commonly employed categorical cutoff for
dipping (1).
Statistical analysis
Continuous variables were described by mean and standard
deviation for data with normal distribution or median and
25th–75th percentiles for data with skewed distribution.
Categorical variables were shown as number and proportion.
Continuous variables were compared using one way analysis
of variance (ANOVA) for normal distribution, and Wilcoxon
signed-rank test for skewed distribution. Categorical variables
were compared using Chi-square test.
To explore the potential association of sleep status as well as
its seven components in relation to BP rhythm pattern in hyper-
tensive, multivariate logistic analysis was used and other hyper-
tension risk factors including sex, age, body mass index (BMI),
status of smoking, status of drinking, physical activity, history of
hypertension and anti-hypertensive drugs were adjusted for.
Linear correlation and regression was used to assess the relation
of nocturnal BP drop with the PSQI score. In addition, to
evaluate the associations between sleep status and nocturnal BP
dipping value, multiple linear regression analysis (entry) was also
conducted with adjustment of hypertension risk factors. All
analyses were carried out using Statistic Package for Social
Science (SPSS) version 19 software (SPSS Inc., Chicago, IL,
USA) and the level of statistical significance was set at p < 0.05.
Results
Basic characteristics
For all of the 1006 individuals, the median age was 76 years
(range, 60–93 years), and 594 (59.0%) were men. The mean of
hypertension’s history was 16.5 year (standard deviation: ±12.1),
and 86.5% of patients taken antihypertensive drugs currently.
The main reasons for hospitalization of patients were cardiovas-
cular disease, such as hypertension, nonfatal arrhythmia, cor-
onary heart diseases, etc. The basic characteristics, reasons for
hospitalization of patients and antihypertensive drug of those
subjects in different BP rhythm groups are presented in Table 1.
Ambulatory blood pressure rhythm
There were no significant differences in 24-SBP and 24-
DBP between different BP rhythm groups (all p > 0.05;
Table 1). There were significant differences in d-SBP,
d-DBP, n-SBP, and n-DBP between different BP rhythm
groups (all p < 0.05; Table 1). According to the order of
reverse dipper, non-dipper and dipper BP rhythm group,
d-SBP and d-DBP tended to increase, n-SBP and n-DBP
tended to decrease.
Sleep status in different blood pressure rhythm groups in
hypertensive
Scores of PSQI and each component of it in individuals with
different BP rhythm groups are presented in Table 1. There
were significant differences in Scores of PSQI and each compo-
nent of it between different BP rhythm groups (all p < 0.05;
Table 1). Reverse dipper BP rhythm group received significantly
higher scores of PSQI than other groups (12.4 ± 4.1 vs 9.5 ± 4.5
or 9.2 ± 4.4), and had higher scores on six components with the
exception of use sleep drug as compared with other groups.
There were no significant differences were found with regards
to the scores of PSQI and its seven components between non-
dipper group and dipper group (all p > 0.05; Table 1).
 CLINICAL AND EXPERIMENTAL HYPERTENSION 3

Table 1. Characteristics of the participants according to blood pressure rhythm categories.

Blood pressure rhythm
Reverse-dipper Non-dipper Dipper
Characteristics (492) (382) (132) p-value
Blood pressure
24h-SBP(mmHg) 129.8 ± 18.2 128.5 ± 18.9 127.7 ± 167 0.397
24h-DBP(mmHg) 71.2 ± 9.1 71.8 ± 10.2 70.5 ± 12.0 0.389
d-SBP(mmHg) 127.0 ± 18.5 130.2 ± 19.6 131.7 ± 17.5a 0.007
d-DBP(mmHg) 70.1 ± 9.2 73.2 ± 10.6a 73.2 ± 12.6a <0.001
n-SBP(mmHg) 138.3 ± 22.2 124.3 ± 17.8a 113.7 ± 16.0aa <0.001
n-DBP(mmHg) 73.8 ± 12.1 67.2 ± 10.1a 61.6 ± 12.1aa <0.001
Antihypertensive drug
ACEI or ARB (%) 232 (47.2) 164 (42.9) 56 (42.4) 0.380
β-AB (%) 290 (58.9) 166 (43.5)a 76 (57.6)a <0.001
CCB (%) 256 (52.0) 146 (38.2)a 84 (63.6)aa <0.001
Diuretic (%) 60 (12.2) 20 (5.2)a 8 (6.1)a 0.001
Reasons for hospitalization
Hypertension 130 (26.4) 129 (33.8) 41 (31.1) 0.059
Atrial fibrillation 43 (8.7) 25 (6.5) 17 (12.9) 0.075
Unstable angina 141 (28.7) 69 (18.1)a 27 (20.5)a 0.001
Stable angina 175 (35.6) 147 (38.5) 46 (34.8) 0.612
Others 3 (0.6) 12 (3.1) 1 (0.8) 0.181
Basic characteristics
Male (%) 262 (53.3) 248 (64.9)a 84 (63.6)a 0.001
Age (year) 76 (66–84) 73 (65–82)a 70 (64–83)a 0.001
BMI (kg/m2) 25.2 (22.7–28.4) 24.8 (23.1–27.7)a 24.1 (21.5–26.6)a <0.001
Current smoker (%) 80 (16.3) 72 (18.8) 6 (4.5)aa <0.001
Current drinker (%) 38 (7.7) 12 (3.1)a 4 (3.0)a 0.005
Active exercise (%) 40 (8.1) 32 (8.4) 20 (15.2)aa 0.037
Hypertension history(year) 15 (10–30) 12 (10–20)a 10 (1–20)aa <0.001
Sleep status
PSQI (score) 12.4 ± 4.1 9.5 ± 4.5a 9.2 ± 4.4a <0.001
Subjective sleep quality(score) 2.1 ± 0.7 1.7 ± 0.9a 1.6 ± 1.1a <0.001
Sleep latency(score) 2.1 ± 1.0 1.6 ± 1.0a 1.5 ± 0.9a <0.001
Sleep duration(score) 2.1 ± 0.9 1.7 ± 1.0a 1.6 ± 0.9a <0.001
Sleep efficiency(score) 2.0 ± 1.0 1.5 ± 1.0a 1.7 ± 1.0a <0.001
Sleep disturbance(score) 2.1 ± 0.9 1.6 ± 1.0a 1.5 ± 0.7a <0.001
Use sleep drug(score) 0.9 ± 1.2 0.7 ± 1.2 0.6 ± 1.1a 0.006
Daytime dysfunction(score) 1.2 ± 1.1 0.8 ± 1.0a 0.8 ± 1.1a <0.001
24h-SBP: 24 hours mean systolic blood pressure, 24hDBP: 24 hours mean diastolic blood pressure, d-SBP: daytime mean systolic blood pressure, d-DBP: daytime
mean diastolic blood pressure, n-SBP: nighttime mean systolic blood pressure, n-DBP: nighttime mean diastolic blood pressure, ACEI: angiotensin converting
enzyme inhibitor, ARB: angiotensin receptor antagonist, β-AB:β-adrenergic blocker, CCB: calcium channel blocker, BMI: body mass index, PSQI: Pittsburgh Sleep
Quality Index.
a
Significantly different (p < 0.05) from group of reverse-dipper.
a
Significantly different (p < 0.05) from group of non-dipper.

Association of sleep status in related to ABH rhythm
pattern in hypertensive
The results of multivariate logistic regression analyses
about the association between sleep status (PSQI score
and its components) and BP rhythm in hypertensive are
presented in Table 2. After adjusting for sex, age, body
mass index (BMI), status of smoking, status of drinking,
physical activity, history of hypertension and anti-hyper-
tensive drugs, PSQI score were found to be associated
with the prevalence of reverse dipper, but not the pre-
valence of non-dipper and dipper BP rhythm group in
hypertensive. And the corresponding odds ratio (OR)
were 1.17 (95% confidence interval (CI), 1.13–1.21), 0.90
(95% confidence interval (CI), 0.87–0.93), and 0.91 (95%
CI, 0.86–0.96), respectively. Good sleep, general sleep, and
poor sleep were also found to be in relation to reverse
dipper BP rhythm in hypertensive compared to very good
sleep (OR = 2.68, 95% CI, 1.65–4.37; OR = 5.87, 95% CI,
3.66–9.42; OR = 6.37, 95% CI, 3.72–10.91). But good
sleep, general sleep, and poor sleep were no found to be
increase the risk of non-dipper and dipper BP rhythm
compare to very good sleep, especially dipper BP rhythm
(all OR<1.00; Table 2). In addition, reverse dipper BP
rhythm was associated with all components of PSQI
score with the exception of sleep efficiency (score 1) as
compared with reference of each components (score 0)
(all OR>1.00; Table 2). Non-dipper BP rhythm was asso-
ciated with subjective sleep quality (score 1), sleep effi-
ciency (score 1), use sleep drug (score 2) as compared
with reference of each components (score 0) (all OR>1.00;
Table 2). Dipper BP rhythm was associated with sleep
latency (score 1), sleep efficiency (score 1), sleep distur-
bance (score 1, 2), use sleep drug (score 3) as compared
with reference of each components (score 0) (all OR>1.00;
Table 2).
Association of sleep status in related to nocturnal blood
pressure dipping in hypertensive
In Table 3, using PSQI score as independent variable and noc-
turnal blood pressure dipping as dependent variable, the linear
correlation and regression presented that the regression coeffi-
cient was −0.647, the intercept was 6.366, while the hypothesis
test of the regression coefficient(t test) is given: t = −9.970,
4 S. ZHAO ET AL.

Table 2. Odds ratios (OR) of scores of PSQI and its components for prevalence of blood pressure rhythm pattern in elderly hypertensive.
Reverse-dipper(492) Non-dipper(382) Dipper(132)
PSQI and sleep Unadjusted OR Adjusted OR(95% Unadjusted OR Adjusted OR(95% Unadjusted OR Adjusted OR(95%
components Grade N (95% CI) CI)* (95% CI) CI)* (95% CI) CI)*
Global PSQI score 1006 1.17(1.141.21) 1.17(1.13–1.21) 0.89(0.87–0.92) 0.90(0.87–0.93) 0.91(0.88–0.95) 0.91(0.86–0.96)
0–5 score Very 146 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
good
6–10 score Good 320 1.83(1.18–2.84) 2.68(1.65–4.37) 0.88(0.60–1.30) 0.72(0.47–1.11) 0.54(0.33–0.88) 0.42(0.23–0.76)
11–15 score General 376 4.71(3.06–7.23) 5.87(3.66–9.42) 0.41(0.28–0.61) 0.39(0.25–0.60) 0.32(0.19–0.54) 0.31(0.17–0.58)
16–21 score Poor 164 5.89(3.58–9.68) 6.37(3.72–10.91) 0.36(022–0.57) 0.38(0.22–0.64) 0.24(0.12–0.49) 0.29(0.13–0.65)
Subjective sleep quality 0 70 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
(score)
1 250 11.37(4.02–32.18) 15.73(5.35–46.26) 1.18(0.70–2.01) 1.09(0.61–1.95) 0.08(0.04–0.16) 0.05(0.02–0.11)
2 432 23.10(8.27–64.52) 29.44(10.16–85.2) 0.43(0.26–0.71) 0.42(0.23–0.74) 0.18(0.10–0.31) 0.12(0.06–0.25)
3 254 18.43(6.52–52.07) 26.93(9.15–79.28) 0.60(0.35–1.03) 0.51(0.28–0.94) 0.15(0.08–0.27) 0.09(0.04–0.20)
Sleep latency(score) 0 134 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
1 252 1.26(0.81–1.96) 1.34(0.83–2.17) 0.69(0.45–1.05) 0.77(0.49–1.21) 1.34(0.76–2.37) 1.14(0.58–2.23)
2 300 1.89(1.23–2.89) 2.28(1.43–3.64) 0.55(0.36–0.82) 0.28(0.37–0.89) 0.98(0.55–1.74) 0.77(0.41–1.47)
3 320 3.80(2.48–5.83) 4.06(2.56–6.46) 0.37(0.24–0.56) 0.45(0.29–0.70) 0.38(0.20–0.73) 0.34(0.16–0.70)
Sleep duration(score) 0 102 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
1 218 2.46(1.45–4.19) 2.05(1.16–3.61) 0.55(0.34–0.89) 0.64(0.39–1.06) 0.71(0.38–1.31) 0.70(0.35–1.39)
2 398 2.63(1.60–4.33) 2.69(1.57–4.62) 0.47(0.30–0.73) 0.47(0.29–0.76) 0.85(0.49–1.47) 0.79(0.41–1.53)
3 288 6.92(4.11–11.65) 7.21(4.10–12.67) 0.29(0.18–0.47) 0.31(0.19–0.51) 0.18(0.08–0.38) 0.18(0.08–0.41)
Sleep efficiency(score) 0 122 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
1 304 0.48(0.31–0.74) 0.76(0.47–1.23) 1.40(0.92–2.13) 1.10(0.69–1.75) 2.07(1.07–4.02) 1.38(0.65–2.94)
2 280 1.57(1.03–2.41) 1.92(1.18–3.11) 0.62(0.40–0.95) 0.61(0.38-.099) 1.02(0.50–2.08) 0.84(0.39–1.85)
3 300 1.98(1.29–3.03) 2.55(1.58–4.10) 0.43(0.28–0.67) 0.42(0.26–0.68) 1.25(0.63–2.49) 0.99(0.46–2.11)
Sleep disturbance(score) 0 98 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
1 244 1.74(1.02–2.95) 2.36(1.27–4.38) 0.53(0.33–0.82) 0.34(0.20–0.59) 1.41(0.70–2.810 1.92(0.86–4.26)
2 392 3.45(2.03–5.52) 3.81(2.08–6.97) 0.22(0.14–0.35) 0.17(0.10–0.30) 1.84(0.96–3.53) 2.60(1.20–5.62)
3 272 5.65(3.35–9.54) 5.70(3.07–10.61) 0.32(0.20–0.51) 0.28(0.16–0.50) 0.00(0.00–0.00) 0.00(0.00–0.00)
Use of sleep drug 0 632 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
(score)
1 128 1.37(0.94–2.01) 1.53(1.01–2.33) 0.68(0.45–1.02) 0.61(0.40–0.94) 1.09(0.64–1.84) 0.89(0.45–1.76)
2 52 1.41(0.80–2.49) 1.57(0.82–3.03) 1.28(0.72–2.25) 1.45(0.75–2.80) 0.00(0.00–0.00) 0.00(0.00–0.00)
3 194 1.58(1.15–2.20) 1.14(0.76–1.64) 0.73(0.52–1.03) 0.54(0.50–1.18) 0.68(0.40–1.13) 1.25(0.68–2.31)
Daytime dysfunction 0 446 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-) 1.00(-)
(score)
1 228 2.29(1.65–3.17) 2.77(1.93–3.98) 0.68(0.49–0.94) 0.61(0.43–0.86) 0.5(0.20–0.61) 0.31(0.17–0.57)
2 218 2.85(2.04–3.98) 2.72(1.85–4.00) 0.53(0.38–0.74) 0.54(0.37–0.79) 0.36(0.21–0.64) 0.42(0.22–0.80)
3 114 2.84(1.86–4.35) 3.11(1.89–5.12) 0.31(0.19–0.51) 0.31(0.18–0.83) 0.97(0.57–1.67) 0.89(0.45–1.75)
PSQI: Pittsburgh Sleep Quality Index, CI: confidence interval.
*Adjusting for sex, age, body mass index (BMI), status of smoking, status of drinking, physical activity, history of hypertension, anti-hypertensive drugs.

Table 3. The relation of nocturnal BP drop with the PSQI score in linear correla-
tion and regression.
lower BMI, active exercise and using ACEI/ARB, but negatively
b associated with sex, current smoker, hypertension history and
ANOVA
PQSI scores after adjusting for hypertension risk factors in
Sum of
Model squares df Mean square F Sig. Model 1 (all p < 0.05; Table 4). To further explore the relation-
Regression 8674.945 1 8674.945 99.395 <0.001a ship between sleep status and nocturnal blood pressure dipping,
Residual 87626.730 1004 87.278 the scores of the other seven components of PSQI which mea-
Total 96301.676 1005
sured the qualitative aspect of sleep were adjusted for in addition
Coefficientsb
to the hypertension risk factors in Model 2 of Table 4. Nocturnal
Unstandardized Standardized
coefficients coefficients
blood pressure dipping levels were positively associated with
Model B Std.error Beta t Sig.
lower BMI, using ACEI/ARB and active exercise, but negatively
(Constant) 6.366 0.768 8.294 <0.001
associated with sex, current smoker, hypertension history, sleep
PSQI sore −0.647 0.065 −3.000 −9.970 <0.001 duration, sleep disturbance, use sleep drug, and daytime dys-
a
Predictors:(Constant),PSQI sore function (all p < 0.05; Table 4).
b
Dependent Variable: nocturnal BP drop

p < 0.001. It also gives the results of variance analysis of regres-
sion coefficient: F = 99.395, p < 0.001. That showed a linear
regression relationship between PSQI score and nocturnal blood
pressure dipping in general, and was negatively correlated. The
sleep status in a large extent affected nocturnal blood pressure
dipping in elderly hypertensive patients.
Multiple linear regression analysis showed that nocturnal
blood pressure dipping levels were positively associated with
Discussion
Taking both sleep quality and quantity into consideration, this
study first examined the association between self-reported
sleep and BP rhythm in elderly patients with hypertension.
Compared with the other two groups, the reverse BP rhythm
group had higher PSQI scores, more prone to poor sleep
status. There was no significance between the dipper and
non-dipper groups. Multivariate logistic analysis of our data
showed significant associations between self-reported poor
 CLINICAL AND EXPERIMENTAL HYPERTENSION 5

Table 4. Risk factors associated with nocturnal blood pressure dipping values in multiple linear regression analyses.
Model 1 multiple linear regression Model 2 multiple linear regression
Variables β-value 95% CI of β P-value β-value 95% CI of β P-value
Male (%) −3.772 −4.987, −2.558 <0.001 −3.717 −4.847, −2.487 <0.001
Age (year) −0.033 −0.104, 0.037 0.350 −0.013 −0.087, 0.061 0.724
BMI (kg/m2) −2.709 −3.975,- 2.587 <0.001 −2.651 −3.843,–2.460 <0.001
Current smoker (%) −2.912 −4.586, −1.238 0.001 −3.249 −4.970, −1.529 0.001
Current drinker (%) −1.876 −4.446, 0.693 0.152 −1.675 −4.272, 0.923 0.283
Active exercise (%) 7.780 5.583, 10.158 <0.001 8.192 5.901,10.484 <0.001
Hypertension history(year) −0.084 −0.133, −0.035 0.001 −0.068 −0.118, −0.018 0.007
ACEI or ARB (%) 2.538 1.374,3.702 <0.001 2.357 1.115,3.558 0.001
β- AB (%) 0.913 −0.231, 2.058 0.118 0.799 −0.362, 1.959 0.177
CCB (%) 0.762 −0.403, 1.928 0.200 0.414 −0.762, 1.590 0.490
Diuretic (%) −0.850 −2.880, 1.180 0.411 −1.144 −3.197, 0.909 0.275
PSQI (score) −0.610 −0.742, −0.478 <0.001 – – –
Subjective sleep quality(score) −1.146 −1.057, 0.765 0.753
Sleep latency(score) 0.135 −0.584,0.854 0.712
Sleep duration(score) −1.643 −2.433,-0.853 <0.001
Sleep efficiency(score) 0.291 −0.506, 1.089 0.474
Sleep disturbance(score) −1.740 −1.523, −0.957 <0.001
Use sleep drug(score) −0.794 −1.308, −0.281 0.002
Daytime dysfunction(score) −0.898 −1.503, −0.294 0.004
BMI: body mass index, ACEI: angiotensin converting enzyme inhibitor, ARB: angiotensin receptor antagonist, β-AB: β-adrenergic blocker, CCB: calcium channel blocker,
PSQI: Pittsburgh Sleep Quality Index.

sleep and reverse dipper BP rhythm, but not non-dipper and
dipper BP rhythm. Even, with the PSQI score as well as its
components increased, there was an increased risk of reverse
dipper BP rhythm, and there was no significant difference
between the dipper and non-dipper groups. In addition, linear
correlation and regression analysis found PSQI score could
reduce nocturnal BP dipping in a great extent, and multiple
linear regression analysis found that PSQI score was nega-
tively correlated with nocturnal BP dipping values after
adjusting for age, sex, and other risk factors of hypertension.
The previous research had shown that poor sleep was
responsible for the non-dipper pattern and reverse-dipper
pattern in hypertensive (11,12). Poor sleep quality had been
found to be associated with non-dippers in younger patients
with initial diagnosis of hypertension, and was an indepen-
dent predictor of it (13). In normal adults, there was also a
relationship between poor sleep and non-dippers (14). To our
knowledge, the relationship between sleep and BP rhythm had
never been elucidated in Chinese elderly hypertensive before.
In our study, individual were divided into three groups by the
nocturnal blood pressure dipping. We found that poor sleep
status was associated with reverse dipper BP rhythm, which
nocturnal BP higher than daytime BP, but not with non-
dipper BP rhythm. The study indicated that the relationship
between poor sleep and nocturnal BP dipping weakening with
increasing age. A potential explanation for this finding might
be that diurnal BP regulation is less sensitive to sleep status in
older individuals. Some previous studies had shown that there
was no correlation between sleep quality and hypertension in
older individuals (15,16). A further explanation might be that
the nocturnal BP dipping of older individuals was influenced
by more factors than adults, include coexistence of various
diseases, the decrease of the autonomic nervous system’s
variability, and exposed to hypertension factors for a longer
time. Because we have not longitudinally assessed sleep qual-
ity and BP dipping in older, and not included the control
group, these explanations are speculative and further research
is necessary to clarify this issue.
As previous study shown, the nocturnal BP dipping
decreased by 10–20%, which was usually to predict CVEs in
adults with hypertension (5,6). In our study, we found that the
revers dipper BP rhythm nocturnal in aged patients with
hypertension accounted for 48.9%, close to the sum of the
dipper group and the non- dipper group. The reverse dipper
BP group had significantly difference in hypertension risk
factors, including age, sex, BMI, status of smoking, status of
drinking, physical activity, history of hypertension and sleep
compared with non-dipper and dipper groups. So, the reverse
dipper BP (the nocturnal BP greater than daytime BP) would
be more appropriate to predict events in older hypertensive.
Additional cohort research is needed to further explore the
relationship between BP pattern and CVEs.
Although blunted blood pressure dipping is more common
in elderly than young, the factors contributing to this difference
are not well understood. Previous investigation had reported the
prevalence of blunted blood pressure dipping among obese
adults (12), a lesser decline in sleep-period sympathetic nervous
system activity (12), poor neighborhood conditions (17),
depression (18) and poor sleep (13,14). A recent article (19)
found that a non-dipping circadian rhythm is associated with
more severe symptoms of psychosis than is a dipping circadian
rhythm among Parkinson’s disease (PD) patients. A variety of
non-motor symptoms in PD are linked to the impairment of the
autonomic nervous system and can be caused by aging pro-
cesses in addition to the Parkinsonism itself (20). The relation-
ship between sleep and BP circadian rhythm, or Parkinson’s
symptoms and BP circadian rhythm, is ultimately attributed to
the dysfunction of autonomic nervous system. 24h ambulatory
BP rhythm is a good response to cardiovascular rhythm, which
are susceptible to a variety of influencing factors. Besides, the
problems relating to sleep might lead to a higher BP at night and
cause non-dipping in PD. It is well known, that up to 90% of PD
patients suffer from sleep disruption (21). So, poor sleep could
aggravate symptoms in patients with PD by affecting blood
pressure rhythm and itself. Also, some findings suggest the
protective effects of marriage, and social contact frequency
6 S. ZHAO ET AL.
(22) for the higher nocturnal BP dipping. The current study
demonstrates that female, high BMI, smoking, not activity
exercise, long hypertension history, and poor sleep contribute
to lower SBP dipping among elderly with hypertension. The
physiological mechanisms have been proposed, and the neu-
roendocrine and sympathetic nervous system activity may be
most important (23,24). The protective factors for nocturnal
blood pressure drops, such as social contact frequency, activity
exercise, may be related to greater BP dipping by reducing levels
of epinephrine, norepinephrine, sympathetic activity, and
increasing parasympathetic nervous system activity (12,25,26).
On the contrary, high BMI, smoking, long hypertension history,
poor neighborhood conditions, depress, and poor sleep, may be
related to lower BP dipping by increasing levels of epinephrine,
norepinephrine, sympathetic activity, and decreasing parasym-
pathetic nervous system activity. In addition, we also found
female had a link with lower BP dipping in elderly hypertensive.
In postmenopausal women, the protective effect of estrogen loss
is a possible cause, which had a direct vasodilator effect on
blood vessels and potentially blunts sympathetic mediated vaso-
constriction (27).
Non-dipper blood pressure was related to the decrease of
parasympathetic nerve impulse and increased sympathetic
nerve pressure, more likely to cause target organ damage than
dipper. In addition, the activation of renin angiotensin aldoster-
one system (RAAS) also leads to the disorder of circadian
rhythm of BP. The choice of medication types and the time of
taking medication inevitably affect nocturnal blood pressure.
The drugs play an important role in the regulation of blood
pressure. Antihypertensive drugs may amend BP rhythm at the
same time of lowering BP by reducing the activity of RASS
system or weakening the sympathetic activity. Vardeny et al
(28) study showed β adrenergic receptor blockers can signifi-
cantly increase the nocturnal BP dipping. Kuroda et al (29)
found bedtime administration of the long-acting ACEI seems
to be a safe and effective means of controlling nocturnal BP in
hypertensive patients. Therefore, some hypertensive patients
(especially non-dipper) may be more suitable for taking such
drugs at night to restore dipper BP rhythm.
Several limitations to our study should be noted. First,
because of the cross-sectional design, our results could not
suggest the establishment of causality of the observed associa-
tions. The assessment of sleep status was based on a self-
report questionnaire, which not provides accurate estimates
of objective sleep measures. A further important limitation is
that we have only assessed the relationship between sleep and
BP dipping in hospitalized elderly hypertensive. Further stu-
dies are needed to incorporate community elderly hyperten-
sive populations. An additional limitation is that no data were
available on socioeconomic status, mood, and anxiety disor-
ders known to affect nocturnal BP dipping in elderly.
Conclusion
The findings from this study indicate that the relationship
between poor sleep and nocturnal BP dipping was weakening
with increasing age, and the nocturnal BP decline rate
decreased with decreasing sleep quality among older people.
Poor sleep quality were associated with reverse dipper BP
rhythm among older people, but not with non-dipper and
dipper BP rhythm. The reverse dipper BP may be more
appropriate to predict events in older people. This finding
warrants confirmation in further prospective studies con-
ducted on a bigger population.
Disclosure
The authors report none of the article contents are under consideration
for publication in any other journal or have been published in any
journal. No portion of the text has been copied from other material in
the literature. All authors declare that there is no conflict of interest.
Notes on contributor
Shaopan Zhao, Shihui Fu, Jiefeng Ren: Contributed to the design of the
study, performed data collection and statistical analyses and drafted the
paper. Leiming Luo: Contributed to the design of the study and critically
revised the paper. All authors read and approved the final manuscript.
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