Sheila Carew

A Review of Approaches to Mobility Telemonitoring of the Elderly in Their Living Environment

Rapid technological advances have prompted the development of a wide range of telemonitoring systems to enable the prevention, early diagnosis and management, of chronic conditions. Remote monitoring can reduce the amount of recurring admissions to hospital, facilitate more efficient clinical visits with objective results, and may reduce the length of a hospital stay for individuals who are living at home. Telemonitoring can also be applied on a long-term basis to elderly persons to detect gradual deterioration in their health status, which may imply a reduction in their ability to live independently. Mobility is a good indicator of health status and thus by monitoring mobility, clinicians may assess the health status of elderly persons. This article reviews the architecture of health smart home, wearable, and combination systems for the remote monitoring of the mobility of elderly persons as a mechanism of assessing the health status of elderly persons while in their own living environment.

A review of postural orthostatic tachycardia syndrome.

A 21-year-old female reports an 18-month history of light-headedness on standing. This is often associated with palpitations and a feeling of intense anxiety. She has had two black-outs in the past 12 months. She is not taking any regular medications. Her supine blood pressure was 126/84 mmHg with a heart rate of 76 bpm, and her upright blood pressure was 122/80 mmHg with a heart rate of 114 bpm. A full system examination was otherwise normal. She had a 12-lead electrocardiogram performed which was unremarkable. She was referred for head-up tilt testing. She was symptomatic during the test and lost consciousness at 16 min. Figure 1 summarizes her blood pressure and heart rate response to tilting. A diagnosis of postural orthostatic tachycardia syndrome with overlapping vasovagal syncope was made.

Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension

INTRODUCTION Orthostatic hypotension (OH) is associated with troublesome symptoms and increased mortality. It is treatable and deserving of accurate diagnosis. This can be time consuming. The current reference standard for its diagnosis is head-up tilt (HUT) testing with continuous beat-to-beat plethysmography. Our objective was to assess the accuracy of sit-stand testing with semi-automatic sphygmomanometry for the diagnosis of OH. DESIGN Retrospective test of diagnostic accuracy. METHODS This was a retrospective study performed using a database maintained by a busy syncope unit. HUT testing was performed using an automated tilt table with Finometer monitoring. A 3 min 70 degrees HUT was performed following 5 min supine. Sitting blood pressure (BP) was measured following 3 min rest. Standing BP was measured within 30 s of assuming the upright posture. The results of sit-stand testing were compared with HUT testing as a reference standard. Both tests happened within 5 min of each other and patients underwent no intervention between tests. RESULTS From a total of 1452 consecutive HUTs, we identified 730 with pre-test measures of sitting and standing BP. The mean age of this group was 70.57 years (SD = 15.1), 62% were female. The sensitivity of sit-stand testing was calculated as 15.5%, specificity as 89.9%, positive predictive value as 61.7%, negative predictive value as 50.2% and the likelihood ratio as 1.6. The area under the Receiver Operator Curve was 0.564. CONCLUSION We have demonstrated that sit-stand testing for OH has very low diagnostic accuracy. We recommend that the more time-consuming reference standard method of diagnosis be used if the condition is suspected.

A Clinical Evaluation of a Remote Mobility Monitoring System based on SMS Messaging

The objective of this work was to evaluate the accuracy and viability of a mobility telemonitoring system, based on the short message service (SMS), to monitor the functional mobility of elderly subjects in an unsupervised environment A clinical trial was conducted consisting of 6 elderly subjects; 3 male, 3 female (mean: 81.7, SD: 5.09). Mobility was monitored using an accelerometer based portable unit worn by each monitored subject for eleven hours. Every 15 minutes the mobility of the subject was summarized and transmitted as an SMS message from the portable unit to a remote server for long term analysis. The activPALtrade Trio Professional physical activity logger was simultaneously used for comparison with the portable unit. On conclusion of the trial each subject completed a questionnaire detailing their satisfaction with the portable unit and any recommendations for improvements. Overall a percentage difference of 2.31% was found between the activPALtrade Trio and the portable unit for the detection of sitting. For the combined postures of standing and walking the percentage difference was calculated as 2.9%. A bivariate correlation and regression analysis was performed on the entire data set of one subject. Strong positive correlations were found for the detection of sitting (r = 0.996) and for the combined postures of standing and walking (r = 0.994). Subjects suggested that a lighter, smaller and wireless unit would be more effective.

The changing face of orthostatic and neurocardiogenic syncope with age

AIM Reports of the outcomes of syncope assessment across a broad spectrum of ages in a single population are scarce. It is our objective to chart the varying prevalence of orthostatic and neurocardiogenic syncope (NCS) as a patient ages. METHODS This was a retrospective study. All consecutive patients referred to a tertiary referral syncope unit over a decade were included. Patients were referred with recurrent falls or orthostatic intolerance. Tilt tests and carotid sinus massage (CSM) were performed in accordance with best practice guidelines. RESULTS A total of 3002 patients were included (1451 short tilt, 127 active stand, 1042 CSM and 382 prolonged tilt). Ages ranged from 11 to 91 years with a median (IQR) of 75 (62-81) years. There were 1914 females; 1088 males. Orthostatic hypotension (OH) was the most commonly observed abnormality (test positivity of 60.3%). Those with OH had a median (IQR) age of 78 (71-83) years. Symptomatic patients were significantly younger than asymptomatic (P = 0.03). NCS demonstrated a bimodal age distribution. Of 194 patients with carotid sinus hypersensitivity, the median age (IQR) was 77 (68-82) years. Those with vasovagal syncope (n = 80) had a median (IQR) age of 30 (19-44) years. There were 57 patients with isolated postural orthostatic tachycardia syndrome. Of the total patients, 75% were female. They had a median (IQR) age of 23 (17-29) years. CONCLUSION We have confirmed, in a single population, a changing pattern in the aetiology of syncope as a person ages. The burden of disease is greatest in the elderly.

What is the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome

AIMS The aim of this study is to define the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome (POTS). METHODS AND RESULTS This was a case-control study. Cases were identified retrospectively from a database of patients referred with orthostatic intolerance (OI). All met the diagnostic criteria for POTS. Controls were enrolled prospectively. All subjects underwent tilting to 70 degrees for 40 min if tolerated. Continuous monitoring was provided by a Finometer. Analysis of responses to tilting was performed on 28 cases and 28 controls. The mean age in the case group was 23.6 and in the control group was 26.2. The majority was female in both groups (cases = 4F:3M, controls = 2F:1M). All cases met the criteria for POTS within 7 min of orthostasis. No controls demonstrated a sustained tachycardia. The prevalence of vasovagal syncope (VVS) was 36% in cases vs. 7% in controls (P = 0.02) and 25% in the remaining patients (n = 233) on the OI database (P = 0.259). CONCLUSION A 10 min tilt will diagnose POTS in the majority of patients. It will not, however, be sufficient to identify the overlap that exists between POTS and VVS. The optimal duration of tilt testing in patients suspected of POTS is 40 min.

Near death and neurocardiogenic syncope

We report the case of an 18-year-old female who presented as an out-of-hospital ventricular fibrillation cardiac arrest. She required ICD insertion and recovered without deficit. Following recurrent syncopal episodes we diagnosed the co-existence of Neurocardiogenic syncope.

Recurrent loss of consciousness

An electrocardiograph and beat-to-beat blood pressure recordings were performed during right sided supine carotid sinus massage on a 78 year old man (figure)⇓. He reported frequent episodes of loss of consciousness, which were typically of sudden onset followed within minutes by rapid recovery to full health. Some were associated with jerking movements of his limbs. He linked some of these episodes to turning his head. He had no important comorbidities but had recently fallen and sustained a fracture. Simultaneous beat-to-beat blood pressure (above) and electrocardiograph (below) tracings performed during right sided supine carotid sinus massage. Arrow indicates onset of 5 second carotid sinus massage. Image created with BeatScope software, using data obtained from a Finometer device ### Short answers