Beruflich Dokumente
Kultur Dokumente
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
Article views: 1
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
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.
Association of sleep status in related to ABH rhythm (all OR<1.00; Table 2). In addition, reverse dipper BP
pattern in hypertensive rhythm was associated with all components of PSQI
score with the exception of sleep efficiency (score 1) as
The results of multivariate logistic regression analyses
compared with reference of each components (score 0)
about the association between sleep status (PSQI score
(all OR>1.00; Table 2). Non-dipper BP rhythm was asso-
and its components) and BP rhythm in hypertensive are
ciated with subjective sleep quality (score 1), sleep effi-
presented in Table 2. After adjusting for sex, age, body
ciency (score 1), use sleep drug (score 2) as compared
mass index (BMI), status of smoking, status of drinking,
with reference of each components (score 0) (all OR>1.00;
physical activity, history of hypertension and anti-hyper-
Table 2). Dipper BP rhythm was associated with sleep
tensive drugs, PSQI score were found to be associated
latency (score 1), sleep efficiency (score 1), sleep distur-
with the prevalence of reverse dipper, but not the pre-
bance (score 1, 2), use sleep drug (score 3) as compared
valence of non-dipper and dipper BP rhythm group in
with reference of each components (score 0) (all OR>1.00;
hypertensive. And the corresponding odds ratio (OR)
Table 2).
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 Association of sleep status in related to nocturnal blood
poor sleep were also found to be in relation to reverse pressure dipping in hypertensive
dipper BP rhythm in hypertensive compared to very good
sleep (OR = 2.68, 95% CI, 1.65–4.37; OR = 5.87, 95% CI, In Table 3, using PSQI score as independent variable and noc-
3.66–9.42; OR = 6.37, 95% CI, 3.72–10.91). But good turnal blood pressure dipping as dependent variable, the linear
sleep, general sleep, and poor sleep were no found to be correlation and regression presented that the regression coeffi-
increase the risk of non-dipper and dipper BP rhythm cient was −0.647, the intercept was 6.366, while the hypothesis
compare to very good sleep, especially dipper BP rhythm 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
Discussion
p < 0.001. It also gives the results of variance analysis of regres- Taking both sleep quality and quantity into consideration, this
sion coefficient: F = 99.395, p < 0.001. That showed a linear study first examined the association between self-reported
regression relationship between PSQI score and nocturnal blood sleep and BP rhythm in elderly patients with hypertension.
pressure dipping in general, and was negatively correlated. The Compared with the other two groups, the reverse BP rhythm
sleep status in a large extent affected nocturnal blood pressure group had higher PSQI scores, more prone to poor sleep
dipping in elderly hypertensive patients. status. There was no significance between the dipper and
Multiple linear regression analysis showed that nocturnal non-dipper groups. Multivariate logistic analysis of our data
blood pressure dipping levels were positively associated with 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 As previous study shown, the nocturnal BP dipping
dipper BP rhythm. Even, with the PSQI score as well as its decreased by 10–20%, which was usually to predict CVEs in
components increased, there was an increased risk of reverse adults with hypertension (5,6). In our study, we found that the
dipper BP rhythm, and there was no significant difference revers dipper BP rhythm nocturnal in aged patients with
between the dipper and non-dipper groups. In addition, linear hypertension accounted for 48.9%, close to the sum of the
correlation and regression analysis found PSQI score could dipper group and the non- dipper group. The reverse dipper
reduce nocturnal BP dipping in a great extent, and multiple BP group had significantly difference in hypertension risk
linear regression analysis found that PSQI score was nega- factors, including age, sex, BMI, status of smoking, status of
tively correlated with nocturnal BP dipping values after drinking, physical activity, history of hypertension and sleep
adjusting for age, sex, and other risk factors of hypertension. compared with non-dipper and dipper groups. So, the reverse
The previous research had shown that poor sleep was dipper BP (the nocturnal BP greater than daytime BP) would
responsible for the non-dipper pattern and reverse-dipper be more appropriate to predict events in older hypertensive.
pattern in hypertensive (11,12). Poor sleep quality had been Additional cohort research is needed to further explore the
found to be associated with non-dippers in younger patients relationship between BP pattern and CVEs.
with initial diagnosis of hypertension, and was an indepen- Although blunted blood pressure dipping is more common
dent predictor of it (13). In normal adults, there was also a in elderly than young, the factors contributing to this difference
relationship between poor sleep and non-dippers (14). To our are not well understood. Previous investigation had reported the
knowledge, the relationship between sleep and BP rhythm had prevalence of blunted blood pressure dipping among obese
never been elucidated in Chinese elderly hypertensive before. adults (12), a lesser decline in sleep-period sympathetic nervous
In our study, individual were divided into three groups by the system activity (12), poor neighborhood conditions (17),
nocturnal blood pressure dipping. We found that poor sleep depression (18) and poor sleep (13,14). A recent article (19)
status was associated with reverse dipper BP rhythm, which found that a non-dipping circadian rhythm is associated with
nocturnal BP higher than daytime BP, but not with non- more severe symptoms of psychosis than is a dipping circadian
dipper BP rhythm. The study indicated that the relationship rhythm among Parkinson’s disease (PD) patients. A variety of
between poor sleep and nocturnal BP dipping weakening with non-motor symptoms in PD are linked to the impairment of the
increasing age. A potential explanation for this finding might autonomic nervous system and can be caused by aging pro-
be that diurnal BP regulation is less sensitive to sleep status in cesses in addition to the Parkinsonism itself (20). The relation-
older individuals. Some previous studies had shown that there ship between sleep and BP circadian rhythm, or Parkinson’s
was no correlation between sleep quality and hypertension in symptoms and BP circadian rhythm, is ultimately attributed to
older individuals (15,16). A further explanation might be that the dysfunction of autonomic nervous system. 24h ambulatory
the nocturnal BP dipping of older individuals was influenced BP rhythm is a good response to cardiovascular rhythm, which
by more factors than adults, include coexistence of various are susceptible to a variety of influencing factors. Besides, the
diseases, the decrease of the autonomic nervous system’s problems relating to sleep might lead to a higher BP at night and
variability, and exposed to hypertension factors for a longer cause non-dipping in PD. It is well known, that up to 90% of PD
time. Because we have not longitudinally assessed sleep qual- patients suffer from sleep disruption (21). So, poor sleep could
ity and BP dipping in older, and not included the control aggravate symptoms in patients with PD by affecting blood
group, these explanations are speculative and further research pressure rhythm and itself. Also, some findings suggest the
is necessary to clarify this issue. protective effects of marriage, and social contact frequency
6 S. ZHAO ET AL.
(22) for the higher nocturnal BP dipping. The current study rhythm among older people, but not with non-dipper and
demonstrates that female, high BMI, smoking, not activity dipper BP rhythm. The reverse dipper BP may be more
exercise, long hypertension history, and poor sleep contribute appropriate to predict events in older people. This finding
to lower SBP dipping among elderly with hypertension. The warrants confirmation in further prospective studies con-
physiological mechanisms have been proposed, and the neu- ducted on a bigger population.
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 Disclosure
exercise, may be related to greater BP dipping by reducing levels The authors report none of the article contents are under consideration
of epinephrine, norepinephrine, sympathetic activity, and for publication in any other journal or have been published in any
increasing parasympathetic nervous system activity (12,25,26). 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.
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, Notes on contributor
norepinephrine, sympathetic activity, and decreasing parasym-
pathetic nervous system activity. In addition, we also found Shaopan Zhao, Shihui Fu, Jiefeng Ren: Contributed to the design of the
study, performed data collection and statistical analyses and drafted the
female had a link with lower BP dipping in elderly hypertensive. paper. Leiming Luo: Contributed to the design of the study and critically
In postmenopausal women, the protective effect of estrogen loss revised the paper. All authors read and approved the final manuscript.
is a possible cause, which had a direct vasodilator effect on
blood vessels and potentially blunts sympathetic mediated vaso-
constriction (27). References
Non-dipper blood pressure was related to the decrease of 1. Fagard RH, Thijs L, Staessen JA, et al. Night-day blood pressure
parasympathetic nerve impulse and increased sympathetic ratio and dipping pattern as predictors of death and cardiovascu-
nerve pressure, more likely to cause target organ damage than lar events in hypertension. J Hum Hypertens. 2009;23:645–53.
dipper. In addition, the activation of renin angiotensin aldoster- 2. Dolan E, Stanton A, Thijs L, et al. Superiority of ambulatory over
one system (RAAS) also leads to the disorder of circadian clinic blood pressure measurement in predicting mortality: the
Dublin outcome study. Hypertension. 2005;46:156–61.
rhythm of BP. The choice of medication types and the time of 3. Salles GF, Reboldi G, Fagard RH, et al. Prognostic effect of the
taking medication inevitably affect nocturnal blood pressure. nocturnal blood pressure fall in hypertensive patients: the ambu-
The drugs play an important role in the regulation of blood latory blood pressure collaboration in patients with hypertension
pressure. Antihypertensive drugs may amend BP rhythm at the (ABC-H) meta-analysis. Hypertension. 2016;67:693–700.
same time of lowering BP by reducing the activity of RASS 4. Clement DL, Buyzere MLD, Bacquer DAD, et al. Prognostic value
of ambulatory blood pressure recordings in patients with treated
system or weakening the sympathetic activity. Vardeny et al hypertension. N Engl J Med. 2003;348(24):2407–15.
(28) study showed β adrenergic receptor blockers can signifi- 5. Davidson MB, Hix JK, Vidt DG, et al. Association of impaired
cantly increase the nocturnal BP dipping. Kuroda et al (29) diurnal blood pressure variation with a subsequent decline in
found bedtime administration of the long-acting ACEI seems glomerular filtration rate. Arch Intern Med. 2006;166:846–52.
to be a safe and effective means of controlling nocturnal BP in 6. Kario K, Pickering TG, Matsuo T, et al. Stroke prognosis and
abnormal nocturnal blood pressure falls in older hypertensives.
hypertensive patients. Therefore, some hypertensive patients Hypertension. 2001;38:852–57.
(especially non-dipper) may be more suitable for taking such 7. Pickering TG. The clinical significance of diurnal blood pressure
drugs at night to restore dipper BP rhythm. variations, dippers and non-dippers. Circulation. 1990;81:700–02.
Several limitations to our study should be noted. First, 8. Erden I, Erden Ec Fau - Ozhan H, Ozhan H Fau - Basar C, et al.
because of the cross-sectional design, our results could not Poor-quality sleep score is an independent predictor of non dip-
ping hypertension. Blood Press Monit. 2010;15:184–87.
suggest the establishment of causality of the observed associa- 9. Silva AP, Moreira C Fau - Bicho M, Bicho M Fau - Paiva T, et al.
tions. The assessment of sleep status was based on a self- Nocturnal sleep quality and circadian blood pressure variation.
report questionnaire, which not provides accurate estimates Rev Port Cardiol. 2000;19:991–1005.
of objective sleep measures. A further important limitation is 10. Tsai PS, Wang SY, Wang MY, Su, et al. Psychometric evaluation
that we have only assessed the relationship between sleep and of the Chinese version of the Pittsburgh sleep quality index
(CPSQI) in primary insomnia and control subjects. Qual Life
BP dipping in hospitalized elderly hypertensive. Further stu- Res. 2005;14:1943–52.
dies are needed to incorporate community elderly hyperten- 11. Zhang J, Wang C, Gong W, et al. Poor sleep quality is responsible
sive populations. An additional limitation is that no data were for the non-dipper pattern in hypertensive but not in normoten-
available on socioeconomic status, mood, and anxiety disor- sive chronic kidney disease patients. Nephrology (Carlton).
ders known to affect nocturnal BP dipping in elderly. 2016;10:12839.
12. Sherwood A, Routledge FS, Wohlgemuth WK, et al. Blood pres-
sure dipping: ethnicity, sleep quality, and sympathetic nervous
Conclusion system activity. Am J Hypertens. 2011;24:982–88.
13. Yilmaz MB, Yalta K, Turgut OO, et al. Sleep quality among
The findings from this study indicate that the relationship relatively younger patients with initial diagnosis of hypertension:
between poor sleep and nocturnal BP dipping was weakening dippers versus non-dippers. Blood Press. 2007;16:101–05.
14. Loredo JS, Nelesen R, Ancoli-Israel S, et al. Sleep quality and
with increasing age, and the nocturnal BP decline rate blood pressure dipping in normal adults. Sleep. 2004;27:1097–103.
decreased with decreasing sleep quality among older people. 15. Gangwisch JE, Heymsfield SB, Boden-Albala B, et al. Short sleep
Poor sleep quality were associated with reverse dipper BP duration as a risk factor for hypertension: analyses of the first
CLINICAL AND EXPERIMENTAL HYPERTENSION 7
National Health and Nutrition Examination Survey. 23. Southwick SM, Vythilingam M, Charney DS. The psychobiology
Hypertension. 2006;47:833–39. of depression and resilience to stress: implications for prevention
16. Wang Q, Xi B, Liu M, et al. Short sleep duration is associated with and treatment. Ann Rev Clin Psychol. 2005;1:255–91.
hypertension risk among adults: a systematic review and meta- 24. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK. The relationship
analysis. Hypertens Res. 2012;35:1012–18. between social support and physiological processes: a review
17. Scuteri A, Spalletta G, Cangelosi M, et al. Decreased nocturnal with emphasis on underlying mechanisms and implications for
systolic blood pressure fall in older subjects with depression. health. Psychol Bull. 1996;119:488–531.
Aging Clin Exp Res. 2009;21:292–97. 25. Sherwood A, Steffen PR, Blumenthal JA, Kuhn C, Hinderliter AL.
18. Frank Euteneuer, Winfried Rief, Paul J Mills, et al. Neighborhood Nighttime blood pressure dipping: the role of the sympathetic
problems and nocturnal blood pressure Dipping. Health Psychol. nervous system. Am J Hypertens. 2002;15:111–18.
2014;33:1366–72. 26. Jiang Ya, Tang Yu-Rong, Xie Chen, et al. Influence of sleep dis-
19. Stübner E, Vichayanrat E, Low DA, et al. Non-dipping nocturnal orders on somatic symptoms, mental health, and quality of life in
blood pressure and psychosis parameters in PD. Clin Auton Res. patients with chronic constipation. Medicine. 2017;96:e6093.
2015;25:109–16. 27. Gilligan DM, Badar DM, Panza JA, et al. 3rd Acute vascular effects of
20. Stübner E, Vichayanrat E, Low D, et al. Twenty-four hour non- estrogen in postmenopausal women. Circulation. 1994;90:786–91.
invasive ambulatory blood pressure and heart rate monitoring in 28. Vardeny O, Peppard PE, Finn LA, et al. β2 adrenergic receptor
Parkinson’s Disease. Front Neurol. 2013;4:49. polymorphisms and nocturnal blood pressure dipping status in
21. Chaudhuri KR, Healy DG, Schapira AH. Non-motor symptoms of the Wisconsin Sleep Cohort Study. J Am Soc Hypertens.
Parkinson’sdisease: diagnosis and management. Lancet Neurol. 2011;5:114–22.
2006;5:235–45. 29. Kuroda T, Kario K, Hoshide S, et al. Effects of bedtime vs.
22. Fortmann AL, Gallo LC. Social support and nocturnal blood morning administration of the long-acting lipophilic angiotensin:
pressure dipping: a systematic review. AM J Hypertens. converting enzyme inhibitor trandolapril on morning blood pres-
2013;26:302–10. sure in hypertensive patients. Hypertens Res. 2004;27:15–20.