A Clinical, Physiology and Pharmacology Evaluation of Orthostatic Hypotension in the Elderly

Abstract

Orthostatic hypotension is very common in the elderly. It increases morbidity and is an independant predictor of all cause mortality. It is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing. Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes. Drugs like antihypertensives and tricyclic antidepressants are very common causes of orthostatic hypotension. Diagnosis is based on the history and a thorough clinical examination. Based on the history and physical examination, further testing of the heart, kidneys and autonomic nervous system may be required in selected patients. Non pharmacological methods like slow position change, increased fluid and sodium intake, compression stockings and elevation of head of the bed are the key to management of orthostatic hypotension. After these methods, pharmacological treatment with fludrocortisone and midodrine should be tried. Other drugs like desmopresin acetate, xamoterol, erythropoetin and ocreotide can be used as second line agents in selected patients.

Insights into the clinical management of the syndrome of supine hypertension – orthostatic hypotension (SH-OH): The Irish Longitudinal Study on Ageing (TILDA)

“…Although most patients with OH are asymptomatic or have few non-specific symptoms [9], a marked orthostatic blood pressure drop may cause symptoms of orthostatic intolerance (OI) such as dizziness, light-headedness, and/or loss or near-loss of consciousness [10,11]. These symptoms are attributed to hypoperfusion of the central nervous system during orthostasis [12].…”

Intolerance to initial orthostasis relates to systolic BP changes in elders

“…OH may cause symptoms of orthostatic intolerance (OI) such as dizziness, light-headedness, visual disturbances and/or loss or near-loss of consciousness [3,23]. These symptoms are generally attributed to retinal and cerebral hypoperfusion [19].…”

Withdrawal of Fall‐Risk‐Increasing Drugs in Older Persons: Effect on Tilt‐Table Test Outcomes

“…OH has been associated with a wide variety of drugs, the main groups being antihypertensives, vasodilators, antidepressants, neuroleptics, sedatives, and anti-Parkinson medication. [29][30][31][32][33][34] The reversibility of OH after withdrawal of these drugs was demonstrated in this study. Given the significant association between normalization of tilt-table test outcomes and nonoccurrence of falls, it is likely that part of the reduction in falls after FRID withdrawal in this same cohort of geriatric outpatients 17 was indeed due to improvement of OH.…”