Last reviewed: November 2017
Last updated: November  2017

Summary

Definition

History and exam

Key diagnostic factors

  • older adult age
  • use of high-risk medications
  • underlying medical condition
  • postural lightheadedness, syncope, and other symptoms of cerebral hypoperfusion

Other diagnostic factors

  • parkinsonian features
  • cerebellar ataxia
  • weight loss
  • resting tachycardia or impaired heart rate variation
  • abnormal GI motility
  • erectile dysfunction and lack of ejaculation
  • anhidrosis, heat intolerance, dry skin, focal hyperhidrosis
  • urinary frequency, urgency, nocturia

Risk factors

  • older adult age
  • frailty and physical deconditioning
  • medications that impair sympathetic tone
  • volume depletion
  • autonomic neuropathy (e.g., diabetes mellitus)
  • Parkinson disease
  • Lewy body dementia
  • multiple system atrophy

Diagnostic investigations

Investigations to consider

  • tilt-table test
  • plasma norepinephrine
  • deep breathing
  • Valsalva maneuver
  • nerve conduction studies and EMG
  • quantitative sudomotor axon reflex test (QSART)
  • heart rate variability
  • 24-hour blood pressure monitoring
  • autoimmune antibodies
  • chest CT
  • serum and urine electrophoresis
  • fat-pad biopsy
Full details

Treatment algorithm

ACUTE

Contributors

Authors VIEW ALL

Professor of Medicine and Pharmacology

Vanderbilt University

Nashville

TN

Disclosures

IB has consulted with Lundbeck and Theravance for the development of droxidopa and other medications for the treatment of orthostatic hypotension. IB has applied for a patent for the development of an automated inflatable abdominal binder for the treatment of orthostatic hypotension.

Assistant Professor

Dysautonomia Center

Department of Physiology and Neuroscience

NYU Langone Medical Center

New York

NY

Disclosures

No competing interests.

Professor of Neurology

Medicine and Pediatrics

New York University School of Medicine

New York

NY

Disclosures

HK receives research support from the National Institutes of Health (U54NS065736 and 1U01NS078025-01) and the Dysautonomia Foundation, Inc. HK has also served as Editor in Chief for Clinical Autonomic Research and has received compensation as a consultant/advisory board member for Lundbeck, and Astra Zeneca.

Peer reviewers VIEW ALL

Robert D. and Patricia E. Kern Professor of Neurology

Mayo Clinic College of Medicine

Rochester

MN

Disclosures

PAL is an author of a reference cited in this monograph.

Professor of Neurology

Mayo Clinic

Jacksonville

FL

Disclosures

WPC declares that he has no competing interests.

Consultant Geriatrician

Beaumont Hospital

Dublin

Ireland

Disclosures

AM has received payment from Shire Pharmaceuticals, manufacturer of midodrine, for providing educational talks, and the department in which he works has received unrestricted educational grants from Shire Pharmaceuticals.

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