An independent predictor of mortality and the cause of significant morbidity associated with falls.
A common problem in frail older people. Orthostatic hypotension-related hospitalisations increase markedly with age.
Common causes include drugs (e.g., alpha-blockers, including tamsulosin [used for treating conditions such as benign prostatic hypertrophy]), diseases causing peripheral neuropathy (e.g., diabetes mellitus), and Parkinson's disease.
Primary neurodegenerative disorders of the autonomic nervous system (pure autonomic failure, and multiple system atrophy or Shy-Drager syndrome) are less common, but cause severe orthostatic hypotension.
Acute or subacute onset should suggest an autoimmune or paraneoplastic disorder.
Treatment consists of addressing any underlying pathology, when possible, followed by non-pharmacological countermeasures (e.g., liberalisation of salt intake, use of abdominal binders or compression stockings). Volume expansion (using mineralocorticoid therapy), short-acting vasopressors, or noradrenaline (norepinephrine) precursor therapy with droxidopa are adjunctive therapies when non-pharmacological measures are insufficient.
Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing. It becomes clinically significant if it is accompanied by symptoms of cerebral hypoperfusion, which can lead to syncope and falls. This monograph concentrates on orthostatic hypotension caused by autonomic problems.
History and exam
- 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
- tilt-table test
- plasma noradrenaline (norepinephrine)
- deep breathing
- Valsalva manoeuvre
- 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
Professor of Medicine and Pharmacology
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.
Department of Physiology and Neuroscience
NYU Langone Medical Center
No competing interests.
Professor of Neurology
Medicine and Pediatrics
New York University School of Medicine
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.
Robert D. and Patricia E. Kern Professor of Neurology
Mayo Clinic College of Medicine
PAL is an author of a reference cited in this monograph.
Professor of Neurology
WPC declares that he has no competing interests.
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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