11/14/24, 10\:48 AM Postural Hypotension in Older Adults

Postural Hypotension in Older Adults

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Postural hypotension\: reduction in systolic BP ≥20mmHg or diastolic BP ≥10mmHg within 3 minutes of standing.
Prevalence\: ~16% in adults over 65, up to 50% in care homes.
Causes\: impaired barore
Neurogenic causes\: autonomic dysfunction in diabetes, Parkinson’s disease, certain cancers.
Non-neurogenic causes\: cardiac impairment, hypovolaemia, vasodilation, medications (diuretics, antihypertensives, alpha-
blockers, insulin, levodopa, tricyclic antidepressants).
Symptoms\: dizziness, weakness, confusion, blurred vision, nausea, syncope (in severe cases).
Older adults’ susceptibility\: hypovolaemia, decreased barore
morbidities, deconditioning.
Exacerbating factors\: quick positional changes, prolonged standing, dehydration, physical exertion, alcohol, large meals,
straining, fever.
Management aims\: raise standing BP, reduce orthostatic symptoms, improve standing time and ADLs.
Non-pharmacological management\: patient education, avoid high-risk situations, compression stockings, abdominal
binders, physical activity, counter-manoeuvres, elevated bed head, increased salt and water intake.
Pharmacological management\: consider after non-pharmacological measures;
volume), midodrine (vasopressor), pyridostigmine (acetylcholinesterase inhibitor). Monitor for side e
Complications\: falls, decreased mobility, reduced independence, increased all-cause mortality, risk of cardiovascular
disease.
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A comprehensive topic overview

Background

Postural hypotension, also known as orthostatic hypotension, is de
20mmHg, or diastolic BP of 10mmHg, that occurs within three minutes of standing. 1
It is a signi
morbidity and adverse events in older adults. In the community, the prevalence of postural hypotension in adults aged over
65 is estimated to be approximately 16%; however, can be as high as 50% for those living in organized spaces such as care
homes. 2
This article aims to provide an overview of postural hypotension, with a special emphasis on relevant
considerations for adults aged 65 and above. The pharmacological and non-pharmacological approaches to managing
postural hypotension will be discussed as well.

Physiology of postural hypotension

When we stand, blood shifts from the chest to below the diaphragm. This
the
blood pressure.
3
The gravity-induced reduction in blood pressure is detected by baroreceptors in the aortic arch and carotid sinus. These
baroreceptors trigger barore
blood pressure (Figure 1). There is an increase in sympathetic out
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reducing parasympathetic stimulation to the heart. 1
circulatory system to increase total peripheral resistance. 3
blood pressure.
The baroreceptors also send signals to the arterioles and venules in the
These measures overall work to increase and thus normalise
4
Figure 1. Baroreceptor re
Postural hypotension occurs when these mechanisms to regulate blood pressure are impaired. The body is unable to
maintain the same blood pressure on sitting up or standing.
Postural hypotension can occur due to one or more of the following\:
Failure of barore
Volume depletion
End-organ dysfunction
5

Causes of postural hypotension

There are several underlying causes of postural hypotension. It is useful to break them down into neurogenic vs. non-
neurogenic aetiologies.
Neurogenic
Neurogenic hypotension occurs when there is an insu
neurons. This limits vasoconstriction, and so the body is unable to increase and normalise blood pressure on standing or
sitting up. 2
Neurogenic hypotension is most often seen in disorders that cause autonomic dysfunction including\:
Type 2 diabetes mellitus
Parkinson’s disease
Small cell lung carcinoma, monoclonal gammopathies, light chain disease, or amyloid. If a patient presents with a
subacute onset of postural hypotension that is rapidly progressing, these conditions that cause autonomic failure need
to be ruled out.
1
Non-neurogenic
Non-neurogenic postural hypotension fundamentally arises from either hypovolaemia, cardiac failure or venous pooling.
5
Cardiac impairment (this includes myocardial infarction and aortic stenosis)
Reduced intravascular volume (dehydration, adrenal insu
States that induce vasodilation (including fevers)
1
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Medications\: It is vital to obtain a comprehensive medication history from patients presenting with postural hypotension.
Common medications that can induce postural hypotension include the following\:
Diuretics
Alpha-adrenoceptor blockers for prostatic hypertrophy
Antihypertensive drugs,
Insulin, levodopa, and tricyclic antidepressants can also cause vasodilation and postural hypotension in predisposed
patients
2

Clinical features of postural hypotension

The symptoms of postural hypotension are caused by cerebral hypoperfusion. They include\:
Dizziness
Weakness
Confusion
Blurred vision
Nausea
In severe cases, syncope. When older patients present with syncope, a lying and standing blood pressure measurement
is essential to identify postural hypotension as a potential contributor.
1

Why are older adults more susceptible to postural hypotension?

Firstly, older adults are more prone to hypovolaemia. This is due to an increase in natriuretic peptides, and the reduction in
renin, angiotensin and aldosterone with age. They have an impaired ability to conserve water and sodium; this is
exacerbated by a diminished thirst response.
5
Changes to the cardiovascular system also contribute to postural hypotension in older adults. Older adults have decreased
barore6
1
Chronic
hypertension, which is seen in a large proportion of adults over the age of 65, also results in reduced barore
and left ventricular compliance. 1
Older adults have a blunted response to the recruitment of the sympathetic nervous
system in blood pressure control.
6
Older adults are more likely to be on medications that are associated with inducing postural hypotension, such as
furosemide and terazosin. Polypharmacy is an issue with this demographic, as many individuals will be on multiple anti-
hypertensives as well. 7
In parallel, older adults tend to have a higher prevalence of co-morbidities such as chronic
hypertension and diabetes, which are known contributors to postural hypotension. 2
Finally, older adults are more likely to
experience greater severity of the symptoms from postural hypotension, due to deconditioning from lack of exercise.
1

Exacerbating factors

Several factors may predispose or worsen postural hypotension. These factors need to be addressed and discussed with
patients as part of the management of postural hypotension. 5
Lifestyle-related factors should be discussed with patients
using appropriate motivational interviewing techniques\:
Rising quickly after prolonged sitting or recumbency
Prolonged motionless standing
Time of day (early morning after nocturnal diuresis)
Dehydration
Physical exertion
Alcohol intake
Carbohydrate-heavy meals
Straining during micturition or defecation
Fever
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Management of postural hypotension

It is important to consider postural hypotension as a syndrome, rather than simply emphasising and treating singular
causes.
Overall, the aims of managing postural hypotension in older adults are\:
To raise standing blood pressure without also raising supine blood pressure
To reduce orthostatic symptoms
To increase the time the patient can stand
To improve the ability of patients to perform activities of daily living
5
In order to address these aims, the management of postural hypotension targets three main physiologic processes\:
Reducing venous pooling
Increasing blood volume
Increasing vasoconstriction
2
Non-pharmacological management
Non-pharmacological measures are recommended as the
Firstly, education about the condition is an important aspect of management. A simple way of explaining postural
hypotension to an older patient could be as follows\:
“P o s t u r a l h y p o t e n s i o n i s a d r o p i n b l o o d p r e s s u r e w h e n y o u s i t u p o r s t a n d . N o r m a l l y o u r b o d i e s a r e a b l e t o r e s t o r e t h i s
b l o o d p r e s s u r e . B u t i n p o s t u r a l h y p o t e n s i o n , y o u r b l o o d p r e s s u r e d o e s n’ t go b a c k t o n o r m a l , w h i c h i s w h y y o u m a y f e e l
d i z z y , n a u s e o u s o r h a v e b l u r r y v i s i o n o n s t a n d i n g . T h e r e a r e s e v e r a l t h i n g s t h a t c a n c o n t r i b u t e t o p o s t u r a l h y p o t e n s i o n , a s d i a b e t e s , P a r k i n s o n’ s d i s e a s e a n d v a r i o u s m e d i c a t i o n s . L e t' s d i s c u s s s o m e s t r a t e gi e s t o t r y a n d p r e v e n t y o u r b l o o d
p r e s s u r e f r o m d r o p p i n g s o m u c h w h e n s t a n d i n g.”
s u c h
Furthermore, avoidance of high-risk situations should be emphasised to patients. This includes situations include rising
quickly from sitting or supine positions, prolonged standing, hot environments and large meals.
6
Strategies to reduce venous pooling include the use of compression stockings and abdominal binders. These prevent
1
backward blood
wherever possible to reduce venous pooling.
In patients with enough cognition, counter-manoeuvres against postural hypotension can be taught. These include
exercises such as toe raising, leg elevation and leg crossing. These involve contraction of the muscles below the waist;
reducing venous capacitance, thereby increasing total peripheral resistance, and facilitating venous return to the heart.
6
These countermeasures can help maintain blood pressure during activities of daily living.
Measures to expand blood volume include keeping the head of the bed elevated (reverse Trendelenburg). This increases
plasma volume by decreasing overnight diuresis, with activation of the renin-angiotensin-aldosterone system. 6
Increasing
salt and water intake, including the use of regular boluses of water, are other possible measures to increase blood volume.
8
Pharmacological management
Pharmacological management should be considered after non-pharmacological interventions have been trialled, and
approached cautiously for polypharmaceutical patients. Prior to prescribing any new medication, a thorough review of the
patient’s past and present medications and allergies should be performed. In this regard, you may consider stopping
potential exacerbating medications. 7
After this has been completed, you may consider prescribing some of the medications
discussed below.
Fludrocortisone
Fludrocortisone is a synthetic mineralocorticoid that expands plasma volume. 8
This medication can be useful if non-
pharmacological measures and cessation of exacerbating medications have proved unsuccessful. It has demonstrated
good e
contraindicated in patients who have heart failure, ascites and chronic renal failure. Side e
hypertension and severe hypokalaemia, so it is vital that a patient’s potassium levels are monitored when commenced on
1
Fludrocortisone can be started at 100mcg once daily in the morning.*
Midodrine
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Midodrine is a vasopressor that is short-acting and can be useful in neurogenic postural hypotension. 6
It has a short
duration of action and the literature suggests that it can be e
However, it is largely ine8
Caution should be exercised in patients with severe
heart failure, urinary retention and underlying hypertension. Midodrine has unique side e
hypertension, scalp paraesthesia and pilomotor reactions, such as goosebumps. 6
Midodrine can be titrated for dosing up
to three times daily, with a starting dose of 2.5mg.*
Pyridostigmine
Pyridostigmine is an acetylcholinesterase inhibitor, that can be used for postural hypotension as it has a vasoconstrictive
e6
It also exacerbates supine
hypertension in a dose-dependent manner. 5
Pyridostigmine has a starting dose of 30mg.*
* Consult your local BNF before prescribing these medications

Complications & prognosis

Postural hypotension is a signi
on patients’ con
also important to recognise that postural hypotension can be a barrier against a patient being able to live independently in
their own home. The prognosis of postural hypotension is dependent on the contributing factors being identi
managed appropriately. One study found that at the 5-year follow-up, individuals with postural hypotension had
signi9
Postural
hypotension is considered an independent risk factor for both mortality and cardiovascular disease.
10

Take-home messages

Postural hypotension is associated with signi
Consider postural hypotension as a syndrome, rather than focusing on and treating singular causes
Management should be directed at increasing blood volume, decreasing venous pooling, and increasing
vasoconstriction, while minimizing supine hypertension as able.
Patient education and non-pharmacological measures are vital aspects of managing postural hypotension and should
be instituted prior to any pharmacological measures.

References

MacDonald MJ, Clair A, Khoury L, Molnar FJ. 4 D-A I D \: a p r a c t i c a l a p p r o a c h t o t h e a s s e s s m e n t o f o r t h o s t a t i c h y p o t e n s i o n i n
o l d e r p a t i e n t s . Published in 2016. [LINK]
C, Lipsitz LA, Biaggioni I. A S H p o s i t i o n p a p e r \: e v a l u a t i o n a n d t r e a t m e n t o f o r t h o s t a t i c h y p o t e n s i o n . Published in 2013.
Shibao [LINK]
Lanier JB, Mote in 2011. [LINK]
MB, Clay EC. E v a l u a t i o n a n d m a n a g e m e n t o f o r t h o s t a t i c h y p o t e n s i o n . A m e r i c a n f a m i l y p h y s i c i a n . Published
Roholts, N. File\: B a r o r e c e p t o r r e [LINK]
Figueroa JJ, Basford JR, Low PA. P r e v e n t i n g a n d t r e a t i n g o r t h o s t a t i c h y p o t e n s i o n \: a s e a s y a s A , B , C . Published in 2010.
[LINK]
Klair A, MacDonald MJ, Molnar FJ, Khoury L. p e r s p e c t i v e . Published in 2017. [LINK]
Mills PB, Fung CK, Travlos A, Krassioukov A. r e v i e w . Published in 2015. [LINK]
T r e a t m e n t o f o r t h o s t a t i c h y p o t e n s i o n i n o l d e r p a t i e n t s \: t h e ge r i a t r i c
N o n p h a r m a c o l o g i c m a n a g e m e n t o f o r t h o s t a t i c h y p o t e n s i o n \: a s y s t e m a t i c
Ryan DJ, Cunningham CJ, Published in 2012. [LINK]
Fan CW. N o n- p h a r m a c o l o g i c a l m a n a g e m e n t o f o r t h o s t a t i c h y p o t e n s i o n i n t h e o l d e r p a t i e n t .
Ricci F, Fedorowski A, Radico F, Romanello M, Tatasciore A, Di Nicola M, Zimarino M, De Caterina R. C a r d i o v a s c u l a r
m o r b i d i t y a n d m o r t a l i t y r e l a t e d t o o r t h o s t a t i c h y p o t e n s i o n \: a m e t a-a n a l y s i s o f p r o s p e c t i v e o b s e r v a t i o n a l s t u d i e s . in 2015. [LINK]
Published
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Aronow WS. P r o g n o s i s o f O r t h o s t a t i c H y p o t e n s i o n . Published in 2016. [LINK]

Reviewer

Dr Bodhi Wimalasena
Consultant Geriatrician

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Contents

Background
Physiology of postural hypotension
Causes of postural hypotension
Clinical features of postural hypotension
Why are older adults more susceptible to postural hypotension?
Exacerbating factors
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