Orthostatic hypotension (OH) is defined as a sudden drop in blood pressure upon standing from a sitting or supine position. It is also known as postural hypotension. Diagnosis is made if the blood pressure drops by or greater 20mmHg systolically and 10mmHg diastolically. This occurs within three minutes of standing after lying facing up for 5 minutes or at 60% angle on a tilt table. This sudden drop in blood pressure is due to failure of autonomic reflex, volume depletion, or adverse reaction to medication. Symptoms on presentation are commonly related to reduced blood flow to the brain but many patients can be asymptomatic. Frequent falls occur due to this disease process resulting in a high rate of morbitity and mortality and multiple hospital admissions.

Orthostatic hypotension etiology can be caused by

1. Neurogenic. This occurs due to autonomic instability secondary to neuropathic disease, neurodegenerative disease, or aging eg Diabetes, Lewy body dementia, Demyelinating diseases, Huntington’s, Parkinson’s, MSA.
2. Non neurogenic. Volume depletion eg Dehydration, Hyperglycemia, Hemorrhage, Vomiting.
3. Medication related. eg vasodilators, diuretics, antidepressants, antipsychotics and dopaminergic drugs , polypharmacy

 

Signs and Symptoms

The person will present with symptoms occurring when rise from standing or sitting, particularly if done rapidly. The related signs and symptoms are due to reduced cerebral blood flow. These include: lightheadedness; generalised tiredness; vertigo; blurred vision; difficulty concentrating; palpitations; anxiety; nausea; falls

Diagnostic Procedures

Take the BP

5 minutes after lying down facing upwards. Record or memorize this number

1 minute after standing

3 minutes after standing

A drop in systolic BP of 20mmHg or greater, a drop in systolic BP of 10mmHg or greater is diagnostic tool. Three subcategories exist

 

1. Classic as defined above
2. Delayed OH, when the blood pressure changes as noted above go beyond 3 minutes
3. Initial, which is a normal finding. A drop 40 mmHg systolic and 20 mmHg diastolic BP on initial 15 seconds or less of standing, which returns to normal in less than 30 seconds.

 

Management / Interventions

Apart from removing any offending medications, the initial line of management are lifestyle related. These include; Drinking 2-3 litres of water, in small boluses over the day; increasing salt intake or salt supplements; elevating bed head at night to decrease fluid to kidneys with resultant urine production and fluid loss; use of compression stockings and corsets when out; exercising major muscle groups eg static gluteals just before standing or on standing; counting a slow 10 before moving on from sit to stand position.

Pharmacologic treatment via MD consultation should be considered after conservative lifestyle interventions have failed to relieve symptoms. Medications that work through different mechanisms in order to increase vascular tone are utilised. However, since some of these medications may result in side effects, we encourage our patients to consider conservative care first through physiotherapy and chiropractic care.

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