Geriatric Quick Consult       Falls in Older Patients      DO #4

Check for postural hypotension: measure blood pressure supine and upright.

Knowledge Action
Orthostatic hypotension is defined as a fall is systolic blood pressure of 20 mm Hg or more after standing or during head-up tilt.1 BP should be checked in the morning during one to three minutes of standing after resting supine for 5-10 minutes. An older patient can be orthostatic without being hypovolemic. Small changes in systolic pressure (10-20 mm Hg) can be attributed to age-related changes in blood pressure homeostasis. Other possible contributing factors are medications, pure autonomic failure, multi-system atrophy, Parkinson’s disease, diabetes with neuropathy, post-prandial hypotension or cardiovascular disease. Orthostatic hypotension is often associated with supine systolic hypertension and is not always reproducible.

Increased splanchnic blood flow makes post-prandial hypotension a common problem in older patients.

Taking numerous cardiovascular medications at the same time of day can also be an important factor.

An older patient with orthostatic hypotension may be asymptomatic or present with dizziness, unsteadiness, pre-syncope, deterioration in cognitive status, falls and fractures.

Treatment options for orthostatic hypotension include treatment of the causes, conservative measures and medications.

Conservative measures include:

  • modification of medications that contribute to orthostasis
    • cardiovascular
    • psychotropic
    • anti-Parkinsonian
  • increasing fluid intake, eating small frequent meals to decrease postprandial hypotension
  • placing elastic stockings on the legs
  • elevating the head of bed 20 degrees to decrease early morning orthostasis.
The most commonly used medications for orthostatic hypotension in older patients are fludrocortisone and midodrine; they may cause hypokalemia and supine hypertension.

These drugs should usually be prescribed only by experienced practitioners.

  • Have patient rest supine for 5-10 minutes

  • Check blood pressure supine, then have patient stand up

  • Check blood pressure after one to three minutes of standing up

  • Ask about feeling faint or weak after meals

  • Re-arranged the medication schedule

  • Think of orthostasis as the reason for a variety of complaints

  • Start with basic conservative measures to correct orthostasis

  • In selected cases, use medications to treat orthostasis

References:

  1. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Neurology 1996; 46:1470.
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