Orthostatic Hypotension
Orthostatic hypotension or postural hypotension is defined as a drop in systolic blood pressure of 20mm Hg or more, or a systolic pressure of less than 90mm Hg within three minutes of standing relative to blood pressure measured supine. The drop in systolic pressure may or may not be accompanied by symptoms such as lightheadedness, dizziness, weakness, nausea or syncope. Among older adults, orthostatic hypotension is associated with an increased risk of falling, stroke and myocardial infarction. While orthostatic hypotension may be a symptom of primary autonomic dysfunction, it is more commonly associated with chronic diseases (e.g. diabetes, renal failure, Parkinson’s disease), dehydration, use of antihypertensive and antidepressant medications that may further compromise underlying autonomic dysfunction, and de-conditioning. Studies have shown that the incidence of postural hypotension increases with age and frailty. Among adults aged >65 years prevalence is approximately 20%; in those aged >75 years approximately 30%; and as high as 50% among institutionalized frail older adults living in long term care. Treatment begins with non-pharmacologic measures and may include withdrawal of any medication that could contribute to the problem, fluid replacement in those diagnosed with dehydration, increased salt intake, physical maneuvers, compression stockings, and regular exercise. If non-pharmacological measures fail, pharmacologic agents may be used. 1
The increased incidence of postural hypotension among older adults and its association with increased risk of falling underscores the importance of checking postural blood pressures as part of a comprehensive falls risk assessment. Interventions include a review of all medications with the elimination of offending medications as possible; prescribing the lowest dose of the fewest number of medications; physical counter maneuvers (e.g. ankle pumps, upper extremity movements) with habitual getting up slowly when moving supine to standing; hydration; and reconditioning exercise regimens. Visit the CCFP website (www.fallprevention.org) for more information
Measuring Postural Blood Pressure
•Measure blood pressure after lying quietly supine for five minutes.
•Recheck blood pressure immediately upon standing.
•Recheck again after two minutes standing.
If the systolic blood pressure drops 20mm Hg OR is less than 90 mmHg, relative to the pressure measured supine, the reading is considered positive. All older adults should have their postural blood pressure measured at least yearly. Simply asking if one feels dizzy or lightheaded upon standing is not sufficient to detect postural hypotension as many older adults may not have obvious symptoms.
One barrier to checking for postural hypotension, particularly where older adults routinely get blood pressures checked such as in senior centers, has been the lack of a place to rest supine. A portable massage table works well and some senior centers in the greater Hartford area have purchased one just for this purpose.
For more information about the Connecticut Collaboration for Fall Prevention, visit the website www.fallprevention.org or call 203-737-2109 ©2005, Mary E. Tinetti, M.D.
1Gupta V, Lipsitz LA. Orthostatic Hypotension in the Elderly: Diagnosis and Treatment. The American Journal of Medicine. 2007;120: 841-847.
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