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Non-pharmacological management of orthostatic hypotension in the older patient

  • Daniel J Ryan (a1), Conal J Cunningham (a1) and Chie Wei Fan (a1)
  • DOI: http://dx.doi.org/10.1017/S0959259811000220
  • Published online: 20 December 2011
Abstract
Summary

Orthostatic hypotension (OH) occurs in up to 30% of community-dwelling older people. Its presence confers a greater risk of incident co-morbid disease and all-cause mortality. As per guidelines, first-line treatment should consist of non-pharmacological therapies. Effective lifestyle modification advice includes the avoidance of rapid postural changes and large meals. Physical counter-manoeuvres, when comprehensively described, effectively abate symptom progression. Patients should drink 1.5 to 2 litres of water daily, though reports suggest only half of older people comply with this regime. Moderate salt consumption is advised, though with caution as supine hypertension often co-exists. Compression hosiery benefits older people and, contrary to popular opinion, is well tolerated. Potential, future therapies include impedance threshold devices. Older patients with OH frequently have co-morbid disease such that a pharmacological approach is ill-advised. They respond well to non-pharmacological therapies and these should form the primary therapeutic approach.

Copyright
Corresponding author
Address for correspondence: Dr Daniel Ryan, Falls and Blackouts Unit, St James Hospital, Dublin 8, Ireland. Email: d_jamesryan@yahoo.co.uk
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This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

2H Luukinen , K Koski , P Laippala , SL Kivela . Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med 1999; 159: 273–80.

3LM Allcock , K Ullyart , RA Kenny , DJ Burn . Frequency of orthostatic hypotension in a community-based cohort of patients with Parkinson's disease. J Neurol Neurosurg Psychiatry 2004; 75: 1470–71.

4S McIntosh , D Da Costa , RA Kenny . Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a ‘syncope’ clinic. Age Ageing 1993; 22: 5358.

6WB Applegate , BR Davis , HR Black , WM Smith , ST Miller , AJ Burlando . Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort. J Am Geriatr Soc 1991; 39: 1057–64.

8IO Poon , U Braun . High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther 2005; 30: 173–78.

9A Fedorowski , B Hedblad , G Engström , O Melander . Directionality of blood pressure response to standing may determine development of heart failure: prospective cohort study. Eur J Heart Failure 2011; 13: 496503.

10N Franceschini , KM Rose , BC Astor , D Couper , S Vupputuri . Orthostatic hypotension and incident chronic kidney disease. Hypertension 2010; 56: 1054–59.

11A Fedorowski , L Stavenow , B Hedblad , G Berglund , PM Nilsson , O Melander . Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). Eur Heart J 2010; 31: 8591.

12A Fedorowski , B Hedblad , G Engström , J Gustav Smith , O Melander . Orthostatic hypotension and long-term incidence of atrial fibrillation: the malmö preventive project. J Int Med 2010; 268: 383–89.

13GC Verwoert , FU Mattace-Raso , A Hofman , J Heeringa , BH Stricker , MM Breteler , JC Witteman . Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc 2008 56: 1816–20.

14P Gallagher , D O'Mahony . STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing 2008; 37: 673–79.

15H Hamilton , P Gallagher , C Ryan , S Byrne , D O'Mahony . Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 2011; 171: 1013–19.

17LL Pyszka , TM Seys Ranola , SM Milhans . Identification of inappropriate prescribing in geriatrics at a Veterans Affairs hospital using STOPP/START screening tools. Consult Pharm 2010; 25: 365–73.

18NS Beckett , R Peters , AE Fletcher , JA Staessen , L Liu , D Dumitrascu , V Stoyanovsky , RL Antikainen , Y Nikitin , C Anderson , A Belhani , F Forette , C Rajkumar , L Thijs , W Banya , CJ Bulpitt ; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. New Engl J Med 2008; 358: 1887–98.

19N van der Velde , AH van den Meiracker , HA Pols , BH Stricker , TJ van der Cammen . Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc 2007; 55: 734–39.

20AA Ejaz , WE Haley , A Wasiluk , JF Meschia , PM Fitzpatrick . Characteristics of 100 consecutive patients presenting with orthostatic hypotension. Mayo Clin Proc 2004; 79: 890–94.

21H Lahrmann , P Cortelli , M Hilz , CJ Mathias , W Struhal , M Tassinari . EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol 2006; 13: 930–36.

23A Pathak , M Lapeyre-Mestre , JL Montastruc , JM Senard . Heat-related morbidity in patients with orthostatic hypotension and primary autonomic failure. Mov Disord 2005; 20: 1213–19.

24RW Jansen , LA Lipsitz . Post-prandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med 1995; 122: 286–95.

25D O'Donovan , C Feinle , A Tonkin , M Horowitz , KL Jones . Post-prandial hypotension in response to duodenal glucose delivery in healthy older subjects. J Physiol 2002; 540: 673–79.

26KL Jones , D O'Donovan , A Russo , JH Meyer , JE Stevens , Y Lei , J Keogh , A Tonkin , M Horowitz . Effects of drink volume and glucose load on gastric emptying and postprandial blood pressure in healthy older subjects. Am J Physiol Gastrointest Liver Physiol 2005; 289: G24048.

27JR Shannon , A Diedrich , I Biaggioni , J Tank , RM Robertson , D Robertson , J Jordan . Water drinking as a treatment for orthostatic syndromes. Am J Med 2002; 112: 355–60.

28K Narkiewicz , RL Cooley , VK Somers . Alcohol potentiates orthostatic hypotension: implications for alcohol-related syncope. Circulation 2000; 101: 398402.

29W Wieling , JJ van Lieshout , AM van Leeuwen . Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Auton Res 1993; 3: 5765.

30CT Krediet , W Wieling . Manoeuvres to combat vasovagal syncope. Europace 2003; 5: 303.

31DG Ghrist , GE Brown . Postural hypotension with syncope: its successful treatment with ephidrin. Am J Med Sci 1928; 175: 336–49.

32WA Jeffers , H Montgomery , AC Burton . Types of orthostatic hypotension and their treatment. Am J Med Sci 1941; 202: 114.

34AG Bickelmann , EJ Lippschutz , CF Brunjes . Hemodynamics of idiopathic hypotension. Am J Med 1961; 30: 2638.

35AD Ten Harkel , JJ van Lieshout , W Wieling . Effects of leg-muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure. Clin Sci (Lond) 1994; 87: 553–58.

36JJ van Lieshout , AD ten Harkel , W Wieling . Physical manoeuvres for combating orthostatic dizziness in autonomic failure. Lancet 1992; 339: 897–98.

37CM Bouvette , BR McPhee , TL Opfer-Gehrking , PA Low . Role of physical countermaneuvers in the management of orthostatic hypotension: efficacy and biofeedback augmentation. Mayo Clin Proc 1996; 71: 847–53.

38I Biaggioni , DS Goldstein , T Atkinson , D Robertson . Dopamine-beta-hydroxylase deficiency in humans. Neurology 1990; 40: 370–73.

39S Takishita , T Touma , N Kawazoe , H Muratani , K Fukiyama . Usefulness of leg-crossing for maintaining blood pressure in a sitting position in patients with orthostatic hypotension – case reports. Angiology 1991; 42: 421–25.

40N van Dijk , F Quartieri , JJ Blanc , R Garcia-Civera , M Brignole , A Moya , W Wieling ; PC-Trial Investigators. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial). J Am Coll Cardiol 2006; 48: 1652–57.

41C Podoleanu , R Maggi , M Brignole , F Croci , A Incze , A Solano , E Puggioni , E Carasca . Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study. J Am Coll Cardiol 2006; 48: 1425–32.

42JJ Figueroa , JR Basford , PA Low . Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med 2010; 77: 298306.

43J Jordan , JR Shannon , E Grogan , I Biaggioni , D Robertson . A potent pressor response elicited by drinking water. Lancet 1999; 353: 723.

44PE Cryer , MW Haymond , JV Santiago , SD Shah . Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med 1976; 295: 573–77.

45NL Benowitz . Clinical pharmacology of nicotine. Ann Rev Med 1986; 37: 2132.

46D Robertson Robertson , JC Frölich , RK Carr , JT Watson , JW Hollifield , DG Shand , JA Oates . Effects of caffeine on plasma renin activity, catecholamines and blood pressure. N Engl J Med 1978; 298: 181–86.

47VE Claydon , C Schroeder , LJ Norcliffe , J Jordan , R Hainsworth . Water drinking improves orthostatic tolerance in patients with posturally related syncope. Clin Sci (Lond) 2006; 110: 343–52.

48J Jordan , JR Shannon , BK Black , Y Ali , M Farley , F Costa , A Diedrich , RM Robertson , I Biaggioni , D Robertson . The pressor response to water-drinking in humans: a sympathetic reflex? Circulation 2000; 101: 504–9.

49J Tank , C Schroeder , M Stoffels , A Diedrich , AM Sharma , FC Luft , J Jordan . Pressor effect of water-drinking in tetraplegic patients may be a spinal reflex. Hypertension 2003; 41: 1234–39.

50C Schroeder , VE Bush , LJ Norcliffe , FC Luft , J Tank , J Jordan , R Hainsworth . Water-drinking acutely improves orthostatic tolerance in healthy subjects. Circulation 2002; 106: 2806–11.

51CW Fan , C Walsh , CJ Cunningham . The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial. Age Ageing 2011: 40: 187–92.

52EM Scott , JP Greenwood , SG Gilbey , JB Stoker , DA Mary . Water ingestion increases sympathetic vasoconstrictor discharge in normal human subjects. Clin Sci (Lond) 2001; 100: 335–42.

53R Joannides , N Moore , V de la Gueronniere , C Thuillez . Effect of water on arteries. Lancet 1999; 354: 516.

54P Flevari , K Fountoulaki , D Leftheriotis , C Komporozos , J Lekakis , D Kremastinos . Vasodilation in vasovagal syncope and the effect of water ingestion. Am J Cardiol 2008; 102: 1060–63.

55Y Endo , K Yamauchi , Y Tsutsui , Z Ishihara , F Yamazaki , S Sagawa , K Shiraki . Changes in blood pressure and muscle sympathetic nerve activity during water drinking in humans. Jpn J Physiol 2002; 52: 421–27.

56P Rossi , GI Andriesse , PL Oey , GH Wieneke , JM Roelofs , LM Akkermans . Stomach distension increases efferent muscle sympathetic nerve activity and blood pressure in healthy humans. J Neurol Sci 1998; 161: 148–55.

57A Lipp , J Tank , G Franke , G Arnold , FC Luft , J Jordan . Osmosensitive mechanisms contribute to the water-drinking-induced pressor response in humans. Neurology 2005; 65: 905–7.

58CJ Mathias . A 21st century water cure. Lancet 2000; 356: 1046–48.

59D Denton , R Weisinger , NI Mundy The effect of increased salt intake on blood pressure of chimpanzees. Nat Med 1995; 1: 1009–16.

60P Elliott , J Stamler , R Nichols , AR Dyer , R Stamler , H Kesteloot , M Marmot . Intersalt revisited: further analyses of 24-hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group. BMJ 1996; 312: 1249–53.

61K Stolarz-Skrzypek , T Kuznetsova , L Thijs , V Tikhonoff , J Seidlerová , T Richart , Y Jin , A Olszanecka , S Malyutina , E Casiglia , J Filipovský , K Kawecka-Jaszcz , Y Nikitin , JA Staessen ; European Project on Genes in Hypertension (EPOGH) Investigators. Fatal and non-fatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA 2011; 305: 1777–85.

62AL Mark , WJ Lawton , FM Abboud , AE Fitz , WE Connor , DD Heistad . Effects of high and low sodium intake on arterial pressure and forearm vascular resistance in borderline hypertension. A preliminary report. Circ Res 1975; 36 (suppl 1): 194–98.

64M Shichiri , H Tanaka , R Takaya , H Tamai . Efficacy of high sodium intake in a boy with instantaneous orthostatic hypotension. Clin Auton Res 2002; 12: 4750.

65H El-Sayed , R Hainsworth . Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart 1996; 75: 134–40.

66BL Mtinangi , R Hainsworth . Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope. Clin Auton Res 1998; 8: 231–35.

67VL Cooper , R Hainsworth . Effects of dietary salt on orthostatic tolerance, blood pressure and baroreceptor sensitivity in patients with syncope. Clin Auton Res 2002; 12: 236–41.

68VE Claydon , R Hainsworth . Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope. Hypertension 2004; 43: 809–13.

71CJ Mathias , JR Kimber . Postural hypotension: causes, clinical features, investigation, and management. Ann Rev Med 1999; 50: 317–36.

72O Oldenburg , A Kribben , D Baumgart , T Philipp , R Erbel , MV Cohen . Treatment of orthostatic hypotension. Curr Opin Pharmacol 2002; 2: 740–47.

75JC Denq , TL Opfer-Gehrking , M Giuliani , J Felten , VA Convertino , PA Low . Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res 1997; 7: 321–26.

77E Stead , R Ebert . Postural hypotension: a disease of the sympathetic nervous system. Arch Intern Med 1941; 67: 546–62.

78H Tanaka , H Yamaguchi , H Tamai . Treatment of orthostatic intolerance with an inflatable abdominal band. Lancet 1997; 349: 175.

79AA Smit , W Wieling , J Fujimura , JC Denq , TL Opfer-Gehrking , M Akarriou , JM Karemaker , PA Low . Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res 2004; 14: 167–75.

80R Henry , J Rowe , D O'Mahony . Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension. Lancet 1999; 354: 4546.

81O Gorelik , D Almoznino-Sarafian , V Litvinov , I Alon , M Shteinshnaider , E Dotan , D Modai , N Cohen . Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging. Gerontology 2009 55: 138–44.

83W Wieling , JJ Van Lieshout , R Hainsworth . Extracellular fluid volume expansion in patients with posturally-related syncope. Clin Auton Res 2002; 12: 242–49.

84AR MacLean , EV Allen . Orthostatic hypotension and orthostatic tachycardia: treatment with the ‘head-up’ bed. JAMA 1940; 115: 2162–67.

85JJ van Lieshout , AD ten Harkel , W Wieling . Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res 2000; 10: 3542.

86VA Convertino , DA Ratliff , J Crissey , DF Doerr , AH Idris , KG Lurie . Effects of inspiratory impedance on hemodynamic responses to a squat-stand test in human volunteers: Implications for treatment of orthostatic hypotension. Eur J Appl Physiol 2005; 94: 392–99.

87VA Convertino , DA Ratliff , KL Ryan , DF Doerr , DA Ludwig , GW Muniz , DL Britton , SD Clah , KB Fernald , AF Ruiz , KG Lurie , AH Idris . Hemodynamics associated with breathing through an inspiratory impedance threshold device in human volunteers. Crit Care Med 2004; 32 (suppl): S38186.

88DP Melby , F Lu , S Sakaguchi , M Zook , DG Benditt . Increased impedance to inspiration ameliorates hemodynamic changes associated with movement to upright posture in orthostatic hypotension: a randomized blinded pilot study. Heart Rhythm 2007; 4: 128–35.

89K Lurie , W Voelckel , P Plaisance , T Zielinski , S McKnite , D Kor , A Sugiyama , P Sukhum . Use of an inspiratory impedance threshold valve during cardiopulmonary resuscitation: A progress report. Resuscitation 2000; 44: 219–30.

90S Mittal . Managing orthostatic hypotension: is this inspiration the answer? Heart Rhythm 2007; 4: 128–35.

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