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Orthostatic hypotension in older patients

Part of: Bespoke shallow archive Weizmann

Published online by Cambridge University Press:  01 November 2007

Fiona Kearney ,
Alan Moore  and
Ciaran Donegan
Fiona Kearney
Affiliation:
Beaumont Hospital, Dublin, Ireland
Alan Moore*
Affiliation:
Beaumont Hospital, Dublin, Ireland
Ciaran Donegan
Affiliation:
Beaumont Hospital, Dublin, Ireland
*
Address for correspondence: A Moore, Dept of Geriatric Medicine, Beaumont Hospital, Dublin 9, Ireland.
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Extract

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume. In younger and middle-aged adults, the presence of OH should not be considered a primary diagnosis in itself but rather a starting point in the diagnostic pathway before the primary underlying abnormality has been identified. In older patients however, asymptomatic blood pressure drops are very frequently encountered so that, in certain cases, an exhaustive diagnostic search for an underlying cause is not warranted. However, reversible causes of OH do frequently exist in older patients. Prominent among these are the use of several commonly prescribed cardiovascular drugs and vitamin B12 deficiency.

Type
Clinical geriatrics
Information
Reviews in Clinical Gerontology , Volume 17 , Issue 4 , November 2007 , pp. 259 - 275
Copyright
Copyright © Cambridge University Press 2008

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References

1Tilvis, RS, Hakala, S-M, Valvanne, J, Erkinjuntti, T. Postural hypotension and dizziness in a general aged population: A four-year follow-up of the Helsinki Aging Study. J Am Geriatr Soc 1996; 44: 809–14.Google Scholar
2Raiha, I, Luutonen, S, Piha, J, Seppanen, A, Toikka, T, Sourander, L. Prevalence, predisposing factors and prognostic importance of postural hypotension. Arch Intern Med 1995; 155: 930–35.Google Scholar
3Tinetti, ME, Williams, TF. Fall-risk index for elderly patients based on number of chronic disabilities. Am J Med 1986; 80: 429–34.Google Scholar
4Kapoor, WN, Karpf, M, Wieland, S, Peterson, J, Levey, GS. A prospective evaluation and follow-up of patients with unexplained syncope. N Eng J Med 1983; 309: 197–204.CrossRefGoogle Scholar
5The Consensus Committee Statement of the American Autonomic Society and American Academy of Neurology. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple-system atrophy. Neurology 1996; 46: 1470.CrossRefGoogle Scholar
6Macrae, AD, Bulpitt, CJ. Assessment of postural hypotension in elderly patients. Age Ageing 1989; 9: 17–24.Google Scholar
7Mathias, CJ, Bannister, R. Autonomic Failure: a textbook of clinical disorders of the autonomic nervous system, fourth edition. Oxford University Press 2001: 171–81.Google Scholar
8Ward, C, Kenny, RA. Reproducibility of orthostatic hypotension in symptomatic elderly. Am J Med 1996; 100: 418–22CrossRefGoogle ScholarPubMed
9Thulesius, O. Pathophysiological classification and diagnosis of orthostatic hypotension. Cardiology 1976; 61 (suppl 1): 180–90.Google Scholar
10Gibbons, CH, Freeman, R. Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology 2006; 67: 28–32.CrossRefGoogle ScholarPubMed
11Wieling, W, Krediet, CT, van Dijk, N, Linzer, M, Tschakovsky, ME. Initial orthostatic hypotension: a review of a forgotten condition. Clin Sci (Lond) 2007; 112: 157–65.Google Scholar
12Deegan, BM, O' Connor, M, Lyons, D, O'Laighin, G. A new blood pressure and heart rate signal analysis technique to assess orthostatic hypotension and its subtypes. Conf Proc Eng Med Biol Soc 2007; 2007: 935–38.Google Scholar
13Atkins, D, Hanus, B, Kapoor, W. Syncope and orthostatic hypotension Am J Med 1991; 91: 179–84.Google Scholar
14Alli, C, Avanzini, F, Bettelli, G et al. Prevalence and variability of orthostatic hypotension in the elderly. Results of the Italian Study on Blood Pressure in the Elderly. Eur Heart J 1992; 13: 178–82.Google Scholar
15McIntosh, S, Da Costa, D, Kenny, RA. 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: 53–58.Google Scholar
16Ensrud, KE, Nevitt, MC, Yunis, C et al. Postural hypotension and postural dizziness in elderly women: The study of osteoporotic fractures. Arch Intern Med 1992; 152: 1058–62.CrossRefGoogle ScholarPubMed
17Jin-Shang, Wu, Feng-Hwa, L, Yi-Ching, Y, Chih-Jen, C. Postural hypotension and postural dizziness in patients with diabetes mellitus. Arch Intern Med 1999; 159: 1350–356.Google Scholar
18Hilstead, J, Low, PA. Diabetic autonomic neuropathy. In: Low, PA ed. Clinical autonomic disorders: evaluation and management, second edition. Philadelphia, Pa: Lipincott Raven, 1997: 487–507.Google Scholar
19DeKanter, M, Lilja, B, Elmstahl, S, Eriksson, K-F, Sundkvist, G. A prospective study of orthostatic blood pressure in diabetic patients. Clin Aut Res 1998; 8: 189–93.Google Scholar
20Rutan, GH, Hermanson, B, Bild, DE, Kittner, SJ, LaBaw, F, Tell, GS. Orthostatic hypotension in older adults: the Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension 1992; 19: 508–19.Google Scholar
21Applegate, WB, Davis, BR, Black, HR et al. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort. J Am Geriatr Soc 1991; 39: 1057–64.Google Scholar
22Lipsatz, LA, Storch, HA, Minaker, KL, Rowe, JW. Intra-individual variability in postural blood pressure in the elderly. Clin Sci 1985; 69: 337–41.Google Scholar
23Gribben, B, Pickering, TG, Sleight, P, Peto, R. Effect of age and high blood pressure on baroreflex sensitivity in man. Circ Res 1971; 29: 424–31.Google Scholar
24Luukinen, H, Koshi, K, Laippala, P, Sirkka-Lusa, K. Prognosis of diastolic and systolic hypotension in older persons. Arch Intern Med 1999; 159: 273–79.Google Scholar
25Davis, BR, Langford, HG, Blaufox, MD et al. The association of postural changes in systolic blood pressure and mortality in persons with hypertension: The Hypertension Detection and Follow-Up Program experience. Circulation 1987; 75: 340–46.CrossRefGoogle ScholarPubMed
26Sheldon, JH. On the natural history of falls in old age. BMJ 1960; 2: 1685–90.Google Scholar
27Salgrado, R, Lord, SJ, Packer, J, Ehrlich, F. Factors associated with falling in elderly hospital patients. Gerontology 1994; 40: 325–31.Google Scholar
28Heitterachi, E, Lord, SR, Myerkort, P, McCloskey, I, Fitzpatrick, R. Blood-pressure changes on upright-tilting predicts falls in older people. Age Ageing 2002; 31: 181.Google Scholar
29Self, DA, White, CD, Shaffstall, R et al. Differences between syncope resulting from rapid onset acceleration and orthostatic hypotension. Aviat Space Envir Med 1996;67: 547–54.Google Scholar
30Asmussen, E. The distribution of the blood between the lower extremities and the rest of the body. Acta Physiol Scand 1943; 5: 31–38.CrossRefGoogle Scholar
31Ebert, TJ, Smith, JJ, Barney, JA, Merrill, DC, Smith, GK. The use of thoracic impedance for determining thoracic blood volume in man. Aviat Space Environ Med 1986; 57: 49–53.Google Scholar
32Ludbrook, J. The musculoskeletal pumps of the human lower limb. Am Heart J 1966; 71: 635–41.Google Scholar
33Ludbrook, J, Loughlin, J. Regulation of volume in the lower-limb post-arteriolar vessels in the lower limb. Am Heart J 1964; 67: 493–507.Google Scholar
34Wolthius, RA, LeBlanc, A, Carpentier, WA, Bergman, SA Jr. Response of local vascular volumes to lower-body negative pressure stress. Aviat Space Environm Med 1975; 46: 697–702.Google Scholar
35Asmussen, E, Christensen, EH, Nielsen, M. The regulation of circulation in different postures. Surgery 1940; 8: 604–16.Google Scholar
36Buckley, JC, Peshock, RM, Blomqvist, CG. Deep venous contribution to hydrostatic blood volume change in the human leg. Am J Cardiol 1988; 62: 449–53.Google Scholar
37Halliwill, JR, Lawlor, LA, Eickhoff, TJ, Joyner, MJ, Mulvagh, SI. Reflex responses to regional venous pooling during lower-body negative pressure in humans. J Appl Physiol 1998; 84: 454–58.Google Scholar
38Lundvall, J, Bjerkhoel, P, Quittenbaum, S, Lindgren, P. Rapid plasma-volume decline upon quiet standing reflects large filtration capacity in dependent limbs. Acta Physiol Scand 1996; 158: 161–67.CrossRefGoogle ScholarPubMed
39Hendricksen, O, Skagen, K. Local and central sympathetic vasoconstrictor reflexes in human limbs during orthostatic stress. In: Christensen, NJ, Hendriksen, O, Lassen, NA eds. The sympathorenal system, Alfred Benzon Symposium 23. Munksgaard, Copenhagen: 1999: 83–94.Google Scholar
40Rowell, LB.Human cardiovascular control. Oxford University Press, New York, N.Y. 1993.Google Scholar
41Chaudhuri, KR, Thomaides, T, Mathias, CJ. Abnormality of superior mesenteric artery blood-flow responses in human sympathetic failure. J Physiol 1992; 457: 477–89.CrossRefGoogle ScholarPubMed
42Skagen, K, Bonde-Petersen, F. Regulation of subcutaneous blood flow during head-up tilt (45 degrees) in normals. Acta Physiol Scand 1982; 114: 31–35.Google Scholar
43Hendricksen, O, Sjersen, P. Local reflex in microcirculation in human skeletal muscle. Acta Physiol Scand 1977; 99: 19–26.Google Scholar
44Hesse, B, Stadeager, C, Rasmussen, S et al. Relative roles of adrenergic mechanisms and the renin-angiotensin system for circulatory adaptation to gravitational stress. In: Christensen, NJ, Hendriksen, O, Lassen, NA eds. The sympathoadrenal system. Alfred Benzon Symposium 23. Munksgaard, Copenhagen: 1999: 129–140.Google Scholar
45Bennet, T, Gardiner, SM. Involvement of vasopressin in cardiovascular regulation. Cardiovasc Res 1985; 19: 57–68.CrossRefGoogle Scholar
46Wieling, W, Wesseling, KH. Importance of reflexes in the circulatory adjustments to postural changes. In: Hainsworth, R, Mark, AL eds,: Cardiovascular reflex control in health and disease, London : WB Saunders, 1993: 35–63.Google Scholar
47Collins, KJ, Exton-Smith, AN, James, MH. Functional changes in autonomic nervous responses with ageing. Age Ageing 1980; 9: 17.CrossRefGoogle ScholarPubMed
48Lyons, D, Roy, S, Patel, M, Benjamin, N, Swift, CG. Impaired nitric oxide-mediated vasodilatation and total body nitric oxide production in healthy old age. Clin Sci 1997; 93: 519–22.Google Scholar
49Hickman, JB, Pryor, WW. Cardiac output in postural hypotension. J Clin Invest 1951; 30: 401–05.Google Scholar
50Bevegard, BS, Jonsson, B, Karlof, I. Circulatory responses to recumbent exercise and head-up tilting in patients with disturbed sympathetic control (postural hypotension). Observations on the effect of norepinephrine infusion and anti-gravity-suit-inflation in the head-up tilt position. Acta Med Scand 1962; 172: 623–36.Google Scholar
51Novak, V, Novak, P, Spies, JM, Low, PA. Autoregulation of cerebral blood flow in orthostatic hypotension. Stroke 1998; 29: 104–11.Google Scholar
52Jacob, G, Atkinson, D, Jordan, J et al. Effects of standing on cerebrovascular resistance on patients with idiopathic orthostatic intolerance. Am J Med 1999; 106: 59–64.Google Scholar
53Passaunt, U, Warkentin, S, Minthon, L, Faldt, R, Edvinsson, L. Cortical blood flow during head-up postural change in patients with orthostatic hypotension. Clin Auton Res 1993: 3: 311–18.Google Scholar
54Morillo, CA, Eckberg, DL, Ellenbogen, KA et al. Vagal and sympathetic mechanisms in patients with orthostatic vasovagal syncope. Circulation 1997; 96: 2509–13.Google Scholar
55Zerbe, R, Henry, DP, Robertson, G. Vasopressin response to orthostatic hypotension. Am J Med 1983; 74: 265–72.Google Scholar
56Kaufmann, H, Oribe, E, Oliver, JA. Plasma endothelin during upright tilt: relevance for orthostatic hypotension? Lancet 1991; 338: 1542–45.Google Scholar
57Kihara, M, Nakasaka, Y, Mitsui, Y, Takahashi, M, Schmelzer, JD. Ageing differentially modifies sensitivity of nerve blood flow to vasocontractile agents (endothelin-1, noradrenaline and angiotensin II) in sciatic nerve. Mech Ageing Devel 2000; 114: 5–14.Google Scholar
58Tunny, TJ, Gordon, RD, Klemm, SA, Bachmann, AW, Finn, WL. Inappropriately elevated levels of atrial naturetic peptide may contribute to the pathophysiology of orthostatic hypotension. Clin Exp Pharm Pharm 1992; 19: 283–86.Google Scholar
59Jacob, G, Robertson, D, Mosqueda-Garcia, R, Ertl, AC, Robertson, RM, Biaggoni, I. Hypovolaemia in syncope and orthostatic intolerance: role of the renin-angiotensin system. Am J Med 1997; 103: 128–33.Google Scholar
60Jacob, G, Biaggoni, I, Mosqueda-Garcia, R, Robertson, RM, Robertson, D. Relation of blood volume and blood pressure. J Am Med Sci 1998; 315: 95–101.Google Scholar
61Chobanian, AV, Tifft, CP, Sackel, H, Pitruzella, A. Alpha and beta adrenergic receptor activity in circulating blood cells in patients with idiopathic orthostatic hypotension and phaeochromocytoma. Clin Exp Hypertens 1982; (4&5): 793–806.Google Scholar
62Wynne, HA, Schofield, S. Drug-induced orthostatic hypotension. In: Kenny, RA, ed. Syncope in the older patient: causes, investigations and consequences of syncope and falls. London: Chapman & Hall, 1996: 137–54.Google Scholar
63van der Velde, N, van der Meiracker, AH, Pols, HAP, Stricker, HC, van der Cammen, TJ. Withdrawal of fall-risk-increasing-drugs in older persons: effect on tilt-table test outcomes. 2007; 55: 734–39.Google Scholar
64Raftos, J. Verapamil in the treatment of angina pectoris. Med J Aust 1980; 2: 78–80.Google Scholar
65Lewis, JG. Adverse reactions to calcium antagonists. Drugs 1983; 25: 196–222.Google Scholar
66Andros, E, Detmar-Hanna, D, Suteparuk, S, Gal, S, Gerber, JG. The effect of ageing on the pharmacokinetics and pharmacodynamics of prazocin. Eur J Clin Pharmacol 1996; 50: 41–6.Google Scholar
67Rosenthal, J. A multicenter trial of doxazocin in West Germany. Am J Cardiol 1987; 59: 40G–9G.Google Scholar
68Davidson, E, Fuchs, J, Rotenberg, Z et al. Drug-related syncope. Clin Cardiol 1989; 12: 577–80.Google Scholar
69Reid, J, Lees, KR, Squire, I. First-dose hypotension and ACE inhibitors in heart failure. Clinical relevance and implications. Chester, UK : Adis International Ltd, 1995.Google Scholar
70Squire, IB, MacFayden, RJ, Reid, JL, Devlin, A, Lees, KR. Differing early blood pressure and rennin-angiotensin system responses to the first dose of angiotensin-converting enzyme inhibitors in congestive heart failure. J Cardiovasc Pharmacol 1996; 27: 657–66.Google Scholar
71Bagger, J. Adverse events with first-dose perindopril in congestive heart failure. Lancet 1997; 350: 520–22.Google Scholar
72Dahlof, B, Devereux, RB, Kjeldsen, SE et al. Cardiovascular mortality and morbidity in the Losartan Intervention for Endpoint Eduction in Hypertension (LIFE) Study: randomised trial against atenolol. Lancet 2002; 359: 995–103.Google Scholar
73Mogensen, CE, Neldam, S, Tikkanen, I et al. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin-dependent diabetes: the Candesartan and Lisinopril Microalbuminuria (CALM) Study. BMJ 2000; 321: 1440–44.Google Scholar
74Bannister, R, Mathias, C. Investigation of auonomic disorders. In: Autonomic failure, a textbook of clinical disorders of the autonomic nervous system, third edition. Oxford: Oxford University Press, 2001: 260–62.Google Scholar
75Kenny, RA, Bayliss, J, Ingram, A, Sutton, R. Head-up tilt-table testing: a useful test for investigating unexplained falls. Lancet 1986; i: 1352–54.Google Scholar
76Jansen, JRC, Schreuder, JJ, Mulier, JP, Smith, NT, Settels, JJ, Wesseling, KH. A comparison of cardiac output derived from the arterial-pressure wave against thermodilution in cardiac surgery patients. Br J Anaesth 2001; 87: 212–22.Google Scholar
77Caine, S, Alsop, K, MacMahon, M. Overlooking orthostatic hypotension with routine blood pressure equipment. Lancet 1998; 352: 458.Google Scholar
78Patel, A, Maloney, A, Damato, AN. On the frequency and reproducibility of orthostatic blood pressure changes in healthy community-dwelling elderly during 60-degree head-up tilt. Am Heart J 1993; 126: 184–88.Google Scholar
79Hainsworth, R, Al-Shamma, YMH. Cardiovascular responses to upright tilting in healthy subjects. Clin Sci 1988; 74: 17–22.Google Scholar
80Wahbha, MM, Morley, CA, Al-Shamma, YMH, Hainsworth, R. Cardiovascular reflex responses in patients with unexpained syncope. Clin Sci 1989; 77: 547–53.Google Scholar
81Almqvist, A, Goldenberg, IF, Milstein, S et al. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Eng J Med 1989; 320: 346–51.Google Scholar
82El-Bedawi, KM, Hainsworth, R. Combined head-up tilt and lower body suction: a test of orthostatic tolerance. Clin Aut Res 1994; 4: 41–47.Google Scholar
83Low, PA, Gilden, JL, Freeman, R, Sheng, K-N, McElligott, MA. Efficacy of midodrine vs. placebo in neurogenic orthostatic hypotension: a randomised double-blind multicentre study. JAMA 1997; 277: 1046–51.Google Scholar
84Low, PA, Opfer-Gehrking, TL, Textor, SC et al. The grading of orthostatic intolerance and orthostatic grade by tilt-up. Neurology 1995; (suppl 5): S19–S25.Google Scholar
85Henry, R, Rowe, J, O'Mahony, D. Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension. Lancet 1999; 354: 45–6.Google Scholar
86Wieling, W, van Lieshout, JJ, van Leuven, AM. Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Aut Res 1993; 3: 57–65.Google Scholar
87Bouvette, CM, McPhee, BR, Opfer-Gehrking, TL, Low, PA. The use of physical counter-manoeuvres in the management of orthostatic hypotension: efficacy and biofeedback augmentation. Mayo Clin Proc 1996;71: 847–53.Google Scholar
88Van Lieshout, JJ, Ten Harkel, ADJ, Wieling, W. Combating orthostatic dizziness in autonomic failure by physical manoeuvres. Lancet 1992; 339: 897–98.Google Scholar
89Takishita, S, Touma, T, Kawazoe, N, Muratani, H, Fukiyami, K. Usefulness of leg-crossing for maintaining blood pressure in a sitting position in patients with orthostatic hypotension–case reports. Angiology 1991; 42: 421–25.Google Scholar
90Mtinangi, BL, Hainsworth, R. Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope. Clin Auton Res 1998; 8: 231–35.Google Scholar
91Oribe, E, Kaufmann, H, Winters, S et al. Fludrocortisone versus beta-adrenergic blockers in the treatment of vasovagal syncope. Neurology 1992; (suppl 3): 213.Google Scholar
92van Liieshout, JJ, ten Harkel, AD, Wieling, W. Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output autonomic failure. Clin Auton Res 2000; 10: 35–42.Google Scholar
93Davies, IB, Bannister, R, Sever, PS et al. The pressor actions of noradrenaline, angiotensin II and saralasin in chronic autonomic failure treated with fludrocortisone. Br J Clin Pharmacol 1979; 8: 253–60.Google Scholar
94Senard, JM, Montastruc, JL. Which drug for which orthostatic hypotension? Fundam Clin Pharmacol 1996; 10: 225–33.Google Scholar
95Robertson, D, Goldberg, MR, Hollister, AS, Wade, D, Robertson, RM. Clonidine raises blood pressure in severe idiopathic hypotension. Am J Med 1983; 74: 193–99.Google Scholar
96Thulesius, O, Giores, JE, Berlin, E. Vasoconstrictor effects of midodrine, ST 1059, noradrenaline, etilifrine and dihydroergotamine on isolated human veins Eur J Clin Pharmacol 1979; 16: 423–24.Google Scholar
97Hoeldtke, RD, Davis, KM, Joseph, J, Gonzales, R, Panidis, IP, Friedman, AC. Haemodynamic effects of octreotide in patients with autonomic neuropathy. Circulation 1991; 84: 168–76.Google Scholar
98Bordet, R, Verwaerde, P, Tran, MA, Marques, MA, Montastruc, JL, Senard, JM. Effects of octreotide on experimental neurogenic orthostatic hypotension in anaesthetized dogs. Fund Clin Pharmacol 1997; 11: 237–44.Google Scholar
99Dusl, RJ, Anderson, DS, Forsythe, AB et al. Treatment of diabetic diarrhoea and orthostatic hypotension with somatostatin analogue ‘SMS 201–295’ Am J Med 1987; 83: 584–88.Google Scholar
100Bordet, R, Benhadjali, J, Liberesa, L et al. Octreotide in orthostatic hypotension in patients with multiple system atrophy. Clin Neuropharmacol 1995; 18: 83–89.Google Scholar
101Hoeldtke, RD, Horvath, GG, Bryner, KD, Hobbs, . Treatment of orthostatic hypotension with midodrine and octreotide. J Clin Endocrinol Metab 1998; 83: 339–43.Google Scholar
102O'Mara, G, Lyons, D. Postprandial hypotension. Clin Geriatr Med 2002; 18: 307–21.Google Scholar
103Youde, J, Ruse, C, Parker, S, Fotherby, M. A high diagnostic rate in older patients attending an integrated syncope clinic. J Am Ger Soc 2000; 48: 783–87.CrossRefGoogle ScholarPubMed