Orthostatic Hypotension (Low blood pressure)

What is Orthostatic Hypotension (Low blood pressure)?

Orthostatic hypotension, also known as postural hypotension, is a condition where your blood pressure drops significantly when you stand up. This condition can affect your quality of life and can increase the risk of falls, heart diseases, dementia, depression, and even death. It is defined as a sharp drop in blood pressure when you shift from sitting or lying down to standing up. Medically, it’s identified when either the top or bottom number of your blood pressure falls by at least 20 or 10 points respectively within three minutes of standing, after you’ve been lying down for five minutes or you’ve been at a 60-degree angle on a tilt table. Usually, this drop in blood pressure happens due to a failure in the body’s automatic reflex, loss of body fluid, or a negative reaction to certain medications.

Typically, symptoms relate to insufficient blood supply to the brain, but sometimes there might be no symptoms at all. It is important to note that this condition is linked to a high risk of health problems and death, commonly due to frequent falls resulting in multiple hospital visits.

Proactive detection in individuals with certain risk factors or symptoms may lead to better health outcomes and avoidance of some complications. Current best practices for identifying and managing orthostatic hypotension are varied and not strongly backed by scientific evidence. However, primary care providers play an essential role in checking for and identifying orthostatic hypotension, as well as assisting patients in making collaborative decisions on managing symptoms and reducing risks.

Orthostatic hypotension occurs due to an unsatisfactory physical response to changes in blood pressure when you stand up. Symptoms may or may not be present, and the condition might be temporary or long-term. In younger patients without fluid loss, chronic failure of the autonomic nervous system is often the cause. Elderly patients and those with autonomic failure often experience a related problem called postprandial hypotension, where the top number of their blood pressure drops by at least 20 points within an hour and a quarter after eating a meal.

What Causes Orthostatic Hypotension (Low blood pressure)?

Orthostatic hypotension, a lowering of blood pressure when standing up, can have many causes. Some relate to neurological issues while others do not, and sometimes the condition can be a side effect of certain medications. Neurological causes could include diseases that damage the nerves, degenerative brain diseases, or simply aging. Examples include diabetes, autoantibodies that affect the nerves, and certain genetic conditions. Degenerative brain diseases include Parkinson’s disease, diseases affecting multiple systems in the body, and pure loss of autonomic function.

Non-neurological causes are usually related to a decrease in body fluids. Additionally, medications can often cause orthostatic hypotension. This is particularly true in older people who are taking multiple medications simultaneously.

Orthostatic hypotension happens due to abnormal or delayed reactions to changes in fluid levels in the body when you stand up. A dramatic drop in blood pressure can occur when standing, causing this condition. There are two types of responses: “classic” orthostatic hypotension that occurs within three minutes of standing, and “delayed” orthostatic hypotension that occurs after three minutes. Most research has been on “classic” orthostatic hypotension, meaning there’s less information on the “delayed” type.

Here’s a list of common causes for orthostatic hypotension:

Neurological Causes:

1. Degenerative brain diseases such as Parkinson’s disease.
2. Peripheral nerve disease from conditions like diabetes or vitamin B12 deficiency.

Non-neurological Causes:

1. Decreased body fluids from causes like anemia or dehydration.
2. Cardiovascular diseases like aortic stenosis or heart failure.
3. Other reasons including adrenal insufficiency or simply aging.

Either Mechanism:

1. Medicated-related causes, which could be any type of medication from alpha-blockers to beta-blockers.
2. Alcohol consumption, either in the short-term or chronic.

Some people may have orthostatic hypotension without any known cause. Certain medications might cause orthostatic hypotension as a side effect. Whether or not people will develop orthostatic hypotension can depend on individual susceptibility, other health conditions, age, and the number of blood pressure medications being taken. The more blood pressure medicines a person is on, the more likely they are to develop orthostatic hypotension.

Risk Factors and Frequency for Orthostatic Hypotension (Low blood pressure)

Orthostatic hypotension, a condition where your blood pressure drops when you stand up, occurs more frequently in people as they get older. Studies have shown that it’s especially common in adults 65 years or older, with up to 18.2% of people in this age group having this condition. Research suggests that one in five adults over 60 and four out of every person living in long-term residential homes have orthostatic hypotension.

• Orthostatic hypotension is less common in younger adults aged 45-49 years, where it affects less than 5%.
• About 15% of those aged between 65 and 69 years have it.
• For those over 85 years, the prevalence increases to over 25%.

In hospitals, the condition is more often seen in elder patients. The numbers can vary depending on factors like hospital practices, how often patients are tested, and how much they’re encouraged to move around.

Those with heart conditions like aortic stenosis, heart inflammation, or irregular heart rhythms are also more likely to experience orthostatic hypotension. Interestingly, this problem can also appear in younger and middle-aged people, particularly if they have chronic autonomic failure, a condition where the autonomic nervous system doesn’t work properly.

Signs and Symptoms of Orthostatic Hypotension (Low blood pressure)

Orthostatic hypotension is a condition diagnosed primarily through a patient’s medical history and a physical examination that includes checking vital signs while standing. It’s important, especially for older patients, to regularly test for orthostatic hypotension because it’s easy to do but often overlooked in clinical settings.

People with orthostatic hypotension usually experience symptoms like lightheadedness, dizziness, or fainting, and less frequently, leg weakness, headaches, or chest pain. It’s often critical to examine what events or triggers preceded these symptoms and to check the patient’s medications. Other potential sources of these symptoms, such as heart-related conditions or neurological causes, need to be ruled out. In elderly individuals, considering the possibility of conditions like dehydration due to diuretic use, blood loss, vomiting, or multiple medications is critical. This is especially important if fainting occurs, as other common causes should also be ruled out, such as seizures and vasovagal syncope.

Some patients don’t show any symptoms, and orthostatic hypotension is only discovered during a routine checkup. In some studies, it’s found that about one-third of patients with orthostatic hypotension show no symptoms. The impact of symptom-free orthostatic hypotension isn’t yet fully understood.

Symptoms usually appear when a person changes their posture and are generally relieved by lying down or sitting. These symptoms could include temporary unconsciousness or a sudden fall. Symptoms might appear first thing in the morning upon waking or throughout the day when changing posture—from sitting to standing or from lying to sitting. While it’s hard to say for certain how indicative these symptoms are, if they occur in relation to postural changes, they should certainly be a cause for testing for orthostatic hypotension.

Here is a simplified list of the symptoms associated with orthostatic hypotension:

• Lightheadedness
• Dizziness
• Temporary loss of consciousness
• Falling
• Blurry vision
• Visual problems
• Difficulty with concentration
• Slowed cognition
• Weakness
• Fatigue
• Shortness of breath
• Chest pain
• Backache
• Pain in the lower extremities
• Coathanger headache (Headache and neck pain in the back of the head and shoulder region)

Testing for Orthostatic Hypotension (Low blood pressure)

When doctors initially evaluate patients with a condition called orthostatic hypotension, they first need to understand any medications the patient is currently taking. This condition can often be triggered or made worse by various drugs, including ones that widen blood vessels, reduce water in the body, treat depression, manage psychosis, or affect dopamine levels in the brain.

If the patient’s medications can’t explain their symptoms, the doctor should next assess the patient’s heart health, starting with an ECG or a heart tracing. They may also run tests to check for anemia, dehydration, diabetes, alcohol addiction, or heart failure. Sometimes orthostatic hypotension may also be a sign of a nerve condition, so the doctor will consider this possibility during the patient’s physical check-up.

To diagnose orthostatic hypotension, the doctor will take the patient’s blood pressure and heart rate while the patient is lying flat. After five minutes, they will ask the patient to stand for two to five minutes and again measure their vitals. If the patient’s top blood pressure number falls by 20 or the bottom number drops by 10, they may have orthostatic hypotension. Doctors may need to repeat these measurements at different times to be more certain of the diagnosis.

The doctor will also talk to the patient about their symptoms. Are they constant or one-off? Do they occur just after the patient changes position? Other lifestyle factors like eating habits, time of day, hydration level, environmental temperature, fitness level, and time spent lying down can also affect the patient’s condition.

Physical examination depends on the symptoms and possible cause; for instance, if a patient has heart palpitations, the doctor might listen for a heart murmur, which might indicate a heart defect.

Patients or caregivers may be asked to monitor blood pressure at home, morning and night, if it is feasible and the patient can move around safely. However, if the patient is at risk of falling or has severe symptoms and needs support while taking readings, home monitoring might not be suitable.

Heart rate also plays a role in diagnosing orthostatic hypotension. If there are changes in blood pressure when the patient stands up, an increase in heart rate of less than 15 beats per minute might suggest a nerve disorder. A larger increase suggests a cause that’s not related to the nerves. However, heart rate alone is not a reliable indicator of the underlying cause, and certain medications, like beta blockers, can interfere with its accuracy.

Treatment Options for Orthostatic Hypotension (Low blood pressure)

The treatment for orthostatic hypotension, a condition where one’s blood pressure drops when standing up, will depend on its cause. The main goal is to alleviate symptoms and reduce risk for further health issues. If a patient doesn’t show symptoms, they generally don’t require any special treatment, except those with Parkinson’s disease due to their increased fall risk and potentially reduced quality of life.

In cases where medication is causing the low blood pressure, cessation or change of the medication might be necessary for improvement. Other factors, like high blood pressure, diabetes, Parkinson’s disease, and dehydration, often need a team-based approach for effective management. It’s important to replace lost fluids fast if dehydration is the main cause of the orthostatic hypotension.

Patients with a type of orthostatic hypotension that’s caused by nerve-related conditions should be instructed on measures such as using compression stockings, increasing fluids and salt intake, and preventing falls. Generally, these non-medicine strategies are enough to manage their condition effectively.

Some causes of orthostatic hypotension like Parkinson’s disease are permanent, but others, like anemia, are short term and can be treated. Health professionals should address reversible causes such as infections, medications, dehydration, and anemia. If necessary, medications that cause low blood pressure could be stopped, changed, or switched to a slow-release version.

Patients should be informed about orthostatic hypotension, its causes, and factors that could potentially make it worse like standing for a long time, eating large meals, having less water, drinking alcohol, heat, straining, and hot baths or showers. There’s limited evidence supporting the effectiveness of these changes, but strategies like wearing compression stockings and abdominal binders could provide some benefit.

Non-medical treatments that can help manage low blood pressure upon standing include:

* Rising slowly from sitting to standing
* Drinking enough fluids
* Avoiding alcoholic drinks, hot weather, large meals, and hot showers or baths
* Sleeping with the head of the bed elevated
* Exercising regularly
* Crossing legs while standing
* Tensing leg and hip muscles after standing

If non-medical interventions don’t lessen symptoms, medication might be needed. Fludrocortisone and midodrine are commonly prescribed drugs. These drugs work to increase the tightness of blood vessels. Midodrine seems to provide more symptom relief than other drugs according to a recent research study. Midodrine, however, is mainly indicated for patients with orthostatic hypotension due to nerve dysfunction and its use for other types is not approved by regulatory bodies.

Another medication called droxidopa can also be considered for treatment but the evidence supporting its use for orthostatic hypotension is still limited.

What else can Orthostatic Hypotension (Low blood pressure) be?

Some people might confuse the sensation of lightheadedness or fainting after eating with a condition known as post-prandial hypotension. Vasovagal syncope, a common form of fainting, could also be mistaken for this condition. It’s typically triggered by factors like pain, emotional stress, heat, dehydration, or staying in one position for a long time. Vasovagal syncope is more common in younger, healthy people and may be preceded by signals like nausea, sweating, and paleness.

Another condition, Carotid sinus syndrome, may also cause confusion. This condition makes people feel faint or experience falls due to an overly sensitive carotid sinus in the neck. Primarily affecting older people, it may be difficult to distinguish from orthostatic hypotension. However, the two conditions can also occur together. A tool known as the tilt-table test can help doctors identify the condition. This test is usually performed in a cardiology clinic for patients who faint and the cause is unknown.

When a doctor suspects a patient has orthostatic hypotension, it’s important for them to also consider the following other possible causes:

• Anemia (low red blood cell count)
• Adrenal insufficiency (weakness in the adrenal glands)
• Cardiac arrhythmia (irregular heartbeat)
• Congestive heart failure (condition where the heart can’t pump efficiently)
• Diabetes insipidus (a type of diabetes that causes excess urination)
• Hyperglycemia (high blood sugar)
• Hypokalemia (low potassium levels in the blood)
• Myocardial infarction (heart attack)
• Myocarditis (inflammation of the heart muscle)
• Pheochromocytoma (a rare tumor of the adrenal glands)

These possibilities should be explored and ruled out to ensure an accurate diagnosis.

What to expect with Orthostatic Hypotension (Low blood pressure)

Orthostatic hypotension often doesn’t cause symptoms or causes only mild symptoms. However, it can increase the risk of death and serious heart problems like heart attacks, heart failure, and irregular heart rhythms. It can also increase the risk of strokes and temporary episodes of dizziness or lightheadedness due to reduced blood flow to the brain. These heart and brain-related issues could be the reason for the increased risk of death associated with orthostatic hypotension.

The blood to your heart flows through an artery known as the left coronary artery when your heart is relaxing (diastole). So, patients who have orthostatic hypotension during the diastole could potentially have reduced blood flow to their heart. This could make their overall health outlook poorer.

Possible Complications When Diagnosed with Orthostatic Hypotension (Low blood pressure)

Orthostatic hypotension, a type of low blood pressure that occurs when you stand up, can lead to reduced physical abilities, balance issues, and difficulties with daily tasks. Research has shown that this condition also increases the risks of several other health issues:

• Falls
• Heart failure
• Coronary heart disease (a condition where the heart’s blood supply is blocked)
• Stroke (a serious condition where the blood supply to a part of the brain is cut off)
• Atrial fibrillation (a heart condition that causes an irregular and often fast heartbeat)
• Death from any cause

Some smaller studies suggest that orthostatic hypotension may also lead to cognitive impairment, depression, and dementia. However, it’s uncertain whether these risks vary for people with or without symptoms and across different age groups.

Preventing Orthostatic Hypotension (Low blood pressure)

General health screenings don’t typically include checks for orthostatic hypotension, which is a condition that can cause dizziness or fainting upon standing up. However, it may be a good idea for certain groups to get tested. For example, according to the National Institute for Health and Care Excellence (NICE), people who have both high blood pressure and type 2 diabetes or individuals who have high blood pressure and are 80 or older should consider getting checked. The American Diabetes Association also encourages regular testing for orthostatic hypotension in patients with diabetes, even if they don’t show any symptoms.

It’s important for everyone to know about this condition and the potential symptoms, which are usually related to changes in body position. People should be aware that their primary doctor can diagnose the condition and provide advice on lifestyle changes to prevent symptoms. The main goal of treatment is to prevent falls in daily life. Making lifestyle changes is the first course of action in treatment, but medication can also be an option if needed.