Treatment: special conditions: Orthostatic hypotension

Abstract

Orthstatic hypotension (OH) is defined as a sustained decrease of systolic blood pressure of at least 20 mm Hg (30 mm Hg in hypertensives) or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing. The incidence of OH increases exponentially after age 65, particularly in frail elderly with coexisting diseases. It can be seen in about 6% of healthy elderly in the community, 18%–54% of nursing home residents, and up to 60% in hospitalized elderly. The most common causes are medications (diuretics, alpha blockers, venodilations, some antidepressants), and systemic diseases that can produce neuropathies (eg, diabetes). Primary neurodegenerative disorders of the autonomic nervous system (pure autonomic failure, multiple system atrophy) are less common but produce severe OH. Parkinson’s disease is part of the spectrum of these autonomic neuropathies, but is often overlooked as a cause of OH. Finally, in a patient with a sub–acute onset of OH with rapid progression, one needs to rule out a primary autoimmune process or a paraneoplastic syndrome (small cell lung cancer, monoclonal gammopathies, light chain disease, amyloid). OH is associated with a 2.6–fold increase in the risk of falls and disability and is an independent risk factor for increased mortality and for the development of chronic kidney disease (comparable to having coronary artery disease, smoking, hypertriglyceridemia, and other risk factors that receive more attention).