Orthostatic Hypotension: A Management Opportunity

JACA Pages: Evidence in Action

Author: Robert Vining, DC and William Alexander, DC/Friday, March 11, 2016/Categories: December 2014

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By Robert Vining, DC and William Alexander, DC 

ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, approximately one-third of adults age 65 and older fall each year.1 Falls are the leading cause of fatal/nonfatal injuries in this age group.2 The causes vary. Orthostatic hypotension (OH) increases fall risk. OH is defined as, “a sustained reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within 3 minutes of standing or head-up tilt to at least 60Åã on a tilt table.”3 OH is caused by one or more underlying conditions, meaning the diagnosis is more of a waypoint than a final destination. We looked at the literature to refresh our understanding of its causes and treatment options.

An Evidence-based Consideration

We entered “orthostatic hypotension management” into the search engine on the PubMed homepage. We refined the resulting unmanageable list of 600 article titles by selecting the filter “Free full-text availability” to display only articles that can be accessed without a fee or subscription. We checked “5 years” to refine our search to include recently published articles. Adding these filters reduced the list to fewer than 60 articles, which we scanned. We selected a review entitled, “Preventing and treating orthostatic hypotension: As easy as A, B, C.”4

Pathophysiology

To summarize the article, gravity pulls circulating blood into the lower body when arising from a seated or supine position. Baroreceptors located predominantly in the aortic arch and carotid sinus detect the resulting reduction in blood pressure and signal the central nervous system to induce peripheral vasoconstriction and increase heart rate to compensate for and offset the pooling effect. Without these adaptive mechanisms, the individual risks transient hypoperfusion of the brain leading to OH symptoms, including lightheadedness, dizziness, visual disturbances, weakness, cognitive impairment and pre-syncope. All create an increased risk for falling.

OH can also manifest as headaches and/or neck pain (i.e., coat-hanger pain) with upright postures, caused by ischemia to the muscles of the neck.5,6 Because these symptoms can be the first noticeable signs of OH, a doctor of chiropractic (DC) could be the initial provider consulted. Occasionally, OH presents as orthostatic dyspnea or angina mimicking potential life-threatening conditions.6 Symptoms are often exacerbated by situations that trigger a fall in cardiac output. Commonly reported triggers include hot environments, alcohol consumption, inadequate fluid intake, fluid loss (severe burns, diarrhea), prolonged static standing, activities increasing intrathoracic pressure (defecating, coughing) and prescription or illegal drug use.

Common etiologies for OH include cardiovascular diseases, neuro/endocrine imbalances, blood volume depletion and medication side effects. (Table 1 provides a brief summary of some common conditions that can cause OH.) Because so many common health conditions can contribute to OH, you will encounter numerous patients with the potential for developing symptoms. In addition, some medications can cause/enhance OH. (Table 2 provides a useful list.)

Limitations

The article we selected is not based on a systematic review of the literature with well-described and thorough search methods. Therefore, the strength of evidence is considered lower than if the review were performed systematically.

What This Process Did for Us

For us, the two most relevant aspects of this article are 1) the reminder that OH can present as neck pain radiating to the head and shoulders, and 2) the following statement: “Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and non-pharmacologic strategies is critical.”

Some non-pharmacological management options the authors include are:
  • wearing an abdominal binder when out of bed;
  • sleeping with the head of the bed raised 4 inches;
  • training patients to perform lower-extremity contracting maneuvers;
  • patient education to recognize symptoms of OH and situations that may precede an event; and
  • mild physical exercise in a supine or seated position.

We were reminded of the importance of screening patients for, and diagnosing, OH. Appropriate management may require more than one provider type and represents a potential opportunity to co-manage or collaborate with other health care providers. Several conditions contributing to OH are more common in older adults, a rapidly growing segment in the United States. As conservative providers focusing on prevention, DCs are well-positioned to help patients manage their condition through education and preventive exercise. Lifestyle modification strategies that help patients recognize, prevent and minimize symptoms may also help reduce falling risk and prevent fall-related injuries.

References

1. Centers for Disease Control and Prevention. Falls among Older Adults: An Overview. 9-20-2013.

2. Web–based Injury Statistics Query and Reporting System (WISQARS). 8-15-2013. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

3. Freeman R, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 2011 Apr;21(2):69-72.

4. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C.Cleve Clin J Med 2010 May;77(5):298-306.

5. Robertson D, Kincaid DW, Haile V, Robertson RM. The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Clin Auton Res 1994 Jun;4(3):99-103.

6. Freeman R. Clinical practice. Neurogenic orthostatic hypotension. N Engl J Med 2008 Feb 7;358(6):615-24.

7. Bradley JG, Davis KA. Orthostatic hypotension. Am Fam Physician 2003 Dec 15;68(12):2393-8.

8. Strobach RS, Anderson SK, Doll DC, Ringenberg QS. The value of the physical examination in the diagnosis of anemia. Correlation of the physical findings and the hemoglobin concentration. Arch Intern Med 1988 Apr;148(4):831-2.

9. Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet 2014 Jun 21;383(9935):2152-67.

10. Garland EM, Hooper WB, Robertson D. Pure autonomic failure. Handb Clin Neurol 2013;117:243-57.

11. Botzel K, Tronnier V, Gasser T. The differential diagnosis and treatment of tremor. Dtsch Arztebl Int2014 Mar 28;111(13):225-35.

12. Gelfand JM. Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation. Handb Clin Neurol 2014;122:269-90.

13. Milazzo V, et al. Drugs and Orthostatic Hypotension: Evidence from Literature. J Hypertens 1(2), 1-8. 3-26-2012.

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