From the Guidelines
For an 87-year-old patient experiencing transient orthostatic dizziness lasting 2 minutes after getting out of bed, initial evaluation should include orthostatic vital sign measurements, complete blood count, basic metabolic panel, and medication review, with treatment prioritizing non-pharmacological approaches and medication adjustments as needed, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Initial Evaluation
The initial evaluation of the patient should include:
- Orthostatic vital sign measurements, with blood pressure and heart rate measured while lying down, then after standing for 1-3 minutes, to assess for orthostatic hypotension, defined as a BP drop of ≥20/10 mmHg 1 and/or 3 min after standing following a 5-min period in the seated or lying position 1.
- Complete blood count and basic metabolic panel to rule out underlying conditions that may be contributing to the dizziness.
- Medication review to identify potential offending agents, such as diuretics and vasodilators, which can exacerbate orthostatic hypotension 1.
Treatment
Treatment should begin with non-pharmacological approaches, including:
- Slow positional changes, such as sitting at bedside for 1-2 minutes before standing, to reduce the risk of orthostatic hypotension.
- Adequate hydration, with a goal of 1.5-2 liters daily, unless contraindicated, to help maintain blood volume.
- Compression stockings to help improve venous return and reduce orthostatic hypotension.
- Salt intake of 6-8 grams daily, if not hypertensive or with heart failure, to help maintain blood volume. Medication adjustments are crucial, particularly reducing or discontinuing vasodilators, diuretics, and psychotropic medications if possible, as these can exacerbate orthostatic hypotension 1. If these measures are insufficient, pharmacological options may be considered, including fludrocortisone or midodrine, which require monitoring for supine hypertension, electrolyte abnormalities, and urinary retention. The underlying mechanism of orthostatic dizziness in elderly patients typically involves age-related baroreceptor dysfunction, reduced vascular compliance, and decreased autonomic response, often exacerbated by medication effects and dehydration, as noted in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
From the Research
Diagnostic Tests
- The diagnosis of orthostatic hypotension can be confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position 2.
- If the patient is unable to stand safely or the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test, head-up tilt table testing is recommended 2.
- Supine and upright blood pressure measurements are essential in establishing whether symptoms are due to orthostatic hypotension 3.
Treatment Options
- Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life 2.
- Initial treatment focuses on the underlying cause and adjusting potentially causative medications 2.
- Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 2, 3.
- First-line medications include midodrine and droxidopa 2, 4.
- Fludrocortisone may improve symptoms, but it has concerning long-term effects 2, 5.
- A stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension is recommended 3.
Management
- Patient education regarding triggering situations and physiological countermanoeuvers is essential 4, 5.
- Lifestyle measures, such as counterpressure manoeuvres, can be adopted to manage orthostatic hypotension 3.
- Pharmacological treatment may be necessary in selected cases, and the goal of therapy is the relief of symptoms and fall prevention 4, 3.