What is the management and treatment for a geriatric patient with orthostatic hypotension, presenting with a systolic blood pressure (SBP) in the 80s when getting up, who is not currently on anti-hypertensive medication?

Management of Orthostatic Hypotension in Geriatric Patients

For geriatric patients with orthostatic hypotension not on anti-hypertensive medications, first-line treatment should focus on non-pharmacological approaches, particularly bolus water drinking and physical counter-maneuvers, before considering pharmacological interventions like midodrine. 1, 2, 3

Initial Assessment and Diagnosis

• Confirm orthostatic hypotension by measuring BP after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing
• Document the systolic BP drop (≥20 mmHg) and associated symptoms
• Rule out potential causes:
  • Dehydration
  • Medication side effects (even non-antihypertensives like sedatives or alpha-blockers for prostate)
  • Autonomic dysfunction
  • Adrenal insufficiency

Non-Pharmacological Interventions (First-Line)

Implement these interventions based on efficacy and patient acceptability:

1. Bolus water drinking (480 mL) - 56% response rate with average 12 mmHg SBP increase 3

   • Drink before anticipated positional changes or symptoms
   • Most effective single intervention with good acceptability

2. Physical counter-maneuvers - 44% response rate 3

   • Leg crossing
   • Muscle pumping/contractions
   • Bending forward when standing
   • Highly acceptable as they can be performed discreetly and require no equipment

3. Abdominal compression - 52% response rate with 10 mmHg SBP improvement 3

   • Use elastic abdominal binders
   • Mixed acceptability among patients

4. Additional measures:

   • Smaller, more frequent meals
   • Increased salt intake (if no contraindications)
   • Elevate head of bed during sleep
   • Avoid rapid position changes

Pharmacological Interventions (Second-Line)

If non-pharmacological measures are insufficient after 3-4 weeks of consistent use:

1. Midodrine - alpha-1 agonist 4

   • Starting dose: 2.5-5 mg three times daily
   • Maximum dose: 10 mg three times daily
   • Last dose no later than 6 PM to avoid supine hypertension
   • Monitor for supine hypertension (>200 mmHg systolic can occur)
   • Increases standing systolic BP by 15-30 mmHg at 1 hour post-dose

2. Fludrocortisone (if no contraindications)

   • Start at low dose and titrate carefully
   • Monitor for fluid retention and electrolyte imbalances

Monitoring and Follow-Up

• Reassess BP response to interventions (both standing and supine)
• Monitor for supine hypertension, especially with pharmacological treatment
• Evaluate symptom improvement and functional capacity
• Follow up within 2-4 weeks of intervention initiation

Important Considerations

• Avoid compression stockings as first-line therapy despite traditional recommendations - only 32% response rate and poor acceptability in elderly 3, 5
• Combination non-pharmacological therapies offer little additional benefit over single effective therapies 6
• For patients ≥85 years or with moderate-to-severe frailty, prioritize quality of life over strict BP targets 1
• If pharmacological treatment is needed, start with low doses and titrate slowly 7

When to Refer

Consider referral to a specialist (geriatrician, neurologist, or cardiologist) if:

• Severe, persistent symptoms despite interventions
• Suspected neurogenic orthostatic hypotension
• Significant supine hypertension complicating management