What is the treatment for an elderly parent with diastolic hypotension?

Management of Diastolic Hypotension in Elderly Patients

The first-line treatment for diastolic hypotension in elderly patients should focus on non-pharmacological interventions, with careful medication adjustment and only selective use of pharmacological agents when absolutely necessary. 1

Initial Assessment and Diagnosis

• Confirm orthostatic hypotension by measuring blood pressure in both supine/sitting and standing positions
  • Defined as a decrease in BP of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 2, 3
• Evaluate for symptoms of cerebral hypoperfusion: dizziness, lightheadedness, unsteadiness, falls, syncope
• Review current medications that may contribute to hypotension

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

• Physical counter-maneuvers (most acceptable to patients) 4:
  • Leg crossing
  • Squatting
  • Tensing lower body muscles when changing positions
• Lifestyle modifications:
  • Bolus water drinking (rapid intake of 500ml water) before standing 4
  • Avoid rapid position changes
  • Elevate head of bed by 5-10 degrees when sleeping
  • Increase salt intake to 2g/day unless contraindicated 2
  • Avoid excessive alcohol intake 2
  • Maintain physical activity as feasible 2

Step 2: Medication Review and Adjustment

• Identify and discontinue or reduce medications that can worsen hypotension 5:
  • Diuretics (especially thiazides and furosemide)
  • Vasodilators (nitrates)
  • Alpha-blockers (terazosin)
  • Beta-blockers
  • ACE inhibitors (lisinopril)
  • Antidepressants (trazodone)
• Use more gradual dose titration when adjusting medications 2

Step 3: Pharmacological Treatment (If Non-Pharmacological Measures Fail)

• Midodrine (alpha-1 agonist) 6, 3:
  • Indicated for symptomatic orthostatic hypotension
  • Monitor for supine hypertension (BP >200 mmHg systolic)
  • Use only in patients whose lives are considerably impaired despite standard care
  • Continue only if significant symptomatic improvement occurs
• Fludrocortisone (mineralocorticoid) can be considered but has concerning long-term effects 3

Special Considerations for Elderly Patients

• Initial doses and subsequent dose titration should be more gradual due to greater risk of adverse effects 2
• For patients with coexisting hypertension, target blood pressure should be <140/90 mmHg if tolerated 2
• For patients ≥80 years, consider a systolic BP target of 120-129 mmHg if tolerated, using the "as low as reasonably achievable" (ALARA) principle if not well tolerated 2, 1
• Monitor for orthostatic hypotension regularly in all hypertensive individuals over 50 years old 2

Follow-Up and Monitoring

• Measure both sitting/supine and standing blood pressure at each visit
• Assess symptoms of orthostatic hypotension
• Monitor renal function and electrolytes, particularly if medication changes are made 1
• Evaluate effectiveness of interventions based on symptom improvement rather than specific BP targets 3

Common Pitfalls to Avoid

• Overaggressive BP reduction in elderly patients can lead to orthostatic hypotension and falls 2
• Compression stockings, while recommended in guidelines, have poor acceptability among elderly patients due to difficulty applying/removing and stigma 4
• Focusing solely on BP numbers rather than symptoms and quality of life 3
• Neglecting to check for orthostatic changes by measuring only seated BP 2
• Using multiple potentially causative medications concurrently increases OH risk significantly 5

The prevalence of orthostatic hypotension is high in elderly populations (up to 20%) and is associated with increased cardiovascular risk, falls, and mortality 3. Treatment should prioritize symptom improvement and functional status rather than arbitrary blood pressure values.