What is the workup for orthostatic hypotension in an 82-year-old female who otherwise feels healthy?

Workup for Orthostatic Hypotension in an 82-Year-Old Female

The workup for orthostatic hypotension in an elderly patient should include a comprehensive orthostatic blood pressure assessment, evaluation of underlying causes, and assessment of symptom severity to guide management decisions. 1

Diagnostic Approach

Initial Assessment

• Confirm orthostatic hypotension by performing a bedside Schellong test:
  • Measure BP and heart rate after 5 minutes in supine position
  • Measure again after 3 minutes of standing
  • Diagnostic criteria: ≥20 mmHg drop in systolic BP or ≥10 mmHg drop in diastolic BP 1, 2
• If patient cannot stand safely or clinical suspicion remains high despite normal bedside test, consider head-up tilt table testing 2

Classify Type of Orthostatic Hypotension

• Determine if neurogenic (inadequate autonomic compensation) or non-neurogenic (volume depletion, medication-related)
• Assess heart rate response to standing:
  • Minimal heart rate increase with BP drop suggests neurogenic cause
  • Significant heart rate increase suggests non-neurogenic cause 1

Medication Review

• Identify medications that may cause or worsen orthostatic hypotension:
  • Antihypertensives (especially α-blockers, vasodilators)
  • Diuretics
  • Antidepressants (especially tricyclics)
  • Antipsychotics
  • Antiparkinsonian medications
  • Opioids 3

Laboratory Evaluation

• Complete blood count (to assess for anemia)
• Basic metabolic panel (electrolytes, renal function)
• Blood glucose (to rule out diabetes)
• Morning cortisol (if adrenal insufficiency suspected)
• Vitamin B12 levels (if deficiency suspected)
• Thyroid function tests 1

Cardiovascular Assessment

• ECG (to assess for arrhythmias or conduction abnormalities)
• Consider echocardiogram if heart failure suspected
• Carotid sinus massage (if carotid sinus hypersensitivity suspected) 1

Autonomic Function Testing

• For patients with suspected neurogenic orthostatic hypotension:
  • Heart rate variability with deep breathing
  • Valsalva maneuver
  • Quantitative sudomotor axon reflex test (QSART)
  • Thermoregulatory sweat test 1, 4

Postprandial Assessment

• Consider measuring BP before and after meals
• Significant drop (≥20 mmHg systolic) within 2 hours after eating suggests postprandial hypotension, common in elderly 1

Special Considerations for Elderly Patients

Comorbidity Evaluation

• Assess for conditions common in elderly that may contribute:
  • Diabetes mellitus (increases prevalence of OH in all age groups) 2
  • Parkinson's disease or other synucleinopathies (may present with OH as earliest manifestation) 4
  • Heart failure
  • Dehydration
  • Venous insufficiency 1

Functional Assessment

• Evaluate impact on daily activities
• History of falls or near-falls
• Fear of falling
• Activity restrictions due to symptoms 1

Supine Hypertension Assessment

• Measure BP in supine position
• Many elderly patients with OH also have supine hypertension, complicating management 3, 1

Common Pitfalls to Avoid

• Failing to test for orthostatic hypotension before starting or intensifying BP-lowering medication 3
• Overlooking orthostatic hypotension as a cause of falls in elderly patients 1
• Focusing only on BP numbers rather than symptom improvement 1
• Inadequate monitoring for supine hypertension 1
• Attributing symptoms solely to age without proper evaluation 1

Next Steps After Diagnosis

After completing the workup and confirming orthostatic hypotension, treatment should focus on non-pharmacological approaches first (increased fluid/salt intake, compression garments, physical counterpressure maneuvers) before considering pharmacological options like fludrocortisone, midodrine, or droxidopa based on the underlying cause and symptom severity 1, 3.