Can I give a small bolus to an 89-year-old patient with orthostatic hypotension?

Management of Orthostatic Hypotension in an 89-Year-Old Patient

Yes, a small fluid bolus can be given to an 89-year-old patient with orthostatic hypotension, but non-pharmacological measures should be tried first before considering pharmacological interventions or IV fluids. 1

Initial Management Approach

• For immediate management of orthostatic hypotension, place the patient in Trendelenburg position to increase systolic blood pressure to 100-110 mmHg 1
• Small boluses (5-10 mL/kg) of normal saline can be administered for orthostatic hypotension, especially in elderly patients 1
• Assess for signs of orthostatic hypotension before discharge from care, defined as a drop in blood pressure of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 1

Non-Pharmacological Interventions (First-Line)

• Increased fluid and salt intake is an effective first-line treatment for orthostatic hypotension 1, 2
• Physical counter-maneuvers (leg crossing, squatting) are highly acceptable to patients as they require no equipment, can be performed discreetly, and are only needed during postural changes 3, 2
• Consider compression with knee-high or thigh-high compression stockings, though these may have poor adherence due to difficulty applying/removing and stigma concerns 1, 3
• Abdominal binders can be helpful for preventing orthostatic hypotension without increasing baseline blood pressure 4

Pharmacological Management (If Needed)

• If non-pharmacological measures are insufficient, midodrine is the only FDA-approved medication specifically for symptomatic orthostatic hypotension 5, 6
• Initial midodrine dosing should begin with 10 mg three times daily, taken at 4-hour intervals during daytime hours when the patient needs to be upright 5, 6
• Midodrine should be used only in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacological treatment 6
• Fludrocortisone can be considered as a valuable starter drug if additional pharmacological intervention is needed 2

Special Considerations for Elderly Patients

• Orthostatic hypotension is highly prevalent in older adults (6% in community-dwelling elderly to 33% in elderly hospital inpatients) 1
• Patients over 65 years are at higher risk for orthostatic hypotension, requiring careful titration of therapy 1
• Elderly patients with widely variable blood pressure deserve consideration for a slow titration approach to avoid excessive hypotension 1
• Monitor for supine hypertension, as midodrine can cause marked elevation of supine blood pressure (>200 mmHg systolic) 6, 7

Cautions and Monitoring

• Assess for orthostatic hypotension before and after intervention by measuring blood pressure after having the patient sit or lie for 5 minutes and then 1 and/or 3 minutes after standing 1
• The goal of therapy should be to minimize postural symptoms rather than to restore normotension 5
• Continue midodrine only for patients who report significant symptomatic improvement 6
• Monitor for common side effects of midodrine, including piloerection (goosebumps) 5
• Be cautious with fluid boluses in patients with cardiac disease, as myocardial depression may limit the amount of fluid the patient can tolerate 1

When to Consider Alternative Approaches

• For patients with persistent orthostatic hypotension despite initial management, consider additional agents like pyridostigmine, which facilitates cholinergic neurotransmission without worsening supine hypertension 1, 4
• In patients with autonomic dysfunction, a water bolus can acutely but transiently increase blood pressure 4
• If the patient has concurrent hypertension, consider angiotensin receptor blockers or calcium channel blockers as they may be preferable antihypertensives for patients with orthostatic hypotension 4