Should blood pressure medication be reduced in a patient with recurrent falls and mild orthostatic hypotension?

Management of Recurrent Falls with Mild Orthostatic Hypotension

Blood pressure medication should be reduced in patients with recurrent falls and mild orthostatic hypotension, as medication reduction is a recommended component of effective fall-reducing interventions. 1

Assessment of Orthostatic Hypotension

• Orthostatic hypotension is defined as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing 1, 2
• Proper assessment requires measuring blood pressure after 5 minutes of rest in sitting or lying position, followed by measurements at 1 and 3 minutes after standing 3, 2
• The presence of orthostatic hypotension after exclusion of other causes suggests possible autonomic dysfunction that should be confirmed by additional testing 1

Connection Between Falls and Orthostatic Hypotension

• Case series report an overlap of symptoms between falls and syncope, with a causal association between cardiovascular disorders (particularly orthostatic hypotension) and falls 1
• Orthostatic hypotension is an independent risk factor for falls and overall mortality 4
• The combination of recurrent falls and orthostatic hypotension strongly suggests a need for medication adjustment 5

Medication Management Approach

First Steps:

• Review and alter or stop medications as appropriate in light of fall risk, with particular attention to:
  • Patients taking four or more medications 1
  • Those taking psychotropic medications (neuroleptics, benzodiazepines, antidepressants) 1
  • Antihypertensive medications that worsen orthostatic hypotension 3

Specific Medication Considerations:

• Reduce or withdraw medications that cause hypotension when appropriate 1
• Consider switching BP-lowering medications that worsen orthostatic hypotension to alternative therapies rather than simply reducing dosage 3
• Avoid beta-blockers and alpha-blockers in frail elderly patients unless specifically indicated 3, 4
• Angiotensin receptor blockers and calcium channel blockers may be preferable antihypertensives for patients with both hypertension and orthostatic hypotension 4

Evidence Supporting Medication Reduction

• A study of nursing home residents with systolic BP 80-120 mmHg and falls found that antihypertensive deintensification was associated with significantly lower risk of recurrent falls (13.6% reduction) among residents with SBP 80-100 mmHg 5
• Reduction of medications was a prominent component of effective fall-reducing interventions in community-based and long-term care multifactorial studies 1
• Uncontrolled hypertension can actually worsen orthostatic hypotension, so both conditions should be managed appropriately 4

Additional Management Strategies

• Physical counter-pressure maneuvers can be beneficial in patients with orthostatic hypotension 1
• Compression garments (at least thigh-high and preferably including the abdomen) can improve orthostatic symptoms 1
• Consider encouraging increased salt and fluid intake if appropriate (unless contraindicated by hypertension, renal disease, or heart failure) 1
• Acute water ingestion (≥240 mL) can temporarily restore orthostatic tolerance, with peak effect occurring 30 minutes after ingestion 1

Monitoring After Medication Adjustment

• Regular monitoring of both standing and supine blood pressure is essential after medication changes 3
• Consider the 24-hour blood pressure profile when adjusting medications 6
• Watch for potential worsening of supine hypertension when reducing antihypertensive medications 7

Caution

• While reducing antihypertensive medication can decrease fall risk in those with orthostatic hypotension, one study noted a slightly higher risk of death (4.3%) among residents with SBP 101-120 mmHg after medication reduction 5
• The goal should be to find the optimal balance between fall prevention and adequate blood pressure control 4