From the Guidelines
For a 91-year-old patient with symptomatic orthostatic hypotension and no heart failure, I strongly recommend a daily salt intake of 6-9 grams (about 1-2 teaspoons) and fluid intake of at least 240-480 mL of water, as needed, for temporary relief of orthostatic hypotension symptoms. This approach is based on the most recent and highest quality evidence from the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The guideline suggests that encouraging increased salt and fluid intake may be reasonable in selected patients with neurogenic orthostatic hypotension, as it can improve blood pressure and decrease symptoms. Key considerations for implementation include:
- Gradually increasing salt and fluid intake to monitor for improvement in symptoms
- Adding salt to food during meals and spreading water intake throughout the day
- Using salt tablets (typically 1 gram each) if dietary salt is insufficient
- Monitoring blood pressure regularly, both lying down and standing, to assess effectiveness
- Adjusting the regimen under medical supervision if the person has kidney disease, hypertension, or heart conditions other than heart failure
- Recognizing that symptoms should improve within 1-2 weeks of consistent implementation. It is essential to note that the presence of glucose or salt may reduce the pressor effect of water, and the long-term effects of increased salt and fluid intake are unknown 1. Therefore, regular monitoring and adjustments to the regimen are crucial to ensure the best possible outcome for the patient.
From the Research
Recommended Salt and Water Intake Guidelines
- For a 91-year-old patient with symptomatic orthostatic (postural) hypotension and no heart failure, increasing sodium intake is recommended as a nonpharmacologic approach to manage orthostatic hypotension 2.
- Increasing fluid intake is also a recommended nonpharmacologic strategy to help manage orthostatic hypotension 3, 4.
- However, there is no specific guideline for the exact amount of salt and water intake recommended for this patient population.
- The goal of therapy is to relieve symptoms, and treatment should focus on the underlying cause and adjusting potentially causative medications, as well as nonpharmacologic strategies such as dietary modifications and physical maneuvers 3.
Considerations for Treatment
- Fludrocortisone is considered a first- or second-line pharmacological therapy for orthostatic hypotension, alongside mechanical and positional measures such as increasing fluid and salt intake and venous compression methods 5.
- However, the evidence for the effects of fludrocortisone on blood pressure, orthostatic symptoms, or adverse events in people with orthostatic hypotension is very uncertain 5.
- Other medications such as midodrine and droxidopa may also be considered as first-line treatments for orthostatic hypotension 3.