What is the treatment for orthostatic hypotension in the elderly?

Treatment of Orthostatic Hypotension in the Elderly

Begin with non-pharmacological interventions as first-line therapy, and if symptoms persist despite these measures, initiate midodrine as the first-line pharmacological agent, with fludrocortisone as an alternative or addition for refractory cases. 1, 2

Initial Assessment and Diagnosis

Before initiating or intensifying any treatment, confirm orthostatic hypotension by measuring blood pressure after 5 minutes of sitting or lying, then at 1 and/or 3 minutes after standing—a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirms the diagnosis. 1, 2

Step 1: Identify and Eliminate Reversible Causes

The most critical first step is discontinuing or switching medications that worsen orthostatic hypotension rather than simply reducing doses. 1, 2 Drug-induced autonomic failure is the most frequent cause of orthostatic hypotension in the elderly. 2

• Discontinue or switch diuretics, vasodilators, alpha-1 adrenergic blockers, tricyclic antidepressants, and other culprit medications 2, 3
• For patients requiring blood pressure control, switch to long-acting dihydropyridine calcium channel blockers or RAS inhibitors as preferred first-line agents 2, 4
• Avoid alcohol, which causes both autonomic neuropathy and central volume depletion 2

Step 2: Non-Pharmacological Interventions (First-Line)

The European Society of Cardiology recommends pursuing non-pharmacological approaches as first-line treatment, particularly for patients with supine hypertension. 1

Fluid and Dietary Modifications

• Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure 2, 5
• Increase salt intake to 6-9 grams daily if not contraindicated 2, 5
• Eat smaller, more frequent meals to reduce postprandial hypotension 2, 6
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 2, 6

Physical Maneuvers and Positioning

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years with prodromal symptoms 2, 6
• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension 2
• Advise gradual staged movements with postural changes 2

Compression Garments

• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling 2, 5

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

The therapeutic goal is minimizing postural symptoms and improving functional capacity, not restoring normotension. 2, 5

First-Line: Midodrine

Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy. 2, 7

• Starting dose: 2.5-5 mg three times daily 2, 7
• Titration: Can be increased up to 10 mg three times daily based on response 2
• Critical timing: Last dose must be taken at least 3-4 hours before bedtime (not later than 6 PM) to prevent supine hypertension during sleep 2, 7
• Mechanism: Alpha-1 agonist that increases vascular tone through arteriolar and venous constriction 7
• Expected effect: Increases standing systolic BP by 15-30 mmHg for 2-3 hours 7

Common pitfall: Do not administer midodrine after 6 PM, as this significantly increases the risk of nocturnal supine hypertension. 2

Alternative or Addition: Fludrocortisone

• Starting dose: 0.05-0.1 mg once daily 2, 5
• Titration: Increase to 0.1-0.3 mg daily based on response (maximum 1.0 mg daily) 2
• Mechanism: Mineralocorticoid that acts through sodium retention and vessel wall effects 2
• Monitoring requirements: Check for supine hypertension, hypokalemia, congestive heart failure, and peripheral edema 2
• Contraindications: Avoid in patients with active heart failure, significant cardiac dysfunction, or pre-existing supine hypertension 2

Evidence quality note: Fludrocortisone has only very low-certainty evidence from small, short-term trials, but it remains widely used in clinical practice. 2

Combination Therapy for Refractory Cases

For patients who do not respond adequately to monotherapy, combine midodrine and fludrocortisone—they work through complementary mechanisms (alpha-1 adrenergic stimulation versus sodium retention). 2

Second-Line Options

• Droxidopa: FDA-approved for neurogenic orthostatic hypotension, particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy 2, 5
• Pyridostigmine: May be beneficial in refractory neurogenic orthostatic hypotension with a favorable side effect profile, though evidence is limited 2

Critical Monitoring Parameters

• Measure orthostatic vital signs at each follow-up visit 2
• Monitor supine blood pressure to detect treatment-induced supine hypertension—this is the most important limiting factor for pressor agents 2
• Check electrolytes periodically if using fludrocortisone due to mineralocorticoid effects causing potassium wasting 2
• Reassess within 1-2 weeks after medication changes 2

Special Considerations for the Elderly

Intensive blood pressure lowering does not increase the risk of orthostatic hypotension or falls in elderly patients. In fact, data from SPRINT and meta-analyses show that intensive BP treatment actually reduced the risk of orthostatic hypotension, possibly through improved baroreflex function and reduced arterial stiffness. 1 Therefore, asymptomatic orthostatic hypotension during hypertension treatment should not trigger automatic down-titration of therapy. 1

For patients aged ≥85 years or those with moderate-to-severe frailty who require both hypertension treatment and orthostatic hypotension management, long-acting dihydropyridine calcium channel blockers or RAS inhibitors are preferred first-line agents. 4

Common Pitfalls to Avoid

• Do not simply reduce the dose of offending medications—switch to alternative agents instead 1, 2
• Do not combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring 2
• Do not overlook volume depletion as a contributing factor 2
• Do not use fludrocortisone in patients with heart failure or supine hypertension 2
• Do not automatically down-titrate antihypertensive therapy in patients with asymptomatic orthostatic hypotension 1