What is the cause of hypotension in an 80-year-old (octogenarian) individual?

From the Guidelines

Hypotension in an 80-year-old patient is most likely caused by orthostatic hypotension, which is a common condition in very old and frail patients, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The diagnosis of orthostatic hypotension should be considered, especially when the patient experiences symptoms such as dizziness or lightheadedness upon standing.

• The 2024 ESC guidelines recommend testing for orthostatic hypotension by measuring blood pressure 1 and/or 3 minutes after standing, after the patient has sat or lain down for 5 minutes 1.
• The guidelines also suggest that non-pharmacological approaches should be the first-line treatment for orthostatic hypotension in patients with supine hypertension, and that BP-lowering medications that worsen orthostatic hypotension should be switched to alternative therapies 1. Other potential causes of hypotension in an 80-year-old patient include:
• Medication side effects, particularly from antihypertensives, diuretics, antidepressants, or alpha-blockers
• Volume depletion from inadequate fluid intake, diarrhea, vomiting, or excessive diuresis
• Cardiac causes such as heart failure, arrhythmias, or valvular disease
• Sepsis or other infections
• Endocrine disorders like adrenal insufficiency or hypothyroidism
• Neurological causes including autonomic dysfunction, which increases with age and diabetes. Immediate management should focus on identifying the underlying cause while ensuring adequate hydration and, if necessary, temporarily discontinuing contributing medications, as recommended by the guidelines 1.

From the Research

Hypotension in the Elderly

• Hypotension, especially very low diastolic blood pressure, can be an at-risk situation in very old and frail patients, as well as those with coronary heart disease 2.
• Orthostatic hypotension, a decrease in blood pressure after transitioning from a supine to an upright position, may be symptomatic or asymptomatic and is a common issue in elderly patients 2.
• The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes, and/or polymedication 2.

Medication-Related Hypotension

• Certain medications, such as beta-blockers, can increase the risk of hypotension in elderly patients 3, 4.
• Alpha-blockers, commonly prescribed for hypertension, have been associated with a higher risk of hypotension and related adverse events, including syncope, in women of advanced age 5.
• The use of beta-blockers as first-line therapy for hypertension has been questioned due to their relatively weak effect on reducing stroke and lack of effect on coronary heart disease compared to other antihypertensive drugs 3.

Clinical Features and Treatment

• Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy 2.
• First-intention treatment for orthostatic hypotension aims to correct modifiable factors and limit the circulatory consequences of orthostatism, such as elastic venous compression 2.
• The choice of antihypertensive medication should be carefully considered in elderly patients, taking into account the potential risks and benefits of each medication, as well as the patient's individual characteristics and comorbidities 3, 4, 5.