What are the management and prevention strategies for orthostatic hypotension in older patients or those with medical conditions affecting blood pressure regulation?

Management and Prevention of Orthostatic Hypotension in Older Patients

For older patients with orthostatic hypotension, begin with medication review and discontinuation of offending agents (especially beta-blockers, alpha-blockers, and diuretics), followed by non-pharmacological interventions (increased fluid/salt intake, compression stockings, head-of-bed elevation), and reserve pharmacological treatment with fludrocortisone and/or midodrine or droxidopa for symptomatic patients who fail conservative measures. 1, 2

Diagnostic Approach

Proper Measurement Technique

• Measure blood pressure after 5 minutes of rest in supine or sitting position, then at 1 and/or 3 minutes after standing 1
• Orthostatic hypotension is confirmed when systolic BP drops ≥20 mmHg or diastolic BP drops ≥10 mmHg within 3 minutes of standing 3, 1, 2
• Obtain both lying and standing blood pressures periodically in all hypertensive individuals over 50 years old 3

Clinical Assessment

• Evaluate for symptoms including dizziness, lightheadedness, postural unsteadiness, fainting, and cognitive impairment that indicate baroreceptor dysfunction 3, 1
• Assess for signs of end-organ hypoperfusion such as altered mental status and decreased urine output 4
• The diagnosis has poor reproducibility in elderly patients, so multiple measurements may be needed to confirm the condition 5

Non-Pharmacological Management (First-Line)

Medication Optimization

• Immediately review and discontinue or reduce offending medications including antihypertensives, diuretics, alpha-blockers, beta-blockers, vasodilators, and tricyclic antidepressants 4, 2
• For patients with both supine hypertension and orthostatic hypotension, switch BP-lowering medications that worsen orthostatic hypotension to alternative therapies rather than simply reducing dosage 1, 2
• Avoid beta-blockers and alpha-blockers in frail elderly patients unless specifically indicated 1
• Do not automatically reduce antihypertensive medications in patients with asymptomatic orthostatic hypotension, as intensive BP control actually reduces orthostatic hypotension risk 2

Physical Countermeasures

• Increase fluid intake (water bolus treatment during periods of increased orthostatic stress) 6
• Increase dietary salt intake 2, 6
• Wear compression stockings to reduce venous pooling 2, 6
• Elevate the head of the bed to reduce supine hypertension 2, 6
• Teach physical countermaneuvers to improve orthostatic defenses during activities of daily living 6

Pharmacological Management (Second-Line)

When to Initiate Drug Therapy

• Reserve pharmacological treatment for symptomatic patients who fail conservative measures 6, 7
• The goal is to improve standing BP to minimize symptoms and improve standing time for activities of daily living, without causing excessive supine hypertension 6, 7
• There is no predefined blood pressure target; treatment aims for symptom relief and fall prevention 7

Medication Options

• Fludrocortisone for volume expansion is a cornerstone of treatment 6, 7
• Midodrine or droxidopa as pressor agents for neurogenic orthostatic hypotension 6, 7
• Droxidopa is FDA-approved specifically for neurogenic orthostatic hypotension 1
• Combination therapy with fludrocortisone plus a pressor agent is often necessary 6

Special Considerations for Elderly and Frail Patients

Hypertension Management in Patients with Orthostatic Hypotension

• When initiating treatment for patients aged ≥85 years and/or with moderate-to-severe frailty, use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents, followed by low-dose diuretics if necessary 1
• Consider deprescribing BP-lowering medications if blood pressure drops with progressing frailty 1
• Slow titration approach is warranted in elderly individuals with widely variable BP, history of medication side effects, or documented orthostatic hypotension 3

Monitoring and Follow-Up

• Regular monitoring of both standing and supine blood pressure is essential to avoid excessive supine hypertension 1, 6
• Serial monitoring is necessary because treatment of orthostatic hypotension is imperfect—it is impossible to normalize standing BP without generating some supine hypertension 6

Clinical Significance and Prognosis

Mortality and Morbidity Impact

• Orthostatic hypotension carries a 64% increase in age-adjusted mortality compared with control populations 3
• Strong correlation exists between severity of orthostatic hypotension and premature death, increased falls, and fractures 3
• The condition is highly age-dependent, occurring in approximately 7% of men over 70 years old 3

Common Pitfalls to Avoid

• Do not dismiss orthostatic hypotension as "brittle hypertension"—this misperception contributes to inadequate drug titration and poor BP control 3
• Orthostatic hypotension is a common barrier to intensive BP control that should be clearly documented; if present, drug therapy should be adjusted accordingly and appropriate warnings given to patients 3
• Diuretics and nitrates may further aggravate orthostatic hypotension and should be used cautiously 3