What is the treatment for geriatric patients with orthostatic (postural) hypotension?

From the Guidelines

To treat geriatric patients with orthostatic hypotension, start with non-pharmacological approaches such as gradual position changes, adequate hydration (1.5-2 liters daily), increased salt intake (8-10g daily if no contraindications), compression stockings, and elevating the head of the bed 4-6 inches. If these measures are insufficient, medications can be added. First-line pharmacological options include fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily), which increases sodium retention and blood volume, and midodrine (starting at 2.5mg three times daily, maximum 10mg three times daily), an alpha-1 agonist that increases vascular tone. Droxidopa (100-600mg three times daily) is another option for persistent symptoms. Pyridostigmine (30-60mg three times daily) may help patients with autonomic dysfunction. When prescribing medications, start at low doses and titrate slowly to minimize side effects. Monitor for supine hypertension, especially with midodrine and droxidopa, by avoiding these medications within 4 hours of bedtime. Regularly assess medication effectiveness, side effects, and adjust treatment as needed. The goal is to reduce symptoms and fall risk while maintaining the patient's quality of life and independence, as supported by recent guidelines 1. It is also essential to consider the potential for polypharmacy and its implications in older adults, using tools such as the Beers criteria or the STOPP/START criteria to identify potential inappropriate medications 1. Key considerations include:

• Non-pharmacological interventions as first-line treatment
• Gradual introduction of medications with careful monitoring
• Regular assessment of treatment effectiveness and side effects
• Consideration of the patient's overall health status and potential for polypharmacy. Given the most recent and highest quality evidence, the treatment approach should prioritize non-pharmacological measures and carefully selected pharmacological interventions to minimize risks and maximize benefits for geriatric patients with orthostatic hypotension 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.

To treat geriatric patients with orthostatic hypotension,

• Midodrine can be used, but it should be used with caution due to the potential for marked elevation of supine blood pressure.
• The treatment should be initiated after standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations have been tried.
• Midodrine should be continued only for patients who report significant symptomatic improvement 2.
• It is essential to monitor the patient's blood pressure closely, especially in geriatric patients, due to the potential for supine hypertension.
• The dosage of midodrine is typically 10 mg three times a day, with the last dose not later than 6 P.M. 2.

From the Research

Treatment of Geriatric Patients with Orthostatic Hypotension

• Non-pharmacological interventions may be effective in treating orthostatic hypotension (OH) in geriatric patients, including physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward 3
• Abdominal compression, sleeping with head up in combination with pharmacological treatment, eating smaller and more frequent meals, and drinking 480 mL of water may also be beneficial in improving OH 3
• A stepped-care algorithm approach to treatment may be successful for many patients, but the treatment approach is not standardized 4
• Identification and treatment of reversible causes, as well as non-pharmacologic and pharmacologic therapies, are important in managing OH in geriatric patients 5

Pharmacological and Non-Pharmacological Interventions

• Specific pharmacological and non-pharmacological interventions have been established for the treatment of OH, but randomized data evaluating the impact of therapeutic interventions on morbidity and mortality outcomes are lacking 6
• No single agent has been universally successful in relieving the symptoms of OH, and trials of single agents or combinations of agents are needed to identify the most appropriate therapy for individual patients 5

Importance of Screening and Diagnosis

• Screening blood pressures should be taken in all patients with risk factors for OH, as most patients with OH either have no symptoms or atypical symptoms 4
• Assessment of symptoms and the blood pressure response to standing is an important part of the initial evaluation and follow-up of geriatric patients 7