What causes hypotension in the elderly not on medications, presenting with dizziness?

From the Guidelines

Hypotension with dizziness in elderly individuals not on medications requires immediate attention to prevent falls and potential serious underlying conditions, and the first step is to check blood pressure in both sitting and standing positions to determine if orthostatic hypotension is present. The management of hypotension in the elderly should prioritize non-pharmacological approaches, including increasing fluid intake to 1.5-2 liters daily and adding more salt to the diet, unless contraindicated by heart or kidney disease 1. Some key considerations in managing hypotension in the elderly include:

• Checking for orthostatic hypotension by measuring blood pressure 1 and/or 3 min after standing, after the patient has sat or lain for 5 min 1
• Encouraging increased salt and fluid intake in selected patients with syncope due to dehydration, as sodium supplementation improves plasma volume and orthostatic tolerance 1
• Wearing compression stockings and rising slowly from sitting or lying positions to help manage symptoms
• Investigating underlying causes, including dehydration, anemia, heart problems, neurological disorders, or endocrine issues like adrenal insufficiency
• Considering physical countermaneuvers like crossing legs while standing, tensing calf muscles, or squatting to temporarily maintain blood pressure It is essential to prioritize medical evaluation over self-management alone, as hypotension in the elderly can indicate serious underlying conditions and increase the risk of falls due to reduced cerebral blood flow. In terms of medication management, reducing or withdrawing medications that may cause hypotension can be beneficial in selected patients with syncope, but close supervision is required to avoid worsening preexisting supine hypertension or cardiac arrhythmias 1. Overall, the management of hypotension in the elderly should focus on addressing the underlying causes, managing symptoms, and preventing falls, with a priority on non-pharmacological approaches and medical supervision.

From the FDA Drug Label

Elderly subjects may commonly have conditions that may be exacerbated by fludrocortisone therapy including, but not limited to, hypertension, edema, hypokalemia, congestive heart failure, cataracts, glaucoma, increased intraocular pressure, renal insufficiency, and osteoporosis Elderly subjects may also commonly be taking concomitant drug therapy such as digitalis glycosides, oral anticoagulants, antidiabetic drugs (oral agents and insulin), and aspirin which may interact with fludrocortisone

The answer to the question of hypotension in elderly not on medications with dizziness is not directly addressed by the provided drug labels. However, hypotension is not typically exacerbated by fludrocortisone, and in fact, fludrocortisone is sometimes used to treat conditions related to low blood pressure.

• Key points:
  • Fludrocortisone may have interactions with other medications that can affect blood pressure.
  • Elderly patients may have conditions that can be exacerbated by fludrocortisone.
  • The labels do not provide direct information on the treatment of hypotension in elderly patients with dizziness. 2

From the Research

Hypotension in Elderly Not on Medications with Dizziness

• Hypotensive syndromes are common among older adults, causing significant morbidity like dizziness, syncope, and falls, as well as a resultant decrease in function 3.
• Non-pharmacological measures should be the first line of management for hypotensive syndromes, but it is not always sufficient for subjects with symptomatic hypotensive syndromes 3.
• Several nonpharmacologic strategies for orthostatic hypotension exist, including avoiding large carbohydrate-rich meals, limiting alcohol consumption, maintaining adequate hydration, adding salt to foods, and using compression stockings, tilt-table exercises, or abdominal binders 4.

Management of Hypotension

• If non-pharmacological strategies fail, limited evidence-based pharmacologic treatment options are available, including the use of fludrocortisone, midodrine, pyridostigmine, and droxidopa, as well as pseudoephedrine, octreotide, and atomoxetine 4.
• Midodrine is a prodrug that undergoes enzymatic hydrolysis to the selective alpha 1-adrenoceptor agonist desglymidodrine after oral administration, and it significantly increases 1-minute standing systolic blood pressure compared with placebo 5.
• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and it is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 6.

Treatment of Orthostatic Hypotension

• Orthostatic hypotension is a decrease in blood pressure >20mmHg for systolic and/or >10mmHg for diastolic within 3 minutes after transition from supine to upright, and it may be symptomatic or not 7.
• The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes, and/or polymedication, and first intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression 7.
• Atomoxetine has been shown to be an effective and safe agent for symptom improvement and blood pressure control in elderly patients with primary orthostatic hypotension 4.