Have acute deep vein thrombosis. Exhibit the clinical syndrome of shock. Have severely altered mental status. Have possible spinal injuries. Have lower extremity or pelvic fractures. Are not mobile enough to get out of bed. Equipment Noninvasive blood pressure measurement device.
Blood pressure cuff of correct size for the patient. Procedure Instruct the patient on the process of orthostatic blood pressure measurement and its rationale. Assess by verbal report and observation the patient's ability to stand. Have patient lie in bed with the head flat for a minimum of 3 minutes, and preferably 5 minutes. Measure the blood pressure and the pulse while the patient is supine. Instruct patient to sit for 1 minute. Ask patient about dizziness, weakness, or visual changes associated with position change.
Note diaphoresis or pallor. Check sitting blood pressure and pulse. Instruct patient to stand. If patient is unable to stand, sit patient upright with legs dangling over the edge of the bed. The patient should be permitted to resume a supine position immediately if syncope or near syncope develops. Measure the blood pressure and pulse immediately after patient has stood up, and then repeat the measurements 3 minutes after patient stands. Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement.
Assist patient back to bed in a position of comfort. Document vital signs and other pertinent observations on the nursing flowsheet or in the medical record. Note all measurements taken and the position of the patient during each reading. Evaluation Subtract values 3 minutes after standing or if patient cannot stand, then sitting from lying values. A heart rate increase of at least 30 beats per minute after 3 minutes of standing may suggest hypovolemia, independent of whether the patient meets criteria for orthostatic hypotension.
A blood pressure drop immediately after standing that resolves at 3 minutes does not indicate orthostatic hypotension. However, this finding may be useful to confirm a patient's complaint of feeling dizzy upon standing and may lead to patient education about using caution when arising from a lying or sitting position. Report all findings to the treating medical provider, including all sets of blood pressure and pulse results, and whether the patient experienced pallor, diaphoresis, or faintness when upright.
Page last reviewed January Back to Top. Generalized polyneuropathy, prominent pain, and temperature abnormalities; carpal tunnel syndrome; cardiomyopathy; diarrhea; weight loss.
Fat aspirate; rectal or gingival biopsy for amyloid deposits; genetic testing for hereditary amyloidosis; serum and urine protein electrophoresis for primary amyloidosis. Associated with generalized polyneuropathy; other autonomic symptoms, including gastroparesis, diarrhea, urinary retention, and erectile dysfunction.
Autonomic dysfunction occurs early in course; parkinsonism; progressive dementia precedes or accompanies parkinsonism; fluctuating cognitive impairment; visual hallucinations. Severe, early autonomic dysfunction; parkinsonism; dysarthria; stridor; contractures; dystonia. Magnetic resonance imaging of brain shows changes in putamen, pons, middle cerebellar peduncle, and cerebellum.
Lewy bodies in cytoplasm of CNS neurons, resulting in extrapyramidal motor symptoms. Autonomic dysfunction occurs later, often as adverse effect of disease-specific therapy; parkinsonism; dementia. Lewy bodies in pre- and postganglionic neurons of peripheral autonomic nervous system. Adapted from Freeman R.
Clinical practice. Neurogenic orthostatic hypotension. N Engl J Med. Acute orthostatic hypotension generally resolves with treatment of the underlying cause. In patients with chronic orthostatic hypotension, pharmacologic and nonpharmacologic treatments may be beneficial. All patients with chronic orthostatic hypotension should be educated about their diagnosis and goals of treatment, which include improving orthostatic blood pressure without excessive supine hypertension, improving standing time, and relieving orthostatic symptoms.
Nonpharmacologic treatment should be offered to all patients initially. If potentially contributing medications cannot be discontinued, then patients should be instructed to take them at bedtime when possible, particularly antihypertensives.
Older patients should consume a minimum of 1. Water boluses one mL glass of tap water in one study and two mL glasses of water in rapid succession in another study have been shown to increase standing systolic blood pressure by more than 20 mm Hg for approximately two hours. Sodium may be supplemented by adding extra salt to food or taking 0. A hour urine sodium level can aid in treatment.
Patients with a value of less than mmol per 24 hours should be placed on 1 to 2 g of supplemental sodium three times a day and be reevaluated in one to two weeks, with the goal of raising urine sodium to between and mEq. Lower-extremity and abdominal binders may be beneficial. A randomized, single-blind controlled study using tilt-table testing demonstrated effective management of orthostatic hypotension by application of lower-limb compression bandages. An exercise program focused on improving conditioning and teaching physical maneuvers to avoid orthostatic hypotension has proven to be beneficial.
Squatting has been used to alleviate symptomatic orthostatic hypotension. In patients who do not respond adequately to nonpharmacologic therapy for orthostatic hypotension, medication may be indicated. Fludrocortisone, which is a synthetic mineralocorticoid, is considered first-line therapy for the treatment of orthostatic hypotension. Dosing should be titrated within the therapeutic range until symptoms are relieved, or until the patient develops peripheral edema or has a weight gain of 4 to 8 lb 1.
Hypokalemia, which is dose-dependent and can appear within one to two weeks of treatment, may occur. Midodrine, a peripheral selective alphaadrenergic agonist, significantly increases standing systolic blood pressure and improves symptoms in patients with neurogenic orthostatic hypotension.
Adverse effects include piloerection, pruritus, and paresthesia. Its use is contra-indicated in patients with coronary heart disease, urinary retention, thyrotoxicosis, or acute renal failure. The U. Food and Drug Administration has issued a recommendation to withdraw midodrine from the market because of a lack of post-approval effectiveness data. Its use generally should be restricted to subspecialists. It is believed to have a synergistic effect when combined with fludrocortisone.
Pyridostigmine Mestinon. Pyridostigmine is a cholinesterase inhibitor that improves neurotransmission at acetylcholine-mediated neurons of the autonomic nervous system. In a double-blind crossover study, patients were randomized to groups receiving 60 mg of pyridostigmine; 60 mg of pyridostigmine with 2. Adverse effects include loose stools, diaphoresis, hypersalivation, and fasciculations.
Table 8 outlines nonpharmacologic and pharmacologic options for the management of orthostatic hypotension. Abdominal and lower extremity compression Acute boluses of water up to mL Adequate hydration Isometric, lower-extremity physical exercise Physical maneuvers e.
Sodium supplementation up to 1 to 2 g three times per day Fludrocortisone 9 , 24 , Starting dosage of 0. Midodrine 9 , Starting dosage of 2. Acute renal failure, severe heart disease, urinary retention, thyrotoxicosis, pheochromocytoma. Pyridostigmine Mestinon 24 , Starting dosage of 30 mg two to three times per day, titrate to 60 mg three times per day.
Cholinergic effects, including loose stools, diaphoresis, hypersalivation, fasciculations. Hypersensitivity to pyridostigmine or bromides, mechanical intestinal or urinary obstruction. Generic price listed first, brand price listed in parentheses. Montvale, N. Information from references 9 , 10 , 21 through 24 , 26 , 28 , and Search date: May 31, Already a member or subscriber?
Log in. Interested in AAFP membership? Learn more. Address correspondence to Jeffrey B. Reprints are not available from the authors. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.
Army Medical Department or the U. Army Service at large. Figure 1 provided by Jay Siwek, MD. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy.
Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population. Orthostatic hypotension in older adults. The Cardiovascular Health Study. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. Hollister AS. Orthostatic hypotension. Causes, evaluation, and management. West J Med. EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol. Freeman R. Am Fam Physician.
Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. Practice of Geriatrics. Philadelphia, Pa.
Clinical indicators of dehydration severity in elderly patients. J Emerg Med. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Carlson JE. Assessment of orthostatic blood pressure: measurement technique and clinical applications. South Med J. Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension.
Lamarre-Cliche M, Cusson J. The fainting patient: value of the head-upright tilt-table test in adult patients with orthostatic intolerance. Postural hypotension and postural dizziness in elderly women. The study of osteoporotic fractures. Arch Intern Med. Are current recommendations to diagnose orthostatic hypotension in Parkinson's disease satisfactory?
Mov Disord. Orthostatic hypotension in de novo Parkinson disease. Arch Neurol. Prospective evaluation of patients with syncope: a population-based study. Heaven DJ, Sutton R. Crit Care Med. Low PA, Singer W. Management of neurogenic orthostatic hypotension: an update.
Lancet Neurol. Water drinking as a treatment for orthostatic syndromes. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study.
J Am Coll Cardiol. Bradley WG. Neurology in Clinical Practice. Fludrocortisone in the treatment of hypotensive disorders in the elderly [published correction appears in Heart. A double-blind, dose-response study of midodrine in neurogenic ortho-static hypotension. Food and Drug Administration. Drug safety and availability. Midodrine update. September Accessed January 3, Pyridostigmine treatment trial in neurogenic orthostatic hypotension.
Therapeutic experience with fludrocortisone in diabetic postural hypotension. Br Med J. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Next: Screening for Developmental Delay. Sep 1, Issue. Evaluation and Management of Orthostatic Hypotension. C 6 , 14 Patients with chronic orthostatic hypotension should be counseled to avoid large carbohydrate-rich meals, limit alcohol intake, and ensure adequate hydration. C 6 , 22 Fludrocortisone, midodrine, and pyridostigmine Mestinon are effective therapies for chronic orthostatic hypotension.
Enlarge Print Table 1. Table 1. Enlarge Print Table 2. Table 2. Enlarge Print Table 3. Physical Examination Clues to Diagnosis of Orthostatic Hypotension Examination findings Possible diagnosis Comments Aphasia, dysarthria, facial droop, hemiparesis Stroke — Cardiac murmur or gallop Congestive heart failure, myocardial infarction — Cogwheel rigidity, festinating gait, lack of truncal rotation while turning, masked facies Parkinson disease — Confusion, dry mucous membranes, dry tongue, longitudinal tongue furrows, speech difficulty, sunken eyes, upper body weakness Dehydration in older patients Study of 55 patients 61 to 98 years of age in emergency care setting found these findings highly reliable 12 Decreased libido, impotence in men; urinary retention and incontinence in women Pure autonomic failure 12 — Dependent lower extremity edema, stasis dermatitis Right-sided congestive heart failure, venous insufficiency — Information from references 11 and Table 3.
Enlarge Print Table 4. Indications and Procedure for Head-Up Tilt-Table Testing Indications High probability of orthostatic hypotension despite an initial negative evaluation e. Table 4.
Enlarge Print Figure 1. Patient undergoing head-up tilt-table testing. Figure 1. Enlarge Print Table 5. Responses to Head-Up Tilt-Table Testing Condition Physiologic response Normal Heart rate increases by 10 to 15 beats per minute Diastolic blood pressure increases by 10 mm Hg or more Dysautonomia Immediate and continuing drop in systolic and diastolic blood pressure No compensatory increase in heart rate Neurocardiogenic syncope Symptomatic, sudden drop in blood pressure Simultaneous bradycardia Occurs after 10 minutes or more of testing Orthostatic hypotension Systolic blood pressure decreases by 20 mm Hg or more or Diastolic blood pressure decreases by 10 mm Hg or more Postural orthostatic tachycardia syndrome Heart rate increases by at least 30 beats per minute or Persistent tachycardia of more than beats per minute Information from reference Table 5.
Enlarge Print Table 6. Table 6. Enlarge Print Table 7. Table 7. Enlarge Print Table 8. Management of Orthostatic Hypotension Nonpharmacologic management Abdominal and lower extremity compression 23 Acute boluses of water up to mL 22 Adequate hydration 22 Isometric, lower-extremity physical exercise 10 Physical maneuvers e.
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