Orthostatic Hypotension: Difference between revisions
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== Etiology == | == Etiology == | ||
Orthostatic hypotension etiology causes include: | Orthostatic hypotension etiology causes include: | ||
* Neurogenic | * Neurogenic eg Parkinson's disease, Diabetic nerve damage, Lewy body disease 9one of the most common causes of dementia in older adults), Postural Orthostatic Tachycardia Syndrome (POTS), Vasovagal syncope, Postprandial hypotension See 5 minute video clip below. | ||
{{#ev:youtube|https://www.youtube.com/watch?v=6LcX7fGaUe0&t=215s|width}}<ref>TreatneurogenicOHnow. Neurogenic orthostatic hypotension. Available from: https://www.youtube.com/watch?v=6LcX7fGaUe0&t=215s (last accessed 1.4.2019)</ref> | {{#ev:youtube|https://www.youtube.com/watch?v=6LcX7fGaUe0&t=215s|width}}<ref>TreatneurogenicOHnow. Neurogenic orthostatic hypotension. Available from: https://www.youtube.com/watch?v=6LcX7fGaUe0&t=215s (last accessed 1.4.2019)</ref> | ||
* Volume depletion eg [[Dehydration]], [[Hyperglycemia]], Hemorrhage, Vomiting. | * Non-neurogenic causes of the condition include: [[Myocardial Infarction|Heart attack]]; [[Aortic Valve Disease|Aortic stenosis]]; Vasodilation; Volume depletion (eg [[Dehydration]], [[Hyperglycemia]], Hemorrhage, Vomiting)<ref name=":2">very well health Orthotatic hypotension Available: https://www.verywellhealth.com/postural-hypotension-1764028 (accessed 11.4.2022)</ref>. | ||
* [[Medication and Falls|Medication]] related. eg [[vasodilators]], [[diuretics]], antidepressants, antipsychotics and dopaminergic drugs , [[polypharmacy]].<ref name=":0" /> | * [[Medication and Falls|Medication]] related. eg [[vasodilators]], [[diuretics]], antidepressants, antipsychotics and dopaminergic drugs , [[polypharmacy]].<ref name=":0" /> | ||
== Signs and Symptoms == | == Signs and Symptoms == | ||
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The person will present with symptoms occurring when rise from standing or sitting, particularly if done rapidly. The related signs and symptoms are due to reduced cerebral blood flow. These include: lightheadedness; generalised tiredness; vertigo; blurred vision; difficulty concentrating; palpitations; anxiety; nausea; falls.<ref name=":1">Wikipedia. [https://en.wikipedia.org/wiki/Orthostatic_hypotension Orthostatic hypotension.] Available from: https://en.wikipedia.org/wiki/Orthostatic_hypotension (last accessed 2.4.2019)</ref><br> | The person will present with symptoms occurring when rise from standing or sitting, particularly if done rapidly. The related signs and symptoms are due to reduced cerebral blood flow. These include: lightheadedness; generalised tiredness; vertigo; blurred vision; difficulty concentrating; palpitations; anxiety; nausea; falls.<ref name=":1">Wikipedia. [https://en.wikipedia.org/wiki/Orthostatic_hypotension Orthostatic hypotension.] Available from: https://en.wikipedia.org/wiki/Orthostatic_hypotension (last accessed 2.4.2019)</ref><br> | ||
== Diagnostic Procedures | == Diagnostic Procedures == | ||
Take the BP | Take the BP | ||
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* 1 minute after standing | * 1 minute after standing | ||
* 3 minutes after standing | * 3 minutes after standing | ||
A drop in systolic BP of 20mmHg or greater, a drop in systolic BP of 10mmHg or greater is diagnostic tool | A drop in systolic BP of 20mmHg or greater, a drop in systolic BP of 10mmHg or greater is diagnostic tool<ref name=":1" />. <br> | ||
== Outcome Measures == | == Outcome Measures == | ||
Line 37: | Line 33: | ||
== Management / Interventions == | == Management / Interventions == | ||
Apart from removing any offending medications the initial line of management are lifestyle related. These include; Drinking 2-3 litres of water, in small boluses over the day; increasing salt intake or salt supplements; elevating bed head at night to decrease fluid to kidneys with resultant urine production and fluid loss<ref name=":1" />; use of compression stockings and corsets when out; exercising major muscle groups eg static gluteals just before standing or on standing; counting a slow 10 before moving on from sit to stand position. | Apart from removing any offending medications the initial line of management are lifestyle related. These include; Drinking 2-3 litres of water, in small boluses over the day; increasing salt intake or salt supplements; elevating bed head at night to decrease fluid to kidneys with resultant urine production and fluid loss<ref name=":1" />; use of compression stockings and corsets when out; exercising major muscle groups eg static gluteals just before standing or on standing; counting a slow 10 before moving on from sit to stand position; Exercise, for cases caused by a weakened cardiovascular system<ref name=":2" />. | ||
Pharmacologic treatment should be implemented after lifestyle interventions have failed to relieve symptoms. Medications that work through different mechanisms in order to increase vascular tone are utilised. These include fludrocortisone and midodrine which are the first-line medications, but many other pharmacologic therapies can be used, including pyridostigmine.<ref name=":0" />{{#ev:youtube|https://www.youtube.com/watch?v=s7YcptyqYrQ&app=desktop|width}}<ref>Top doctors UK. How you can increase your BP. Available from: https://www.youtube.com/watch?v=s7YcptyqYrQ&app=desktop (last accessed 2.4.2019)</ref> | Pharmacologic treatment should be implemented after lifestyle interventions have failed to relieve symptoms. Medications that work through different mechanisms in order to increase vascular tone are utilised. These include fludrocortisone and midodrine which are the first-line medications, but many other pharmacologic therapies can be used, including pyridostigmine.<ref name=":0" />{{#ev:youtube|https://www.youtube.com/watch?v=s7YcptyqYrQ&app=desktop|width}}<ref>Top doctors UK. How you can increase your BP. Available from: https://www.youtube.com/watch?v=s7YcptyqYrQ&app=desktop (last accessed 2.4.2019)</ref> | ||
== Physiotherapy == | == Physiotherapy == | ||
[[File:Sit to stands.gif|right|frameless|100x100px]]During a PT session, it will be important to monitor a patient's BP before, during, and after exercise. It will also be necessary to choose appropriate exercises and environment to avoid these symptoms from occurring | |||
'''Falls prevention training'''. OH is positively associated with a greater [[Falls in elderly|falls]] risk.<ref>Mol A, Hoang PT, Sharmin S, Reijnierse EM, van Wezel RJ, Meskers CG, Maier AB. [https://www.ncbi.nlm.nih.gov/pubmed/30583909/ Orthostatic hypotension and falls in older adults: a systematic review and meta-analysis]. Journal of the American Medical Directors Association. 2018 Dec 21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30583909/ (last accessed 2.4.2019)</ref> [[ | * '''[[Falls]] prevention training'''. OH is positively associated with a greater [[Falls in elderly|falls]] risk.<ref>Mol A, Hoang PT, Sharmin S, Reijnierse EM, van Wezel RJ, Meskers CG, Maier AB. [https://www.ncbi.nlm.nih.gov/pubmed/30583909/ Orthostatic hypotension and falls in older adults: a systematic review and meta-analysis]. Journal of the American Medical Directors Association. 2018 Dec 21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30583909/ (last accessed 2.4.2019)</ref> [[Parkinson's]] clients have a 40-60% chance of having OH and hence a significant increase in falls risk.<ref>Isaacson SH, Skettini J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979788/ Neurogenic orthostatic hypotension in Parkinson’s disease: evaluation, management, and emerging role of droxidopa.] Vascular health and risk management. 2014;10:169. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979788/ (last accessed 2.4.2019)</ref> | ||
'''Compression garments'''. Measuring and fitting of appropriate garments and teaching in the fitting of these with aids eg stocking donner. | * '''[[Compression]] garments'''. Measuring and fitting of appropriate garments and teaching in the fitting of these with aids eg stocking donner. | ||
* '''Lifestyle strategies'''. As physiotherapists often are in regular contact with there clients take the time to consul on eg fluid and salt intake; use of bed head raisers; exercises to increase venous return on standing or just prior eg calf pumps, static quads or gluteals; avoiding standing for prolonged periods; not going out in hot sun or stuffy environments; small regular meals to prevent post prandial OH. Advising the patient to refrain from quick postural changes.<ref name="Swan">Swan L, Dupont J. Multiple System Atrophy. Journal of Physical Therapy 1999;79:488-94.</ref> | |||
* '''Education.''' Movement changes eg sit on edge of bed for 30 seconds before rising, count 10 once standing before moving off, rise slowly and wait 10 seconds if out in sun, fluid intake checks and taking water when going out. Swimming/[[aquatherapy]] could be suggested, as the hydrostatic pressure of the water counteracts the hypotension the patient is experiencing.<ref name="Swan" /> | |||
'''Education.''' Movement changes eg sit on edge of bed for 30 seconds before rising, count 10 once standing before moving off, rise slowly and wait 10 seconds if out in sun, fluid intake checks and taking water when going out. | |||
=== Implications of OH === | === Implications of OH === | ||
The importance of treating OH is many fold | The importance of treating OH is many fold | ||
* Dementia risk in increased by having OH<ref>Cardiology advisor. [https://www.thecardiologyadvisor.com/home/topics/hypertension/orthostatic-hypotension-may-increase-risk-for-dementia/ OH may increase risk for dementia.] Available from: https://www.thecardiologyadvisor.com/home/topics/hypertension/orthostatic-hypotension-may-increase-risk-for-dementia/ (last accessed 2.4.2019)</ref> | * Dementia risk in increased by having OH<ref>Cardiology advisor. [https://www.thecardiologyadvisor.com/home/topics/hypertension/orthostatic-hypotension-may-increase-risk-for-dementia/ OH may increase risk for dementia.] Available from: https://www.thecardiologyadvisor.com/home/topics/hypertension/orthostatic-hypotension-may-increase-risk-for-dementia/ (last accessed 2.4.2019)</ref> | ||
* Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident | * Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident [[Coronary Artery Disease (CAD)|CAD]], HF, and [[stroke]].<ref>https://academic.oup.com/eurheartj/article/36/25/1609/2293316 Available from: https://academic.oup.com/eurheartj/article/36/25/1609/2293316 (last accessed 2.4.2019)</ref> | ||
* A increased risk of falls | * A increased risk of falls | ||
* An impaired quality of life<ref name=":0" /><br> | * An impaired [[Quality of Life|quality of life]]<ref name=":0" /><br> | ||
== References == | == References == |
Revision as of 02:20, 11 April 2022
Definition[edit | edit source]
Orthostatic hypotension (OH) is defined as a sudden drop in blood pressure upon standing from a sitting or supine position. It is also known as postural hypotension.
- Diagnosis is made if the blood pressure drops by or greater 20mmHg systolically and 10mmHg diastolically. This occurs within three minutes of standing after being supine for 5 minutes or at 60% angle on a tilt table[1]. This sudden drop in blood pressure is due to failure of autonomic reflex, volume depletion, or adverse reaction to medication.
- Symptoms on presentation are commonly related to reduced blood flow to the brain but many patients can be asymptomatic. Frequent falls occur due to this disease process resulting in a high rate of morbitity and mortality and multiple hospital admissions.[2]
Watch this informative 4 minute viewing.
Etiology[edit | edit source]
Orthostatic hypotension etiology causes include:
- Neurogenic eg Parkinson's disease, Diabetic nerve damage, Lewy body disease 9one of the most common causes of dementia in older adults), Postural Orthostatic Tachycardia Syndrome (POTS), Vasovagal syncope, Postprandial hypotension See 5 minute video clip below.
- Non-neurogenic causes of the condition include: Heart attack; Aortic stenosis; Vasodilation; Volume depletion (eg Dehydration, Hyperglycemia, Hemorrhage, Vomiting)[5].
- Medication related. eg vasodilators, diuretics, antidepressants, antipsychotics and dopaminergic drugs , polypharmacy.[2]
Signs and Symptoms[edit | edit source]
The person will present with symptoms occurring when rise from standing or sitting, particularly if done rapidly. The related signs and symptoms are due to reduced cerebral blood flow. These include: lightheadedness; generalised tiredness; vertigo; blurred vision; difficulty concentrating; palpitations; anxiety; nausea; falls.[6]
Diagnostic Procedures[edit | edit source]
Take the BP
- 5 minutes after lying
- 1 minute after standing
- 3 minutes after standing
A drop in systolic BP of 20mmHg or greater, a drop in systolic BP of 10mmHg or greater is diagnostic tool[6].
Outcome Measures[edit | edit source]
Doing BP measures again as in initial diagnosis.
Management / Interventions[edit | edit source]
Apart from removing any offending medications the initial line of management are lifestyle related. These include; Drinking 2-3 litres of water, in small boluses over the day; increasing salt intake or salt supplements; elevating bed head at night to decrease fluid to kidneys with resultant urine production and fluid loss[6]; use of compression stockings and corsets when out; exercising major muscle groups eg static gluteals just before standing or on standing; counting a slow 10 before moving on from sit to stand position; Exercise, for cases caused by a weakened cardiovascular system[5].
Pharmacologic treatment should be implemented after lifestyle interventions have failed to relieve symptoms. Medications that work through different mechanisms in order to increase vascular tone are utilised. These include fludrocortisone and midodrine which are the first-line medications, but many other pharmacologic therapies can be used, including pyridostigmine.[2]
Physiotherapy[edit | edit source]
During a PT session, it will be important to monitor a patient's BP before, during, and after exercise. It will also be necessary to choose appropriate exercises and environment to avoid these symptoms from occurring
- Falls prevention training. OH is positively associated with a greater falls risk.[8] Parkinson's clients have a 40-60% chance of having OH and hence a significant increase in falls risk.[9]
- Compression garments. Measuring and fitting of appropriate garments and teaching in the fitting of these with aids eg stocking donner.
- Lifestyle strategies. As physiotherapists often are in regular contact with there clients take the time to consul on eg fluid and salt intake; use of bed head raisers; exercises to increase venous return on standing or just prior eg calf pumps, static quads or gluteals; avoiding standing for prolonged periods; not going out in hot sun or stuffy environments; small regular meals to prevent post prandial OH. Advising the patient to refrain from quick postural changes.[10]
- Education. Movement changes eg sit on edge of bed for 30 seconds before rising, count 10 once standing before moving off, rise slowly and wait 10 seconds if out in sun, fluid intake checks and taking water when going out. Swimming/aquatherapy could be suggested, as the hydrostatic pressure of the water counteracts the hypotension the patient is experiencing.[10]
Implications of OH[edit | edit source]
The importance of treating OH is many fold
- Dementia risk in increased by having OH[11]
- Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident CAD, HF, and stroke.[12]
- A increased risk of falls
- An impaired quality of life[2]
References[edit | edit source]
- ↑ Kaufman H. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. 1996. Clin Auton Res 6:125–126.
- ↑ 2.0 2.1 2.2 2.3 Ringer M, Lappin SL. Orthostatic Hypotension. InStatPearls [Internet] 2017 Oct 4. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448192/ (last accessed 1.4.2019)
- ↑ Health Link. Dizziness : what is orthostatic hypotension?. Available from: https://www.youtube.com/watch?v=_N8iwBn9u2s (last accessed 11.4.2022)
- ↑ TreatneurogenicOHnow. Neurogenic orthostatic hypotension. Available from: https://www.youtube.com/watch?v=6LcX7fGaUe0&t=215s (last accessed 1.4.2019)
- ↑ 5.0 5.1 very well health Orthotatic hypotension Available: https://www.verywellhealth.com/postural-hypotension-1764028 (accessed 11.4.2022)
- ↑ 6.0 6.1 6.2 Wikipedia. Orthostatic hypotension. Available from: https://en.wikipedia.org/wiki/Orthostatic_hypotension (last accessed 2.4.2019)
- ↑ Top doctors UK. How you can increase your BP. Available from: https://www.youtube.com/watch?v=s7YcptyqYrQ&app=desktop (last accessed 2.4.2019)
- ↑ Mol A, Hoang PT, Sharmin S, Reijnierse EM, van Wezel RJ, Meskers CG, Maier AB. Orthostatic hypotension and falls in older adults: a systematic review and meta-analysis. Journal of the American Medical Directors Association. 2018 Dec 21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30583909/ (last accessed 2.4.2019)
- ↑ Isaacson SH, Skettini J. Neurogenic orthostatic hypotension in Parkinson’s disease: evaluation, management, and emerging role of droxidopa. Vascular health and risk management. 2014;10:169. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979788/ (last accessed 2.4.2019)
- ↑ 10.0 10.1 Swan L, Dupont J. Multiple System Atrophy. Journal of Physical Therapy 1999;79:488-94.
- ↑ Cardiology advisor. OH may increase risk for dementia. Available from: https://www.thecardiologyadvisor.com/home/topics/hypertension/orthostatic-hypotension-may-increase-risk-for-dementia/ (last accessed 2.4.2019)
- ↑ https://academic.oup.com/eurheartj/article/36/25/1609/2293316 Available from: https://academic.oup.com/eurheartj/article/36/25/1609/2293316 (last accessed 2.4.2019)