Autonomic dysfunction

Question 1

A 72 year old female presents with recurring dizziness. She has postural hypotension thought to be due to autonomic failure and is taking multiple medications for other conditions. How would you approach this situation?

Answer 1

Impression
Postural hypotension in the setting of ?autonomic dysfunction.

DDx

• Autonomic: Diabetes, Parkinson + syndromes (MSA), Lewy body dementia, age-related baroreceptor insensitivity
• Medications: polypharmacy, antihypertensives
• hypovolaemia

Ensure dizziness not syncopal/vertiginous in nature

• cardiac pathology: ACS, valvular, etc
• neurogenic
• vertigo

Question 2

Autonomic dysfunction - Hx

Answer 2

History

• Sx: LOC, visual changes, syncope/pre-syncope on standing, frequency, when started, progression
• HPI: Recent oral intake, diarrhoea/N/V?
• PMHx: dementia, Parkinsons, known diabetes?

Question 3

Autonomic dysfunction - Ex

Answer 3

Examination

• General appearance + Vitals
• Cardiac examination: murmurs, arrhythmias, oedema
• Neurological examination: features of Parkinson’s/neuropathy;s (Gait, cerebellar, tone, bradykinesia, tremor,

Question 4

Autonomic dysfunction - Ix

Answer 4

Investigations

• Bedside: ECG, postural BPs
• Bloods: FBC, UEC, LFT, lipid panel, HbA1C, etc
• Imaging:

Question 5

Autonomic dysfunction - Mx

Answer 5

Management
Supportive
- Oral/IV rehydration
- legs up, compression stockings
- medications review; perhaps benefit from reducing medications
- ACAT referral for discharge, PT/OT referral/review for clearance
- Electrolyte replacement
- falls risk management with OT/PT

Definitive
- Fludrocort: can cause fluid retention and hypokalaemia, however increa
o consider renal and cardiac function before starting, renal/cardiac consult.
- Medications review: assess for polypharmacy, drug interactions, over-zealous blood-pressure control
- Fluid status

Ongoing

• optimise other comorbidities (cardiac or otherwise)
• GP follow-up