Orthostatic hypotension

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 approach this situation?

Imp/DDx/Goals

Answer 1

Impression
Likely orthostatic hypotension. given likely due to autonomic dysfunction, would need to screen for cognitive impairment and forms of dementia including parkinsons, lewy-body dementia and multiple systems atrophy (MSA). Alternatively, need to consider the role of polypharmacy or certain medications that may be contributing to this presentation.

Reduced baroreceptor sensitivity can occur as a normal part of the ageing process.

Goals

• complete comprehensive patient assessment including medications review
• exclude central/organic causes of dizziness/autonomic dysfunction
• initiate appropriate treatment and management

Question 2

Orthostatic hypotension - History

Answer 2

History

• sx: light-headedness, dizziness (characterise vertiginous vs cardiac vs BP),
• RED FLAGS: weakness, chest pain, visual changes, aura
• PMHx: dementia, parkinsons, prev history of same
• meds: BBlockers, antihypertensives, TCAs
• FamHx
• SNAP

Question 3

Orthostatic hypotension - Examination

Answer 3

Examination

• General observation + vitals
• postural BP (drop of >20mmHg significant)
• cardiovascular examination
• neurological examination (parkinsons, other deficits)
• cognitive assessment

Question 4

Orthostatic hypotension - Investigations

Answer 4

Investigations
Is largely a clinical diagnosis, however investigations may be warranted to identify underlying/organic causes.

• Bedside: ECG, Postural BPs, vitals
• Bloods: lipid panel, BNP, Trops, FBC, EUC, BSL
• Imaging: CT-B/MRI-B if suspicious of organic cause
• other: ambulatory BP

Question 5

Orthostatic hypotension - Management

Answer 5

Management:
Non-pharmacological
- hydration/ volume expansion (depending on other co-morbidities ie CKD)
- get up slowly
- patient education
- allied health/aged care assessment
- falls risk prevention education

Pharmacological

• medications review
• change/reduce potentially contributary medications
• consider starting mineralocorticoid therapy (fludrocortisone)
• consider role for short-acting pressor therapy if still refractory to treatment