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Orthostatic Hypotension

Key Facts

  • Orthostatic hypotension is most bothersome in moderate to advanced patients.
  • Dopaminergic medication may be the cause.
  • Patients may not associate orthostatic hypotension with PD.

Clinical Best Practices

  • Evaluate factors that could contribute to orthostatic hypotension and instruct the patient in safety measures.
  • Consider options before initiating pharmacological treatment.

Orthostatic hypotension can affect 20% to 50% of PD patients. It can occur at any stage, but usually is most bothersome in moderate to advanced patients. If occurring early, consider alternative diagnoses such as multiple system atrophy.

Presentation

  • Dizziness or lightheadedness
  • Generalized weakness
  • Clouded mentation
  • Syncope
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Common Causes

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Diagnosis

  • Clinical history and physical examination—24-hour blood pressure (BP) monitor, measurement of orthostatic BP after standing for 3 minutes or home monitoring of orthostatic BP will help in making the diagnosis
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Barriers to Diagnosis 

  • Lack of patient insight–you must have an informed other (spouse or family member)
  • Lack of disclosure
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Treatment Options

  • First, consider reducing or stopping antihypertensive agents.
  • Second, encourage hydration and compression stockings.
  • Third, consider fludrocortisone (monitor potassium), midodrine or indomethacin.
  • Patient education is important.
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Important Caveats to Therapy 

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PD Symptoms Table

Non-motor Symptoms Questionnaire

AAN Guidelines - Practice Parameter: treatment of nonmotor symptoms of Parkinson disease

Low Blood Pressure in PD

References: 

Wood LD, Neumiller JL, Setter SM, Dobbins EK. Clinical review of treatment options for select nonmotor symptoms of Parkinson’s disease. Am J Geriatr Pharmacother. 2010;8(4):294-315.

Senard JM, Brefel-Courbon C, Rascol O, Montastruc JL. Orthostatic hypotension in patients with Parkinson’s disease: pathophysiology and management. Drugs Aging. 2001;18(7):495-505.