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Introduction   

Orthostatic hypotension is a medical condition that can affect any age group, although it’s more common in older adults. It’s important for nurses and healthcare providers to understand the signs and symptoms of orthostatic hypotension, diagnosis, treatment, and potential complications. This course aims to equip learners with knowledge related to orthostatic hypotension. It reviews the definition, epidemiology, pathophysiology, and etiology of orthostatic hypotension. This course also describes the signs and symptoms, diagnosis, and treatment. Lastly, it reviews potential complications along with patient education and prevention strategies.  

Definition 

This section will discuss the definition of orthostatic hypotension.  

Orthostatic hypotension is a sudden drop in blood pressure with position change, like standing up from sitting or lying down flat (supine position) [6]. It is also called postural hypotension.  

For a person to be considered to have orthostatic hypotension, their systolic blood pressure must decrease by 20 mmHg with 3 minutes of standing or their diastolic must decrease by 10 mmHg during the same time. This can be compared to either lying supine and/or sitting blood pressure for a period of 5 minutes [3].  

Orthostatic hypotension can be further divided into two types: classic and delayed. Classic orthostatic hypotension occurs when blood pressure drops within 3 minutes of standing, while delayed occurs after 3 minutes [6].  

Epidemiology 

This section will discuss the epidemiology of orthostatic hypotension. 

In the United States (U.S.), it’s estimated that around 6% of the population has orthostatic hypotension [3]. The likelihood of having this medical condition increases with age, especially for people 65 years and older [6].  

A research study published in 2020 [2] found that the mean age of people with orthostatic hypotension was 67.6 years old with a standard deviation of 9.3 years. It also reported that 26.9% of people with orthostatic hypotension were age 75 and older. Thus, additionally confirming that the chances of developing or having this condition increase with age [2]. 

A systematic review and meta-analysis conducted by (7) analyzed over 23,000 patient records and 26 orthostatic hypotension studies. The systemic review found that 1 in 5 community-dwelling adults over 60 years old had orthostatic hypotension.  

Community-dwelling adults were those who lived in their own home, regardless of if they received home health services. Seadon et al.’s review also reported that 1 in 4 adults over 60 years old who lived in long-term care facilities have orthostatic hypotension as well [7].  

Additionally, orthostatic hypotension is common among patients who have hypertension and those who are being treated with anti-hypertensive medications. This may be due to healthcare providers prescribing too high a dose of blood pressure-lowering medications [2].  

Additionally, people with diabetes are at an increased risk for postural hypotension [9]. Patients who are hospitalized also have a higher rate of developing or having orthostatic hypotension [8]. People with cardiovascular disease are at an increased risk for orthostatic hypotension as well [6].  

Pathophysiology and Etiology of Orthostatic Hypotension 

This section discusses the pathophysiology and etiology of orthostatic hypotension. 

When a person moves to the upright or standing position, gravity pulls the blood from the upper body into the lower extremities [3]. This often leads to pooling of about 300 ml to 800 ml of blood in the lower limbs [6]. The pooling causes a person’s blood pressure to temporarily decrease due to lack of blood return to the heart and thus, decreases cardiac output. A person’s body will compensate by increasing its heart rate to ensure blood flow and pressure are stable throughout the body [3]. This compensatory mechanism is also called a baroceptor reflex, where a person’s body increases sympathetic activity and decreases vagal tone [6].  

Most people do not feel this compensation in heart rate or drop in blood pressure when standing. However, when people do feel this or experience symptoms, this could be an indicator of orthostatic hypotension and lack of baroreceptor reflex. Sometimes the person’s body has difficulty stabilizing their blood pressure after standing for several minutes [3].  

There are a few major causes of orthostatic hypotension, it can be neurogenic, non-neurogenic or medication related. Neurogenic causes can be neurological or neurodegenerative conditions that lead to instability of the autonomic nervous system. Some examples include Parkinson’s disease, diabetes, vitamin B12 deficiency, and autoimmune and rheumatological diseases.  

Non-neurogenic causes can be from fluid volume depletion, prolonged bed rest, advanced age, adrenal insufficiency, and cardiovascular disease. Some non-neurogenic examples are anemia, dehydration, aortic stenosis, heart failure, hypertension, and others.  

Lastly, medications can cause orthostatic hypotension. Common medications are antihypertensives, nitrates, tricyclic antidepressants, diuretics, and beta-blockers amongst others. Chronic and short-term effects of alcohol consumption can cause orthostatic hypotension as well [6]. However, it’s also estimated that about 40% of orthostatic hypotension cases, that the cause is not known [3].  

Clinical Signs and Symptoms 

This section discusses the signs, symptoms, and physical exam findings of orthostatic hypotension. 

Signs and symptoms of orthostatic hypotension can vary depending on the patient and some patients have no symptoms at all. If a patient does have symptoms, these can commonly include: 

• Feeling lightheaded or faint when standing up 
• Dizziness when standing up 
• Falling 
• Temporary loss of consciousness (also known as syncope) 
• Nausea 
• Weakness  

[5]   

Patients can also have less common symptoms such as blurry vision, problems concentrating, fatigue, shortness of breath, chest or back pain, and lower limb pain. Some patients have a suboccipital headache and posterior neck pain, which is also called a “coat hanger” headache or pain [6].  

Diagnosis 

This section reviews how orthostatic hypotension is diagnosed, including diagnostic tests performed. 

Healthcare providers and nurses should screen all patients for signs and symptoms of orthostatic hypotension, especially those who are older. If the healthcare provider or nurse suspects a patient has orthostatic hypotension, they should perform orthostatic vital signs [6].  

To take orthostatic vital signs, the healthcare professional should follow a series of steps and record the findings. First, the patient should lie down for 5 minutes on the exam table and then the patient’s blood pressure and heart rate will be measured and recorded. Next, have the patient stand in the upright position and remeasure their blood pressure and heart rate after standing for 1 minute and then 3 minutes and record.  

As mentioned, a decrease in the systolic of 20 mmHg or greater or decrease in the diastolic of 10 mmHg or greater is considered orthostatic hypotension. If the patient experiences any symptoms, like lightheadedness, this is also considered abnormal, and the patient is positive for orthostatic hypotension [1]. The healthcare provider or nurse may also repeat the blood pressure and heart rate after 3 minutes of standing to screen for delayed orthostatic hypotension [6].  

Diagnosis by the healthcare provider is made by completing a thorough medical history, including the presence of blood pressure decline or symptoms when taking orthostatic vital signs. The healthcare professional should also ask patients about what medications they are currently taking, as some medications can cause this condition, like as mentioned in the pathophysiology and etiology section [6].  

The healthcare provider may also order diagnostic tests to rule out other possible etiologies, including cardiac and neurological causes. An initial test may include an electrocardiogram (ECG) to look for ECG changes, heart blocks, and arrhythmias. Bloodwork, such as a complete blood count (CBC) and comprehensive metabolic panel (CMP), can be helpful to determine if dehydration, anemias, diabetes, or other health conditions may be contributing. Additional tests may also be completed, which are dependent on the healthcare provider’s physical exam findings. For example, if a patient has a murmur, the healthcare provider may order an echocardiogram [6].  

Sometimes it can be difficult to determine the exact underlying cause, since it could be caused by a variety of factors, like for example an antihypertensive drug and the presence of anemia. Additionally, change in heart rate is another factor when taking orthostatic vital signs, as this can oftentimes indicate neurogenic or non-neurogenic causes.  

If a patient’s heart rate does not increase more than 15 beats per minute while standing, this could mean it’s a neurogenic cause. Conversely, if the patient’s heart rate increases more than 15 beats per minute when standing could indicate a non-neurogenic cause. However, the healthcare provider and nurse should also consider what medications the patient is taking, as beta-blockers can mask changes in heart rate [6].  

Treatment and Patient Education 

This section discusses the treatment options and patient education regarding orthostatic hypotension.  

Treatment of postural hypotension depends on the underlying etiology, if readily identified and reversible. For example, if the cause is a medication, then that medication dosage should be decreased or replaced with another medication. If the patient has any underlying medical conditions that are causing orthostatic hypotension, then these should be addressed. For instance, if the patient has vitamin B12 deficiency, then vitamin B12 supplementation would be prescribed by the healthcare provider. Follow-up blood work and appointments would be needed to ensure this alleviates symptoms and the presence of orthostatic hypotension. Remember, postural hypotension can have many contributing factors, so although potentially eliminating one cause does not mean another is not present.  

If the cause is dehydration or infection, the patient may need emergency treatment and intravenous (IV) fluid resuscitation, depending on the severity. For patients that are asymptomatic, treatment does not need to be initiated, except if the patient has Parkinson’s disease. For patients with neurological conditions, like Parkinson’s disease, sometimes this means weaning, discontinuing, or changing certain medications [6].  

Sometimes symptoms of postural hypotension can worsen with certain activities. Therefore, the healthcare provider and nurse should educate patients on avoiding these certain activities. Activities might include standing for too long, drinking alcohol, or taking a hot bath or shower. Additionally, eating large meals and heat or exertion can cause symptoms. Patients with this condition should also be encouraged to stay properly hydrated, especially when in a hot environment, and understand they are at higher risk for falling [6].  

Additional non-pharmacological education given by the healthcare professional may include wearing lower limb compression socks or abdominal binder. Patients should be instructed on gradually changing positions, like when going from lying to standing, and they should sit upright in between for a few minutes to let their body compensate. In addition, patients can cross their legs while standing or tense the muscles in the legs to help with blood pressure changes. Some patients may be instructed to sleep with the head of the bed elevated or practice certain exercises to prevent orthostatic hypotension [6].  

If non-pharmacological treatment and identifying the possible etiology do not reverse orthostatic hypotension, then prescribing medications to help with symptoms may be needed. Some common medications are fludrocortisone, midodrine, and droxidopa [6].  

Potential Complications 

This section will discuss the potential complications related to orthostatic hypotension. 

Orthostatic hypotension can also lead to complications. Since postural hypotension causes a temporary or transient loss of blood flow to the brain, it can lead to falls, trauma, and stroke [4].  

Patients may also be at increased risk for heart disease, atrial fibrillation, and heart failure [6, 4].  

Conclusion

The likelihood of having orthostatic hypotension increases with age and people who are in the 65 years or older age group have a higher prevalence. Therefore, healthcare providers and nurses must recognize the signs and symptoms of this condition along with the importance of taking orthostatic vital signs and screening patients. A thorough history, including medications, and physical exam must be completed to help determine an underlying etiology.  

Oftentimes, there may be several underlying etiologies present, so monitoring and follow-up is key. Patient education should be provided regarding this condition, and prevention strategies to avoid potential symptoms.  

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