Orthostatic hypotension in the elderly

Orthostatic hypotension most commonly occurs in hypertensive elderly patients (age-related autonomic impairment) who have comorbidities that either directly aggravate orthostatic hypotension or require treatment with drugs that aggravate orthostatic hypotension (see Assessment of orthostatic hypotension for examples).

Nocturnal supine hypertension causes a pressure natriuresis, which exacerbates orthostatic hypotension; this is mostly seen in conditions with autonomic failure. Diagnosis of nocturnal supine hypertension may require ambulatory blood pressure (BP) monitoring.

In the absence of autonomic failure, uncontrolled hypertension is associated with an increased risk of orthostatic hypotension; there is evidence that optimising antihypertensive therapy is associated with less orthostatic hypotension in the long termMoloney, 2021. Do not stop appropriate antihypertensive therapies without clear indication or without trying nondrug orthostatic hypotension treatment strategies first.

Neurodegenerative conditions (eg Parkinson disease, multiple system atrophy, dementia with Lewy bodies) are typically associated with a large postural BP drop and significant risk of falls. In the context of cognitive impairment, involvement of carers in management strategies is important.