Monday, June 17, 2024

Parkinson’s Disease Orthostatic Hypotension Treatment

Manage Neurogenic Orthostatic Hypotension

Gail Discusses Parkinson’s Disease and Neurogenic Orthostatic Hypotension

Neurogenic orthostatic hypotension is a condition that is part of a larger category called orthostatic hypotension , which is also known as postural hypotension. nOH is caused by dysfunction in the autonomic nervous system and causes people to feel faint when they stand or sit up. Learn more about nOH in the first part of our article.

The good news is that there is treatment for neurogenic orthostatic hypotension. The goal of treatment is not to achieve normal blood pressure values, but rather, to reduce symptoms of nOH and improve your quality of life.

How Common Is Noh In People With Parkinsons

An estimated 30 to 50% of people with Parkinsons experience nOH. The prevalence of nOH increases with both age and number of years of living with Parkinsons. Although nOH in Parkinsons is relatively common, not everyone will experience symptoms. For that reason, people with Parkinsons should be screened for nOH, even if they have no symptoms.

Conversely, nOH can be one of the earliest symptoms of Parkinsons and can appear several years even decades before the onset of motor problems like tremor or stiffness. Therefore, people who have nOH, but do not have any significant motor or cognitive symptoms, should also be monitored closely to watch for early signs or symptoms of Parkinsons.

Diagnosis Of Neurogenic Orthostatic Hypotension

Once a BP drop indicating OH is identified, further investigationinto the underlying cause is warranted. Patients with nOH can often bedistinguished clinically from patients with non-neurogenic OH by a bluntedorthostatic heart rate response ,although this single variable is not a perfectly sensitive or specific marker. OH accompanied by aminimal increase in heart rate from the supine- and/or seated-to-standingposition may be suggestive of nOH, whereas compensatory heart rateincreases of 15 bpm are usually observed when OH is due to non-neurogeniccauses . The results of a recentstudy suggest that a heart rate increase of < 17 bpm has better sensitivityand specificity for detecting nOH however, the rate of the orthostatic changein heart rate with falling systolic BP may be an even better indicator of nOH than the absolutechange in heart rate alone . As part of the diagnosticevaluation for nOH, exclusion of potentially confounding factors, such asdehydration, acute bleeding, and non-neurogenic causes, is necessary. An electrocardiogram,cardiac history, and medication review should be performed to rule outcardiogenic causes that may affect posturalheart rate .

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What Are The Symptoms Of Noh

nOH can appear with or without symptoms. The typical symptoms of nOH are lightheadedness, dizziness, blurry vision and, when theres a significant drop in blood pressure upon standing up, fainting. Symptoms almost always occur when standing up, less frequently when moving from standing to sitting and abate when lying down. People with nOH may also experience weakness, fatigue, leg buckling, headaches, neck and shoulder discomfort and shortness of breath. Severity of symptoms varies from day to day and fluctuates throughout the day. Often, mornings tend to be most difficult since nOH symptoms are aggravated by overnight urination, which is common in people with Parkinsons. Meals, particularly those rich in carbohydrates and sugars, also cause drops in blood pressure.

In people with Parkinsons, symptoms of nOH can also be non-specific, including fatigue and difficultly concentrating, and may sometimes mimic a levodopa off state. Its easy to miss nOH unless your physician measures your blood pressure while you are in a standing position. Conversely, it is important to realize people with Parkinsons can experience lightheadedness that mimics nOH, but may instead be caused by balance problems or other issues. For this reason, careful evaluation of your symptoms by a movement disorder specialist is strongly advised.

Orthostatic Hypotension: Causes And Treatment

Orthostatic Hypotension in Parkinson Disease

Do you face a blackout when you stand up after sitting or lying down? This could result from orthostatic hypotension.

It is technically low blood pressure that you face after staying put for a while.

It is also known as postural hypotension and can go beyond the blackout making you dizzy or even faint.

If your blood vessels are unable to constrict while standing up, you end up feeling the symptoms.

However, they can improve with medication and by taking an upright position.

This article discusses how you can treat this condition and reduce the symptoms that come along.

Keep reading to know.

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Lifestyle Remedies For Orthostatic Hypotension

  • Staying Hydrated: Dehydration is one of the causes, so it is advised to drink plenty of water throughout the day. Do not remain thirsty for longer and drink water whenever you are sweating profusely.
  • Refrain from alcohol: It worsens the hypotension so completely avoid it.
  • Increasing Salt Intake: This may not be the best idea and you should talk to your healthcare provider first. Nonetheless, it will increase blood pressure but can do so beyond a certain limit which isnt great.
  • Wearing waist-high compression stockings: These help to regulate blood flow. Remove them during night and while sleeping but keep them on for the day.
  • Exercise: But not in hot weather. Cardiovascular and strengthening exercises can help with blood pressure.
  • Get up slowly from bed: Do not jump out of bed, take it slow.
  • Moderate your body temperature: Avoid very hot baths and showers.
  • Avoid sleeping flat on bed: Use pillows to raise your head rather than staying flat.
  • Take small meals: If your blood pressure drops right after eating, take small carbohydrate meals rather than big ones.
  • Keep moving and stretching: if you have to stand for longer periods of time, keep moving your feet and legs. Also, stretch your calf muscles before standing up.
  • Prepare before you stand up: Besides standing slowly, give yourself some time to prepare you are standing. Hold onto something while getting up.


These tips can help overcome mild orthostatic hypotension.

Functional Psychosocial And Healthcare Resource Use Impacts

Falls and their consequences are of high clinical concern inpatients with PD. Falls increase the risk of injuries and increase healthcareresource use . In patients with PD, symptoms of nOHare associated with increased risk of falls and impairment of activities ofdaily living . An increased rate of falls has been demonstrated even inpatients with asymptomatic nOH when compared with patients with PD without nOH . The greater risk of falls in patientswith nOH results in more emergency department visits, hospitalizations, and useof outpatient services . In a retrospective cohortstudy, unadjusted medically attended fall-related costs were significantlyhigher for patients with PD and nOH than for patients with PD alone . Similarly, another retrospective study found thatoverall healthcare costs were more than 250% higher in patients with PD and nOHthan in those with PD alone ,even after adjusting for confounding factors .

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The Effect Of The Anti

One of the initial steps required when assessing a patient who is going to receive any anti-parkinsonian medication/treatment or who needs a dose adjustment is to anticipate the potential effect on his blood pressure, as it is one of the commonly related factors to the appearance of OH .

Several actions could help to improve the detection of this complication, either by the physician or the subject. It seems reasonable to instruct the patient about OH symptoms , although many cases go unnoticed . An initial pressor response assessment could be valuable to have a simple measurement to monitor future changes, as this measurement is one of the easiest ways to appraise OH in various healthcare settings.

Many caveats should be considered prior to establishing the real influence of PD medications on OH. First, there are different diagnostic criteria for defining OH. Additionally, much evidence is based on cross-sectional analyses and other confounding effects, as disease duration or previous autonomous nervous system damage , have not always been considered.

We present the current evidence to estimate the potential role of current PD treatments on OH. The influence of other drugs, such as antidepressants, diuretics, and antihypertensives, is not reviewed here. Nevertheless, they should be considered when dealing with this complication and decreasing the dose or stopping the responsible medication might be advisable.

Living With Postural Hypotension

Parkinson’s Disease and Neurogenic Orthostatic Hypotension

This 7-page fact sheet was developed for people affected by MSA, but is just as useful to those with Parkinsons disease, who are experiencing drops in blood pressure and postural hypotension. It covers symptoms, when they are likely to happen, what to do, exercise and other tips for daily living with OH, including medication options.

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Understanding Blood Pressure Fluctuations In Parkinsons Disease

In this 1-hour webinar Anindita Deb, MD, Movement Disorder Specialist, provides an overview of the human nervous system, which controls blood pressure, before explaining what orthostatic hypotension is, how to monitor nOH, medications that can affect blood pressure, lifestyle changes to improve nOH, how nOH affects cognition and mobility. She then spends considerable time sharing physical maneuvers and medications to treat nOH before answering listener questions.

Is There Any Treatment

There is no cure for multiple system atrophy with orthostatic hypotension. Treatment is aimed at controlling symptoms. Anti-Parkinson medication such as Sinemet may improve the general sense of well-being. Medications to elevate blood pressure while standing are often used, but may cause high blood pressure when lying down. Individuals should sleep with the head of the bed elevated. An artificial feeding tube or breathing tube may be required for problems with swallowing and breathing.

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Whats Hot In Pd If You Are Dizzy Or Passing Out It Could Be Your Parkinsons Disease Or Parkinsons Disease Medications

This 3-page article, with references, is a personal statement by Dr. Okun describing the mis-diagnoses Parkinsons patients can be given when visiting the ER for symptoms of dizziness or syncope outlining what defines a proper diagnosis of orthostatic hypotension, its frequency in people with Parkinsons, medication and lifestyle changes that can help.

Temporal Variants Of Orthostatic Hypotension

Orthostatic Hypotension in Parkinson Disease

In addition to OH defined as a BP drop within 3 min of standing , thereare two other temporally defined forms of OH that can be identified by clinicalBP measurements. Initial OH is a transient drop in BP that occurs immediatelyupon standing and resolves within 3060 s of active standing, and delayed OH isa sustained drop in BP that occurs beyond 3 min of standing . One large study of delayedOH monitored BP during 45 min of head-up tilt however, there is currently noaccepted standard for the length of time to test in the upright position forthis condition .

Initial OH differs from classical and delayed OH in several ways.Initial OH is defined by a greater magnitude of BP decrease within 15 s of active standing, withrestoration of normotensive BP within 3060 s . Signs and symptoms ofinitial OH are similar to those of the classical form of OH . However, initial OH is notassociated with a particular disease state or with autonomic failure, and theprevalence of initial OH in patients with PD is currently unknown .

Delayed OH occurs in some patients with PD and is thought to be related to, or aprecursor of, classical OH . In one study, more than half ofpatients with delayed OH developed classical OH during 10 years of follow-up. Delayed OH may be a mildor early form of sympathetic adrenergic failure and has been associated with thedevelopment of neurodegenerative disorders andincreased mortality .

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How To Avoid Neurogenic Orthostatic Hypotension

If you can recognize your symptoms and are aware of what makes them worse, you can take steps to reduce and avoid them. Most importantly, avoid being dehydrated, especially during the months of hot weather. Ask your doctor to identify the medications you are taking that may lower your blood pressure and see if a change in dose is indicated. Avoid abrupt changes in position.

What Is Neurogenic Orthostatic Hypotension

OH is a sustained fall in blood pressure that happens within 3 minutes of standing. OH can reduce blood flow to organs above the heart, most notably the brain, and its symptoms can have a profound impact on your quality of life. OH is more common in the elderly, and certain medications, dehydration, varicose veins, severe anemia and conditions such as heart disease can lead to OH. OH can also be related to the nervous system. Parkinsons, pure autonomic failure, multiple system atrophy and other types of autonomic dysfunction can all cause OH.

OH can be caused by the body not releasing enough of the neurotransmitter, norepinephrine. When your body doesnt release enough norepinephrine, your blood vessels dont constrict when they need to, lowering your blood pressure and causing you to feel faint when you stand or sit up. When OH is caused by problems in the release of norepinephrine, it is referred to as neurogenic orthostatic hypotension .

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How Is The Treatment Done

The treatment is established by the doctor according to the cause of orthostatic hypotension, so it may be recommended to change the dose of a particular medication that is being used, increase fluid consumption and practice regular, light to moderate intensity exercise. . In addition, it is important to spend a lot of time lying down, and it is recommended to sit or stand up regularly.

In some cases, the doctor may also recommend the use of some medications that promote sodium retention and relieve symptoms, such as Fludrocortisone, for example, or non-steroidal anti-inflammatory drugs that also promote the improvement of postural hypotension.

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Phenylephrine Therapy To Treat Refractory Orthostatic Hypotension In A Patient With Parkinsons Disease

What Causes Orthostatic Hypotension? – What You Need To Know Now

Jaekyoung A. Hong, MD, Sara E. Williford, MD, and John D. Bisognano, MD, PhD


Orthostatic hypotension is characterized by abnormal decrease in systolic blood pressure greater than 20 mm Hg or diastolic BP greater than 10 mm Hg when standing from a supine or sitting position. The symptoms of OH can include syncope, lightheadedness, clamminess, palpitations, diaphoresis, anxiety, visual changes, and nausea these symptoms are resolved by sitting or lying down. Multiple factors can contribute to OH, and some of the common causes include medications such as antihypertensive and psychotropic drugs, hypovolemia, aging, deconditioning often caused by immobility leading to venous pooling, decreased vasoconstriction, and autonomic nervous system dysfunction.1,2

ANS dysregulation due to Parkinsons disease is one of the four different forms of primary autonomic failure, which include multiple system atrophy, pure autonomic failure, and dopamine beta-hydroxylase deficiency.3 In patients with PD, the prevalence of OH is estimated to be 20%.4 The high prevalence of OH in this particular population is mainly due to dopaminergic drugs worsening or inducing OH, and PD as a cause of OH involving autonomic system and decreased delivery of the neurotransmitter norepinephrine to vascular adrenoreceptors.5

Case Presentation


The authors report no relevant financial relationships.

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Morning Bradykinesia Common Device

The head-up tilt test is a passive assessment of orthostatic hypotension and does not activate the leg muscles targeted during strength training. More significant differences may have been observed if an active standing test had been used, the team suggested.

The researchers added that it was not determined whether strength training actually improved muscle strength, and a longer training period might be needed to see meaningful gains. Additional effects of co-existing health problems and other medications cannot be ruled out, they also noted.

Secondary endpoints included cognitive function, mobility, and life quality. Since no primary endpoints were met, secondary endpoints were not analyzed, the researchers noted.

Future studies should be powered to explore the effect of strength training on other parameters such as orthostatic complaints and cognitive symptoms associated with , they wrote.

How Is Orthostatic Hypotension Treated

Droxidopa . fludrocortisone , or midodrine capsules are approved for the treatment of orthostatic hypotension. Common side effects include headache, dizziness, nausea, high blood pressure, and fatigue.

Another approach in treating orthostatic hypotension is to decrease the pooling of blood in the legs with the use of special stockings called compression stockings. These tight stockings compress the veins in the legs, helping to reduce swelling and increase blood flow. There are a number of companies that make these stockings in a wide variety of sizes, and they usually can be found at stores that sell medical supplies, as well as at some pharmacies.

You should wear these stockings when you are up and about. You do not need to wear them when you are in bed. Further, it is recommended that you put the stockings on first thing in the morning while in bed and before getting up for your daily activities. It is important that you do not let the stockings bunch, gather, or roll, since this can compress the veins too much and could harm circulation. You should always watch for signs of decreased circulation, which could include discoloration of the skin, as well as pain or cramping, and numbness of the lower legs and feet.

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Low Blood Pressure In Parkinson’s Disease

This 2-page article discusses the frequency of orthostatic hypotension in those with PD, the cause, symptoms and several simple measures that can be used to restore normal blood pressure regulation, including medication evaluation, increase of fluids and salty foods, caffeine, frequent small meals, environment, clothing, slow position change, bed position and medication options.

Normal Ans Response To Standing

Management of Orthostatic Hypotension in Parkinsons Disease

Postural change induces gravitational redistribution of blood volume, leading to changes in blood pressure. Upon standing, pooling of venous blood in the legs is countered by the normal sympathetic ANS to maintain standing blood pressure. Lying supine also causes gravitational redistribution of blood volume, and the normal ANS minimizes blood pressure from rising too high. Norepinephrine is the major neurotransmitter in the ANS regulation of blood pressure in response to postural changes. Sympathetic activation in response to standing leads to: venoconstriction with increased venous return an increase in heart rate and myocardial contractility with increased cardiac output and vasoconstriction with increased blood pressure. Normal activation of the intact ANS, along with sufficient circulating blood volume, prevents the gravity-induced fall in standing systolic blood pressure , maintaining cerebral perfusion and of other vital organs.

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