Pharmacological Options for Orthostatic Hypotension in Older Adults

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´╗┐Pharmacological Options for Orthostatic Hypotension in Older Adults

Abstract and Introduction

Abstract


Orthostatic hypotension (OH) is a common disorder in older adults with potentially serious clinical consequences. Understanding the key underlying pathophysiological processes that predispose individuals to OH is essential when making treatment decisions for this group of patients. In this article, we discuss the key antihypotensive agents used in the management of OH in older adults. Commonly, midodrine is used as a first-line agent, given its supportive data in randomized, controlled trials. Fludrocortisone has been evaluated in open-label trials and has long-established usage in clinical practice. Other agents are available and in clinical use, either alone or in combination, but larger randomized trial evaluations are yet to be published. It is important to bear in mind that a patient may be taking medications that predispose to or exacerbate the symptoms of OH. Withdrawal of such medications, where possible, should be considered before commencing other pharmacological agents that attenuate the symptoms of OH.

Introduction


Orthostatic hypotension (OH) is a clinical condition that frequently results in troublesome symptoms, such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting hemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume. The assessment of posture-related BP changes in older patients presents the clinician with some specific difficulties. The classical presentation of OH with symptoms such as dizziness, light-headedness and other symptoms of decreased cerebral perfusion may be absent in many older patients. Frequently, patients may not clearly recount a history of posture change prior to a syncopal event or fall. Many individuals present with the consequences of OH, such as, falls, fractures, impaired mobility and loss of confidence. Therefore, maintaining a high index of suspicion for the presence of OH when patients present with such problems appears appropriate.

Making treatment decisions for older patients with OH is made difficult by the lack of an age-specific evidence base for certain aspects of this condition. In particular, trials examining the efficacy of antihypotensive drugs have tended to include only younger and middle-aged adults. The pathophysiology of OH often differs considerably between younger and older adults. This, combined with the difficulty in recording presyncopal symptoms described earlier, makes interpretation of the results of such trials more uncertain when older patients are being considered. In addition, in older adults, the altered endothelial responsiveness in the key homeostatic systems that control blood pressure may mean that the responses produced by pressor agents may not be equivalent in older and younger adults. Despite these concerns, our increasing understanding of the underlying pathophysiology of OH in older patients is beginning to allow the development of rational management strategies.

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