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Neurotherapeutics : the Journal of the... Oct 2020Recognition of the importance of nonmotor dysfunction as a component of Parkinson's disease has exploded over the past three decades. Autonomic dysfunction is a frequent... (Review)
Review
Recognition of the importance of nonmotor dysfunction as a component of Parkinson's disease has exploded over the past three decades. Autonomic dysfunction is a frequent and particularly important nonmotor feature because of the broad clinical spectrum it covers. Cardiovascular, gastrointestinal, urinary, sexual, and thermoregulatory abnormalities all can appear in the setting of Parkinson's disease. Cardiovascular dysfunction is characterized most prominently by orthostatic hypotension. Gastrointestinal dysfunction can involve virtually all levels of the gastrointestinal tract. Urinary dysfunction can entail either too frequent voiding or difficulty voiding. Sexual dysfunction is frequent and frustrating for both patient and partner. Alterations in sweating and body temperature are not widely recognized but often are present. Autonomic dysfunction can significantly and deleteriously impact quality of life for individuals with Parkinson's disease. Because effective treatment for many aspects of autonomic dysfunction is available, it is vitally important that assessment of autonomic dysfunction be a regular component of the neurologic history and exam and that appropriate treatment be initiated and maintained.
Topics: Autonomic Nervous System Diseases; Cardiovascular Diseases; Gastrointestinal Diseases; Humans; Hypotension, Orthostatic; Parkinson Disease; Sexual Dysfunction, Physiological
PubMed: 32789741
DOI: 10.1007/s13311-020-00897-4 -
American Family Physician Jan 2022Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the...
Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of at least 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. Prevalence of orthostatic hypotension in the community setting is 20% in older adults and 5% in middle-aged adults. Risk factors such as diabetes mellitus increase the prevalence of orthostatic hypotension in all age groups. Orthostatic hypotension is associated with a significant increase in cardiovascular risk and falls, and up to a 50% increase in relative risk of all-cause mortality. Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position. If the patient is unable to stand safely or the clinical suspicion for orthostatic hypotension is high despite normal findings on the bedside test, head-up tilt table testing is recommended. Orthostatic hypotension is classified as neurogenic or nonneurogenic, depending on etiology and heart rate response. Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.
Topics: Accidental Falls; Adolescent; Adult; Aged; Blood Pressure; Chest Pain; Diabetes Mellitus; Diet; Dizziness; Droxidopa; Fludrocortisone; Heart Disease Risk Factors; Heart Rate; Humans; Hypotension, Orthostatic; Middle Aged; Midodrine; Quality of Life; Supine Position; Systole; Young Adult
PubMed: 35029940
DOI: No ID Found -
Journal of the American Medical... May 2019Orthostatic hypotension is a potential risk factor for falls in older adults, but existing evidence on this relationship is inconclusive. This study addresses the... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Orthostatic hypotension is a potential risk factor for falls in older adults, but existing evidence on this relationship is inconclusive. This study addresses the association between orthostatic hypotension and falls.
DESIGN
Systematic review and meta-analysis of the cross-sectional and longitudinal studies assessing the association between orthostatic hypotension and falls, as preregistered in the PROSPERO database (CRD42017060134).
SETTING AND PARTICIPANTS
A literature search was performed on February 20, 2017, in MEDLINE (from 1946), PubMed (from 1966), and EMBASE (from 1947) using the terms orthostatic hypotension, postural hypotension, and falls. References of included studies were screened for other eligible studies. Study selection was performed independently by 2 reviewers using the following inclusion criteria: published in English; mean/median age of the population ≥65 years; blood pressure measurement before and after postural change; and assessment of the association of orthostatic hypotension with falls. The following studies were excluded: conference abstracts, case reports, reviews, and editorials. Data extraction was performed independently by 2 reviewers.
MEASURES
Unadjusted odds ratios of the association between orthostatic hypotension and falls were used for pooling using a random effects model. Studies were rated as high, moderate, or low quality using the Newcastle-Ottawa Scale.
RESULTS
Out of 5646 studies, 63 studies (51,800 individuals) were included in the systematic review and 50 studies (49,164 individuals) in the meta-analysis. Out of 63 studies, 39 were cross-sectional and 24 were longitudinal. Orthostatic hypotension was positively associated with falls (odds ratio 1.73, 95% confidence interval 1.50-1.99). The result was independent of study population, study design, study quality, orthostatic hypotension definition, and blood pressure measurement method.
CONCLUSIONS AND IMPLICATIONS
Orthostatic hypotension is significantly positively associated with falls in older adults, underpinning the clinical relevance to test for an orthostatic blood pressure drop and highlighting the need to investigate orthostatic hypotension treatment to potentially reduce falls.
Topics: Accidental Falls; Aged; Blood Pressure; Blood Pressure Determination; Cross-Sectional Studies; Female; Geriatric Assessment; Humans; Hypotension, Orthostatic; Longitudinal Studies; Male; Risk Factors
PubMed: 30583909
DOI: 10.1016/j.jamda.2018.11.003 -
Circulation. Arrhythmia and... Mar 2022Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and... (Review)
Review
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
Topics: Cardiovascular Diseases; Cognitive Dysfunction; Humans; Hypertension; Hypotension, Orthostatic; Syncope
PubMed: 35212554
DOI: 10.1161/CIRCEP.121.010573 -
The New England Journal of Medicine Feb 2020
Review
Topics: Accidental Falls; Aged; Algorithms; Exercise Therapy; Female; Humans; Hypotension, Orthostatic; Independent Living; Medication Reconciliation; Postural Balance; Practice Guidelines as Topic; Risk Factors
PubMed: 32074420
DOI: 10.1056/NEJMcp1903252 -
Practical Neurology Nov 2023Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving...
Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.
Topics: Humans; Hypotension, Orthostatic; Tilt-Table Test; Syncope; Syncope, Vasovagal; Heart Rate; Blood Pressure
PubMed: 37726165
DOI: 10.1136/pn-2023-003749 -
Journal of Neurology Aug 2017Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson's disease, multiple system atrophy, pure autonomic... (Review)
Review
Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson's disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards 'best practices' when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members' discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.
Topics: Humans; Hypertension; Hypotension, Orthostatic; Supine Position
PubMed: 28050656
DOI: 10.1007/s00415-016-8375-x -
American Family Physician Jan 2022
Topics: Blood Pressure; Chest Pain; Diet; Dizziness; Drinking Water; Exercise; Heart Rate; Hot Temperature; Humans; Hypotension, Orthostatic; Supine Position
PubMed: 35029960
DOI: No ID Found -
Autonomic Neuroscience : Basic &... Dec 2020Delayed orthostatic hypotension is a fall in blood pressure beyond 3 min of standing or upright tilt table testing. The prevalence, clinical features and... (Review)
Review
Delayed orthostatic hypotension is a fall in blood pressure beyond 3 min of standing or upright tilt table testing. The prevalence, clinical features and pathophysiology are reviewed. To date, there is little data to support a standardized or recommended treatment. However, the 10-year mortality rates of individuals with delayed orthostatic hypotension are approximately 50%. Despite the fact that delayed orthostatic hypotension carries the same symptoms, risks and high mortality rate as classical orthostatic hypotension, but is under-recognized. The frequency with which delayed orthostatic hypotension develops into classical orthostatic hypotension, the high associated mortality rates and risk of development of the neurodegenerative disorders classified as alpha-synucleinopathies underscores the need for further study of this condition.
Topics: Humans; Hypotension, Orthostatic; Synucleinopathies
PubMed: 32942225
DOI: 10.1016/j.autneu.2020.102724 -
Hypertension (Dallas, Tex. : 1979) Mar 2024Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common... (Review)
Review
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
Topics: Adult; Humans; Hypotension, Orthostatic; American Heart Association; Hypertension; Midodrine; Blood Pressure; Antihypertensive Agents; Autonomic Nervous System Diseases
PubMed: 38205630
DOI: 10.1161/HYP.0000000000000236