Understanding Orthostatic Hypotension: Your Complete Guide
Essential Points:
Understanding Orthostatic Hypotension: Orthostatic hypotension (OH) is a sudden drop in blood pressure when standing, often causing dizziness, lightheadedness, or fainting. It’s a major risk factor for falls, especially in older adults.
Causes and Risk Factors: Aging, chronic conditions like diabetes and Parkinson’s, certain medications, dehydration, and nervous system dysfunction can all contribute to OH. Identifying and managing these factors is crucial for reducing fall risks.
Prevention and Management: Gradual position changes, compression stockings, proper hydration, increased salt intake (under medical guidance), and smaller, more frequent meals can help manage OH symptoms and prevent falls.
Imagine standing up from the couch, and suddenly, the room starts to spin. Your vision blurs, and you feel a wave of dizziness wash over you. If you’ve ever experienced this, you’re not alone. In fact, it’s estimated that 5-16% of middle aged and elderly have orthostatic hypotension (OH), a leading cause of dizziness and falls among the elderly. (1) Falls are the leading cause of injury-related deaths in people over 65, and orthostatic hypotension can play a significant role in many of those falls. (2)
This article will dive into what orthostatic hypotension is, why it happens, how it increases the risk of falling, and what can be done to prevent it. We’ll explore the causes, symptoms, and effective strategies for managing OH, providing you with a comprehensive guide to reduce the risk of falls and improve your safety or that of a loved one.
Whether you’re an older adult, a caregiver, a healthcare professional, or simply someone interested in maintaining good balance and preventing falls, this article is for you. Understanding orthostatic hypotension is a step towards safer, more independent living for many at-risk individuals.
What is Orthostatic Hypotension?
Orthostatic hypotension (OH), also known as postural hypotension, is defined as a sudden drop in blood pressure that occurs when you stand up. Medically, it’s diagnosed when your systolic blood pressure drops by 20 mm Hg or your diastolic blood pressure drops by 10 mm Hg within three minutes of standing up. (3) This drop can lead to feelings of dizziness, lightheadedness, or fainting as your brain momentarily receives less blood flow.
Note: Normal blood pressure is considered 120/80. The top number is termed the systolic blood pressure, while the bottom is termed the diastolic blood pressure. Systolic blood pressure signifies at what pressure your heart pushes blood out into the arteries of your body. The diastolic blood pressure signifies the pressure of the blood against the artery walls while your heart is at rest.
Mechanism
When you move from sitting or lying down to standing, gravity pulls blood down into your legs and abdomen. (4) In a healthy individual, the body reacts quickly to maintain blood pressure by increasing heart rate and tightening blood vessels. This process is known as the baroreceptor reflex, also known as the baroreflex, which helps regulate blood pressure and keeps it stable during posture changes. In people with orthostatic hypotension, this response is delayed or impaired, leading to a drop in blood pressure. When your blood pressure drops suddenly, your brain might not get enough oxygen-rich blood, which can make you feel off balance, dizzy, or even cause you to faint.
Symptoms
Orthostatic hypotension can manifest in several ways, and recognizing these symptoms is the first step to addressing the condition (5):
Dizziness or lightheadedness when standing up
Blurred vision or "seeing spots"
Weakness or fatigue
Nausea
Confusion or difficulty concentrating
Fainting or feeling like you’re about to pass out
Tunnel vision
These symptoms can range from mild to severe and are often more pronounced in older adults, particularly those on medications that affect blood pressure.
Causes and Risk Factors
Aging and Its Role
As we age, several changes in the cardiovascular system increase the likelihood of experiencing orthostatic hypotension. Blood vessels may become stiffer and less responsive to changes in position, and the baroreflex (the system responsible for stabilizing blood pressure) can slow down in its response. (6, 7) This makes it harder for the body to adapt quickly when you stand up, leading to a higher risk of dizziness and falls.
Chronic Conditions
Certain chronic conditions can significantly contribute to the development of OH. Here are a few common examples:
Diabetes: High blood sugar levels over time can damage the nerves that regulate blood pressure, leading to diabetic neuropathy, which increases the risk of OH. (8)
Parkinson’s Disease: This condition affects the autonomic nervous system, which plays a key role in blood pressure regulation. People with Parkinson’s are at a higher risk of developing OH. (9)
Heart Disease: Conditions like congestive heart failure can reduce the heart’s ability to pump blood effectively, leading to lower blood pressure and a greater likelihood of OH. (10)
Medications
Certain medications can also contribute to orthostatic hypotension. (11) These include:
Blood pressure medications, like beta-blockers or ACE inhibitors, which lower blood pressure.
Diuretics, which increase urine production and can lead to dehydration and reduced blood volume.
Antidepressants, which can affect how the nervous system regulates blood pressure.
If you or a loved one takes any of these medications, it's important to monitor for symptoms of OH, especially when starting or adjusting doses.
Dehydration
Dehydration can reduce the volume of blood in your system, making it harder for your body to maintain stable blood pressure when you stand. (12) This is particularly true in older adults, who may not always recognize early signs of dehydration. Keeping hydrated is a simple yet crucial step in managing orthostatic hypotension. (13)
Nervous System Dysfunction
The autonomic nervous system, the part of your brain and nerves that controls internal processes of the body, is responsible for controlling blood pressure changes. When this system is compromised it may lead to neurogenic orthostatic hypotension, which means it’s caused by a malfunctioning nervous system. This can be due to conditions like autonomic neuropathy or certain neurological diseases leading to difficulty stabilizing blood pressure upon standing. (14) This often results in frequent episodes of dizziness and increased fall risk.
Post-Meal Hypotension
In some individuals, especially older adults, blood pressure can drop after eating a meal. (15) This condition is known as postprandial hypotension, and it occurs because digestion diverts blood to the stomach and intestines, leading to a decrease in blood pressure body wide. Eating smaller, more frequent meals can help minimize this effect.
Why Orthostatic Hypotension Leads to Falls
Impact on Balance
Orthostatic hypotension directly affects your body’s ability to maintain balance. (14) When your blood pressure drops suddenly, the decreased blood flow to the brain can disrupt your sense of equilibrium. This makes it harder for your body to stay upright and stable, increasing the risk of losing your balance.
Delayed Reaction
The body’s baroreflex, which helps stabilize blood pressure when changing positions, may be delayed in individuals with orthostatic hypotension. (14, 16) This delay means your body takes longer to adjust to the new posture, leaving a window of vulnerability when you’re more prone to losing your balance. For someone already unsteady, that delay can be the difference between safely getting up and experiencing a dangerous fall.
Visual Disturbances and Cognitive Impact
When blood pressure drops suddenly, it can cause visual disturbances such as seeing spots, blurred vision, or temporary blindness that directly impacts your ability to navigate your surroundings safely. (14, 17) Cognitive symptoms like confusion or difficulty focusing can also make it harder to react quickly, further increasing fall risk. Even a momentary lapse in attention or a slight stumble can lead to a serious fall, especially in older adults.
Case Study With A Patient
Consider Joan, a 78-year-old former patient of mine who experienced a fall while getting up from her favorite chair at home. She had been dealing with frequent dizziness when standing for quite sometime but didn’t think much of it. One afternoon, she stood up quickly, felt a sudden wave of dizziness, and lost her balance, resulting in a fall that fractured her hip. She was sent to rehab for a month and ended up moving into my assistive living building. After consulting her doctor, Joan learned that she had undiagnosed orthostatic hypotension, a condition that had likely caused her fall. With a treatment plan in place, Joan has since made adjustments to reduce her symptoms and lower her fall risk, while also working diligently to build up her balance and strength.
Diagnosing Orthostatic Hypotension
Clinical Tests
Diagnosing orthostatic hypotension typically involves a combination of medical history, symptom review, and clinical tests (18):
Blood Pressure Monitoring: This is usually done while you’re lying down, sitting, and standing, allowing the healthcare provider to observe how your blood pressure changes in different positions.
Tilt Table Test: A more specialized test where you’re strapped to a table that tilts from a lying to an upright position while your blood pressure and heart rate are monitored.
Autonomic Function Tests: If there’s a suspicion of autonomic nervous system dysfunction, additional tests may be conducted to evaluate how well your body regulates blood pressure and heart rate.
Self-Monitoring Tips
You don’t always need to wait for a doctor’s visit to gather useful information. Here are a few ways you can self-monitor for signs of orthostatic hypotension:
Take Your Blood Pressure: Measure your blood pressure while lying down, then again 1-3 minutes after standing. (19) If you notice a significant drop (20 mm Hg systolic or 10 mm Hg diastolic), it’s worth mentioning to your healthcare provider.
Standard automatic blood pressure cuffs are often not entirely accurate but they can give you a relatively accurate number to work from. At minimum, if the machine is calibrated correctly it should be consistent and allow you to see the blood pressure numbers drop relative to its own readings whether they are entirely accurate or not.
Track Symptoms: Keep a journal of any dizziness, lightheadedness, or other symptoms you experience when changing positions. Note the time of day, what you were doing, and any related factors (like meals or medication timing). These notes can help medical professionals see patterns that you may not notice.
Stand Up Slowly: If you experience symptoms, try to stand up slowly and see if the symptoms improve. (20) This can help identify if OH is likely the cause, while also helping to reduce symptoms of it.
When to Seek Help
It’s time to consult a healthcare provider if you or someone you care for:
Experiences frequent dizziness or lightheadedness when standing.
Has fainted or nearly fainted while changing positions.
Notices a significant or sudden change in blood pressure readings during self-monitoring.
Has recently started new medications that affect blood pressure and now experiences symptoms of OH.
Addressing OH early can prevent falls and maintain a safer, more independent lifestyle.
Strategies to Manage and Prevent Orthostatic Hypotension
Managing OH requires a blend of lifestyle adjustments, environmental modifications, and, in some cases, medical intervention. Here are practical strategies to minimize symptoms and maintain safety.
Lifestyle Adjustments
Gradual Position Changes and Movement
One of the simplest yet most effective strategies is to change positions gradually. (20, 21) If you’ve been lying down, take a moment to sit up slowly, then remain seated for a minute before standing. This gradual adjustment gives your blood pressure time to stabilize, reducing the risk of dizziness or fainting.
When getting out of bed in the morning, try sitting on the edge of the bed and performing gentle ankle pumps or leg movements to stimulate circulation before standing.
Creating Body Tension
If you need to get out of bed relatively quickly, tightening the muscles of your core while beginning to stand can help reduce the rush of blood downwards due to gravity. This will allow more blood to remain around your brain as your body’s baroreflex catches up with your body position.
Compression Stockings
Compression stockings are designed to help prevent blood pooling in the lower extremities, a common issue in those with OH. By applying pressure, they encourage blood to return to the heart and maintain stable blood pressure when you stand. (21)
Knee-high or thigh-high stockings are available, and the right choice often depends on personal preference and symptom severity. Consult your doctor for recommendations tailored to your needs.
Increase Fluid and Salt Intake
Adequate hydration is crucial in managing OH. Drinking plenty of water throughout the day increases blood volume, which can help keep your blood pressure stable. (21, 22)
In some cases, increasing salt intake may also help because salt retains water, boosting blood volume. However, this should only be done with a doctor's guidance to avoid excessive salt consumption. (21, 22)
Eating smaller, more frequent meals can help stabilize blood pressure. (23) Large meals can cause blood to pool in the digestive tract, leading to post-meal blood pressure drops.
Avoid alcohol, which can dilate blood vessels and lower blood pressure, and include nutrient-rich foods like lean proteins, whole grains, and a variety of fruits and vegetables to support overall health. (24)
Medication Adjustments
Certain medications can contribute to OH symptoms. (21) If you experience frequent episodes, speak with your healthcare provider about possible adjustments to your medication regimen. Sometimes, dosages can be modified, or medications can be switched to minimize side effects that lower blood pressure.
In general, if you take any medications I recommend getting a yearly medication review by your primary medical provider.
Exercise & Strength Training
Regular exercise is a key component in managing OH. Cardiovascular exercises, like walking or swimming, improve circulation and overall cardiovascular health. (21) Strengthening the legs, particularly through resistance exercises, can support blood return to the heart.
Balance exercises, such as tai chi or balance-specific routines, enhance your body’s ability to recover if you do feel lightheaded. This reduces your risk of falls.
Fall-Proofing the Environment
For those managing OH, creating a fall-proof environment is essential. Use grab bars in key areas like the bathroom and near the bed for support. Install non-slip mats in potentially wet areas such as bathrooms and kitchens.
Reduce clutter in frequently walked paths and consider moving any trip hazards, like loose rugs or cords, out of the way. Adequate lighting is also crucial, especially at night.
Long-term Care and Monitoring
As you get older or if OH symptoms persist, it’s vital to keep a close eye on your condition. Here’s what long-term care for OH might look like:
Regular Check-ups
Schedule regular check-ups with your healthcare provider to monitor blood pressure levels. These check-ups become even more critical if you’re taking blood pressure medications or have conditions that predispose you to OH. Blood pressure measurements in different positions (lying, sitting, and standing) can help track any significant changes.
When OH Becomes Chronic
If your OH symptoms don’t improve or worsen despite lifestyle changes, it may indicate a chronic condition. Symptoms like frequent fainting, severe dizziness, or falls are red flags suggesting you need more specialized care, possibly from a cardiologist or neurologist.
See you primary care provider to discuss these symptoms immediately.
Support Networks
Don’t face OH alone, build a support network. Communicating symptoms to family members, caregivers, and friends ensures that those around you know how to help if you have an episode. Discuss strategies with your healthcare provider, and consider joining a support group for individuals with similar experiences if it is becoming harder to handle.
Final Thoughts: Don’t Get Up Just To Fall
Orthostatic hypotension, characterized by sudden blood pressure drops upon standing, can significantly impact balance and increase the risk of falls. By making gradual lifestyle changes, utilizing practical tools like compression stockings, and focusing on overall health through hydration, diet, and exercise, you can better manage OH symptoms. Regular monitoring and a supportive environment are crucial for safety and well-being.
If you or a loved one experiences symptoms of OH, don’t wait. Start monitoring blood pressure changes and talk to a healthcare provider about any symptoms you notice, even if they seem mild. Small adjustments can make a big difference in maintaining your independence and preventing falls.
For more information on managing balance and falls, check out our Beginner to Intermediate Balance Program. You’ll find exercises tailored to improve your coordination, balance, and enhance your overall stability, so that you can live a safer life on your own terms!
References
Shibao C, Lipsitz LA, Biaggioni I. ASH Position Paper: Evaluation and Treatment of Orthostatic Hypotension. Journal of Clinical Hypertension. 2013;15(3):147-153. doi:10.1111/jch.12062
Older adult falls data. Older Adult Fall Prevention. Published May 9, 2024. https://www.cdc.gov/falls/data-research/index.html#:~:text=Falls%20are%20the%20leading%20cause,ages%2065%20years%20and%20older.
Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Autonomic Neuroscience. 2011;161(1-2):46-48. doi:10.1016/j.autneu.2011.02.004
Magkas N, Tsioufis C, Thomopoulos C, et al. Orthostatic hypotension: From pathophysiology to clinical applications and therapeutic considerations. Journal of Clinical Hypertension. 2019;21(5):546-554. doi:10.1111/jch.13521
Orthostatic hypotension. Cleveland Clinic. Published June 24, 2024. https://my.clevelandclinic.org/health/diseases/9385-low-blood-pressure-orthostatic-hypotension
Torjesen A, Cooper LL, Rong J, et al. Relations of arterial stiffness with postural change in mean arterial pressure in Middle-Aged adults. Hypertension. 2017;69(4):685-690. doi:10.1161/hypertensionaha.116.08116
Aung T, Fan W, Krishnamurthy M. Recurrent syncope, orthostatic hypotension and volatile hypertension: think outside the box. Journal of Community Hospital Internal Medicine Perspectives. 2013;3(2):20741. doi:10.3402/jchimp.v3i2.20741
Rios JFI, Lovblom LE, Perkins BA, Bril V. Orthostatic blood pressure changes and diabetes duration. Journal of Diabetes and Its Complications. 2022;36(5):108169. doi:10.1016/j.jdiacomp.2022.108169
Fanciulli A, Leys F, Falup-Pecurariu C, Thijs R, Wenning GK. Management of orthostatic hypotension in Parkinson’s Disease. Journal of Parkinson S Disease. 2020;10(s1):S57-S64. doi:10.3233/jpd-202036
Gorelik O, Feldman L, Cohen N. Heart failure and orthostatic hypotension. Heart Failure Reviews. 2016;21(5):529-538. doi:10.1007/s10741-016-9541-z
Rivasi G, Rafanelli M, Mossello E, Brignole M, Ungar A. Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive medications. Drugs & Aging. 2020;37(10):725-738. doi:10.1007/s40266-020-00796-5
Ringer M, Lappin SL. Orthostatic hypotension. StatPearls - NCBI Bookshelf. Published May 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK448192/
Shannon JR, Diedrich A, Biaggioni I, et al. Water drinking as a treatment for orthostatic syndromes. The American Journal of Medicine. 2002;112(5):355-360. doi:10.1016/s0002-9343(02)01025-2
Ringer M, Lappin SL. Orthostatic hypotension. StatPearls - NCBI Bookshelf. Published May 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK448192/
Luciano GL, Brennan MJ, Rothberg MB. Postprandial hypotension. The American Journal of Medicine. 2010;123(3):281.e1-281.e6. doi:10.1016/j.amjmed.2009.06.026
Briasoulis A, Silver A, Yano Y, Bakris GL. Orthostatic hypotension associated with baroreceptor dysfunction: Treatment approaches. Journal of Clinical Hypertension. 2014;16(2):141-148. doi:10.1111/jch.12258
Brignole M, Moya A, De Lange FJ, et al. Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. European Heart Journal. 2018;39(21):e43-e80. doi:10.1093/eurheartj/ehy071
Orthostatic hypotension (postural hypotension) - Diagnosis & treatment - Mayo Clinic. Mayo Clinic. Published May 26, 2022. https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553
Gibbon JR, Parry SW, Witham MD, Yarnall A, Frith J. Feasibility, reliability and safety of self-assessed orthostatic blood pressure at home. Age And Ageing. 2022;51(7). doi:10.1093/ageing/afac153
De Bruïne ES, Reijnierse EM, Trappenburg MC, et al. Standing Up Slowly Antagonises Initial Blood Pressure Decrease in Older Adults with Orthostatic Hypotension. Gerontology. 2016;63(2):137-143. doi:10.1159/000450642
Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleveland Clinic Journal of Medicine. 2010;77(5):298-306. doi:10.3949/ccjm.77a.09118
Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. AAFP. Published September 1, 2011. https://www.aafp.org/pubs/afp/issues/2011/0901/p527.html#:~:text=Patients%20with%20chronic%20orthostatic%20hypotension%20should%20be,are%20effective%20therapies%20for%20chronic%20orthostatic%20hypotension.
Puvi-Rajasingham S, Mathias CJ. Effect of meal size on postprandial blood pressure and on postural hypotension in primary autonomic failure. Clinical Autonomic Research. 1996;6(2):111-114. doi:10.1007/bf02291232
Calkins H. Alcohol increases susceptibility to orthostatic stress. Journal Watch. 2000;2000. doi:10.1056/jc200003310000005