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Year : 2011  |  Volume : 14  |  Issue : 5  |  Page : 17-18
 

Assessment and management of orthostatic hypotension in Parkinson's disease



Date of Web Publication21-Jul-2011

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How to cite this article:
. Assessment and management of orthostatic hypotension in Parkinson's disease. Ann Indian Acad Neurol 2011;14, Suppl S1:17-8

How to cite this URL:
. Assessment and management of orthostatic hypotension in Parkinson's disease. Ann Indian Acad Neurol [serial online] 2011 [cited 2019 May 22];14, Suppl S1:17-8. Available from: http://www.annalsofian.org/text.asp?2011/14/5/17/83091


The autonomic nervous system controls vital body functions, namely, the heart rate, blood pressure, bladder and genital functions, through the sympathetic and parasympathetic nervous systems. Dysfunction of the autonomic nervous system in Parkinson's disease (PD) presents as postural or orthostatic hypotension (OH) or impaired urinary, genital, bowel or sweating functions. OH is the hallmark of failure of the sympathetic nervous system. The sympathetic nervous system maintains the blood supply to the brain by keeping the blood pressure (BP) against gravitational stress while standing. Autonomic failure occurs in different Parkinsonian disorders, namely, PD, multiple system atrophy and diffuse Lewy body disease.


   Definition of Orthostatic Hypotension Top


OH is defined as fall in systolic blood pressure (SBP) of 20 mm Hg or more or diastolic blood pressure (DBP) of 10 mm Hg or more on standing or head-up tilt to at least 60°. Measuring BP in supine position alone can be misleading, as patients with OH can misleadingly have supine hypertension.


   Clinical Profile Top


OH occurs in 50.3% of PD patients with the Posture and Gait instability (PIGD) phenotype. It is also common in older patients taking large doses of dopaminergic medications. Parkinsonian patients with OH should be asked for presence of bladder and erectile dysfunction. Patients with OH complain of postural dizziness and light-headedness because of transient fall in cerebral blood flow, but these orthostatic symptoms are poor indicators of OH in PD. This makes it mandatory that all PD patients should undergo BP recording in lying and standing positions even when they do not complain of orthostatic symptoms. [1] OH in PD is often asymptomatic as autonomic failure possibly because it develops gradually.

Drugs used to treat PD including l-Dopa and other dopaminergic medications can both cause or worsen BP falls in the supine [Levodopa-induced Supine Hypotension (LISH)] and standing positions [Levodopa-induced orthostatic hypotension (LOH)].


   Testing Top


OH is tested at the bedside by recording a change in BP of the patients while they are standing for 3 minutes after they are in the supine position for 3 minutes. [2] If the patient has difficulty to stand, change in BP can be checked on changing from supine to sitting positions. OH is tested in the laboratory using a tilt table. OH is defined as a fall of SBP by >20 mm Hg or DBP by >10 mm Hg or both. An increase in heart rate in the presence of OH suggests a normal parasympathetic nervous system.


   Management Top
[3]

It is important to recognize and manage OH as doing this Parkinson's Disease reduces morbidity and mortality in PD. It is essential to educate patients, their family, and caregivers to reduce falls occurring because of OH. In patients with mild OH, non-pharmacological methods like avoiding sudden standing after prolonged rest in the supine position might be enough. Elderly PD patients should be advised not to pass urine while standing. Alcohol and medicines might worsen OH; therefore, it is important to check all medicines they are taking. They should avoid foods rich in carbohydrates. It is helpful to increase the head end of bed by 20° while sleeping. Taking small meals at frequent intervals will avoid postprandial OH. Patients with OH should take 5 g of common salt divided through the day. Exercising the calf muscles by walking or cycling can help to prevent BP falls. In the presence of severe OH, calf muscle exercises using a reclining bicycle can be helpful. Elastic stockings are helpful but could be uncomfortable in warm weather.

Pharmacological methods

It is essential to check and adjust dopaminergic medicines as they can worsen OH. The first choice of drug to use is Fludrocortisone. The next choice is sympathomimetic drugs like ephedrine or midodrine. It is important to start them at a low dose and increase the dose slowly.

 
   References Top

1.Jamnadas-Khoda J, Koshy S, Mathias CJ, Muthane UB, Ragothaman M, Dodaballapur SK. Are current recommendations to diagnose orthostatic hypotension in Parkinson's disease satisfactory? Mov Disord 2009;24:1747-51.   Back to cited text no. 1
    
2.Mathias CJ. Autonomic disorders and their recognition. N Engl J Med 1997;36:721-4.   Back to cited text no. 2
    
3.Mathias CJ. Autonomic diseases: Management. J Neurol Neurosurg Psychiatry 2003;74:42-7.  Back to cited text no. 3
    




 

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