Postural hypotension

Question 1

An 85 year old man presents with a history of a fall onto a tile-covered floor at home, after tripping on a rug. He states that he is dizzy when he stands up, and his blood pressure drops by 20mmHg when he does so. how would you assess and manage him?

Answer 1

Impression
Mechanical vs medical reason for fall. Am concerned about postural hypotension given the BP drops of 20mmHg. There are a number of causes of postural hypotension that should be considered

Symptomatic

• hypovolaemia
• extended bed rest
• old age baroreceptor dysfunction
• medications: vasodilators, ß-blockers, etc

Asymptomatic
- Autonomic neuropathy (parkinsons +, diabetes)

Also consider other causes of syncope (cardiac, neurogenic)

Question 2

Postural hypotension - History

Answer 2

History

• Fall: before, during, after: exact mechanism, any other injuries sustained? history of falls (how many in past 12 months), DAME risk factors
• sx: dizziness? visual changes, LOC? light-headedness vs vertiginous
• Autonomic dysfunction: parkinsons history, fam history, diabetes mellitus?
• PMHx: cardiac disease (Arrhythmia, carotid stenosis, valvular disease)
• Medications: anticoagulants (?head strike), ACEi/ß-Blockers, etc

Question 3

Postural hypotension - Examination

Answer 3

Examination

• General appearance + vitals
• Hydration status assessment - hypovolaemia
• Neurological examination
• Cardiac examination: pulse, murmurs, BP
• Secondary survey for other injuries

Question 4

Postural hypotension - Investigations

Answer 4

Investigations

• Bedside: ECG, BSL
• Bloods: VBG, FBC (Anaemia), Trops, EUC
• Imaging: CT Brain for ?intracranial lesion post-fall
• other: consider ECHO if ?cardiac pathology)

Question 5

Postural hypotension - Management

Answer 5

Management
Manage in MDT environment with physio, geriatrics, cardio, etc

Supportive
- falls risk reduction + patient education about getting up slowly from lying/sitting to standing, ensure adequate hydration + salt intake, sleep with head of bed raised.
- physio referral for strength and balance training
- address DAME risk factors for falls
- medication review to minimise poly pharmacy and cease blood pressure meds as appropriate (in consult with senior colleagues
- consider ACAT referral for input of further home services/aged care package
-

Definitive

• medications to increase blood pressure - Fludrocortisone 0.1mg daily
• optimise other co-morbidities (diabetes given ?autonomic failure)