QuestionSBA
QuestionChoice
Non-pharmacological treatments include increasing water and salt intake, wearing compression garments or bandages, and physical manoeuvres to counter the drop in BP. However, as the question asked for the next best step, reviewing the medication is the most appropriate choice, which can be followed by providing non-pharmacological advice.
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e
Advice high salt diet
QuestionChoice
Pyridostigmine is primarily used to treat myasthenia gravis. It significantly improves standing BP, with the most significant effect on diastolic BP in patients with postural hypotension without worsening supine hypertension. However, it is considered a second-line medication and inappropriate in this scenario.
62090
c
Prescribe pyridostigmine
QuestionChoice
Orthostatic hypotension is a sudden and sustained **drop in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing** from a seated/lying down position. This patient is taking multiple medications: antidepressant (SSRI), calcium channel blockers, and notably, the addition of chlorthalidone (thiazide-like diuretic) six months ago might have most probably resulted in his complaints. Treatment depends on the cause, and non-pharmacological methods should be tried before resorting to medication. If the cause is related to polypharmacy, optimising the patient's treatment plan by removing or replacing the offending drug will be helpful.
62088
a
Stop clorthalidone
QuestionChoice
Fludrocortisone is a synthetic mineralocorticoid hormone that is used to treat orthostatic hypotension by increasing blood volume and blood pressure. It is the first-line medication to treat postural hypotension if all other methods fail and symptoms and BP readings persist the same.
62091
d
Prescribe cyclizine
QuestionChoice
Fludrocortisone is a synthetic mineralocorticoid hormone that is used to treat orthostatic hypotension by increasing blood volume and blood pressure. It is the first-line medication to treat postural hypotension if all other methods fail and symptoms and BP readings persist the same.
62089
b
Prescribe fludrocortisone
Concept
Chapter
# Summary

Postural or orthostatic hypotension is a condition characterised by a significant drop in blood pressure upon standing. Key signs and symptoms include dizziness, syncope, falls, fractures, and more frequent occurrences following meals, exercise, and in warm environments. Key investigations involve identifying a fall of 20mmHg or more in systolic blood pressure, or a fall of 10mmHg or more in diastolic pressure. Management strategies largely depend on the cause and can range from ensuring adequate hydration to evaluating polypharmacy to pharmacotherapy.

# Definition

Orthostatic hypotension is characterised by a decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.

# Epidemiology

Orthostatic hypotension is common in the elderly population, with approximately 50% of elderly individuals living in residential institutions being affected. 

# Aetiology

The causes of orthostatic hypotension include:

- Medications, particularly vasodilators, diuretics, negative inotropes, antidepressants, and opiates
- Chronic hypertension due to the loss of baroreceptor reflexes
- Dehydration
- Sepsis
- Autonomic nervous system dysfunction, such as Parkinson's disease
- Adrenal insufficiency

# Signs and symptoms

Patients with orthostatic hypotension may present with:

- Dizziness
- Syncope
- Falls
- Fractures
- More frequent occurrences after meals or exercise
- More frequent occurrences in warm environments
- Sometimes precipitated by coughing or defecating
- Symptoms can occur several minutes after standing up

# Differential diagnosis

When diagnosing orthostatic hypotension, it is essential to rule out other conditions that may cause similar symptoms. These can include:

- Vertigo: Characterized by a spinning sensation and loss of balance
- Hypoglycemia: Presents with signs such as shakiness, hunger, confusion, and sweating
- Cardiac arrhythmias: Symptoms may include palpitations, chest pain, and shortness of breath

# Investigations

The diagnosis of orthostatic hypotension is confirmed by a significant fall of 20mmHg or more in systolic blood pressure, or a fall of 10mmHg or more in diastolic pressure upon standing.

# Management

Management of orthostatic hypotension depends on the underlying cause and may include:

- Ensuring adequate hydration
- Evaluating polypharmacy to identify medication-related causes
- Implementing strategies to reduce adverse outcomes from falls (e.g., fall alarm, soft flooring)
- Advising behavioral changes such as rising from sitting slowly, maintaining adequate hydration
- Recommending the use of compression stockings
- Employing pharmacotherapy, including fludrocortisone and midodrine, although the evidence base for fludrocortisone is weak

# References

- [NICE Guideline: Orthostatic hypotension due to autonomic dysfunction: midodrine](https://www.nice.org.uk/advice/esnm61/chapter/)
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Geriatrics
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Quesmed Tutorial: Geriatrics
Stop clorthalidone
12479
A 70-year-old man presents with dizziness, headache, light-headedness, and frequent falls over the past month, often feeling faint after standing up from sitting for long periods. His past medical history is significant for depression and hypertension, and he has been taking sertraline and amlodipine for the past two years without any reported side effects. Recently, chlorthalidone was added for hypertension six months ago. 

The patient's blood pressure is 160/90 mmHg while sitting, 130/69 mmHg after standing for 3 minutes, with a pulse rate of 78 beats per minute.
On examination, no other significant findings are noted. Laboratory investigations of complete blood count and serum electrolytes are unremarkable.


Which among the following is the next best step in managing his complaints?
a