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Orthostatic Hypotension

Orthostatic hypotension is a drop in blood pressure on standing that causes dizziness, blurred vision, or fainting, often from dehydration, medications, or nerve disorders.

Cardiovascular
Orthostatic hypotension is a form of low blood pressure that occurs when you stand up. Normally, the nervous system instantly tightens blood vessels and speeds the heart to keep blood flowing to the brain against gravity. When that reflex is slow or blunted, blood pressure drops — defined as a fall of at least 20 mmHg systolic or 10 mmHg diastolic within about three minutes of standing — and the brain is briefly shortchanged. The condition is especially common in older adults and is a major contributor to falls. Causes: Orthostatic hypotension has many causes, and more than one is often present:
  • Dehydration: Too little fluid in the bloodstream from inadequate intake, illness, or diuretics. Florida's year-round heat makes dehydration a particularly common trigger for our patients.
  • Medications: Blood pressure medicines, water pills, prostate medications such as alpha-blockers, some antidepressants, and drugs for Parkinson's disease are frequent culprits.
  • Meals and alcohol: Blood is diverted to the digestive tract after eating, and alcohol relaxes blood vessels. Both can lower standing blood pressure, particularly in older adults after a large, carbohydrate-heavy meal.
  • Nerve disorders: Conditions that damage the autonomic nerves controlling blood vessels, including diabetic neuropathy from long-standing diabetes and Parkinson's disease.
  • Anemia or blood loss: Fewer red blood cells or less blood volume means less pressure to spare; see anemia.
  • Heart problems and deconditioning: A weakened heart, prolonged bed rest, and normal aging all blunt the standing reflex.
Symptoms: Symptoms appear within seconds to minutes of standing and improve with sitting or lying down:
  • Dizziness or lightheadedness: The hallmark symptom, often worst first thing in the morning, after meals, or in hot weather.
  • Blurred or dimming vision: A "graying out" sensation as brain blood flow dips.
  • Weakness, fatigue, or brain fog: Some people feel unsteady or mentally foggy rather than dizzy.
  • Aching across the neck and shoulders: Sometimes called "coat-hanger" pain, this comes from reduced blood flow to the neck and shoulder muscles while upright and typically eases within moments of sitting down.
  • Fainting: The most serious consequence, because of the injuries a fall can cause.
Diagnosis: The key test is simple: blood pressure and heart rate measured lying down and then after one and three minutes of standing. Your physician will also review every medication and supplement you take, examine you for signs of dehydration or nerve disease, and order blood tests such as a blood count, kidney function, and glucose. An electrocardiogram screens for heart rhythm problems that can mimic or worsen the condition. Because readings change through the day, you may be asked to keep a home log of blood pressures and symptoms — including readings taken first thing in the morning and about half an hour after meals, when the drop is often largest. Treatment: Treatment starts with practical measures and medication adjustments:
  • Review of medications: Lowering doses, changing timing, or substituting different drugs is often the single most effective step.
  • Fluids and salt: Drinking water consistently through the day — and, when your physician approves, liberalizing salt — expands blood volume.
  • Behavioral strategies: Rise in stages from lying to sitting to standing, tense the leg muscles before standing, and avoid prolonged standing in heat.
  • Compression garments: Waist-high compression stockings or abdominal binders reduce blood pooling in the legs.
  • Meal and sleep adjustments: Smaller, more frequent meals with less refined carbohydrate limit post-meal drops, and raising the head of the bed a few inches at night reduces morning symptoms for some patients.
  • Prescription options: When symptoms persist, medications such as midodrine or fludrocortisone may be used in carefully selected patients.
Complications: The chief risk is injury from a fall, which in an older adult can mean a hip or wrist fracture — a particular concern for anyone whose bones are already thinned by osteoporosis. Repeated episodes also lead many people to limit walking and activity, and that deconditioning weakens the standing reflex further, creating a cycle worth interrupting early. When to Seek Immediate Care: Seek urgent care for fainting that causes injury, chest pain, black or bloody stools (a sign of internal bleeding), or dizziness that does not improve with lying down. Orthostatic hypotension is very manageable once its causes are identified, and treating it meaningfully reduces fall risk. The primary-care team at Zimmer Medical Group routinely checks orthostatic vital signs for patients with dizziness and tailors a step-by-step plan.

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