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Hypotension management in frail older people

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Topics: Cardiovascular system disordersCare of the elderlyTraining and Development

Guidance to help upskill primary and secondary care clinicians in decision making when managing hypotension in frail older people

This article forms part of a series
  1. Managing cardiovascular disease in frail older people
    1. Atrial fibrillation management in frail older people
    2. Coronary heart disease and risk management in frail older people
    3. Heart failure management in frail older people
    4. Hypertension management in frail older people
    5. Hypotension management in frail older people
Contents
  1. Overview
  2. Hypotension in older people
  3. Measure the BP
  4. Conduct medication review
    1. Medication history
    2. Deprescribe
    3. Prescribe alternative
    4. Modify regimen
  5. Consider co-existing medical conditions
  6. When to refer
  7. Case study
    1. Postural hypotension

Overview

Ensure you are familiar with the principles outlined in Managing cardiovascular disease in frail older people.

Hypotension in older people

Postural hypotension (orthostatic hypotension) is common in older people and typical symptoms include:

  • dizziness within a few seconds of standing
  • light headedness, syncope and falls
  • dim, blurred or tunnel vision
  • dull pain in the back of the neck/shoulders (coat hanger distribution)

Patients can be asymptomatic and they should be assessed to confirm postural hypotension, with a medication review carried out.

Measure the BP

Postural hypotension is defined as a sustained reduction in the systolic BP by at least 20 mmHg or the diastolic BP of at least 10 mmHg within 3 minutes of standing or a 60° head tilt.

Measure the BP either seated or supine and repeat this measurement after the patient has been standing for at least one minute:

  • ask the patient or carer to keep a blood pressure diary over a few days, early morning measurements tend to most consistent
  • measure the heart rate which will increase as the blood pressure drops. An exaggerated increase in heart rate (>15 beats/minute) may suggest dehydration/volume depletion

Conduct medication review

Medication history

Take a full medication history and review medicines that may cause or contribute to hypotension, for example:

  • antihypertensives (diuretics, alpha-blockers, beta blockers)
  • opioids (morphine, oxycodone, fentanyl, buprenorphine)
  • analgesics (gabapentin, pregabalin)
  • antidepressants (tricyclics, trazadone, MAOIs, SSRIs)
  • Parkinson’s medication (levodopa, dopamine agonists)
  • vasodilators (nitrates, calcium channel blockers, phosphodiesterase-5 inhibitors)

Deprescribe

Identify and stop the causative medicine if possible.

Prescribe alternative

Switch to a drug class that has less effect on postural hypotension, e.g. calcium channel blockers.

Modify regimen

Split doses or give a single night-time dose to reduce BP effects.

Consider co-existing medical conditions

Consider co-existing medical conditions that cause or contribute to hypotension, for example:

  • those associated with autonomic dysfunction (e.g. diabetes, Parkinson’s disease)
  • anaemia
  • dehydration
  • infection
  • physical deconditioning

Parkinson’s UK gives useful patient advice on managing low blood pressure.

When to refer

Consider referral to specialist care if symptoms persist or for further advice.

Case study

Postural hypotension

Patient

An 85 year old lady has just been discharged from hospital after an admission with a urinary tract infection. She has a past medical history of diabetes and hypertension and is moderately frail.

Medication history

Her medication is listed as:

  • amlodipine 5mg once a day
  • atorvastatin 20mg once a day
  • doxazosin 2mg once a day
  • lansoprazole 15mg once a day
  • losartan 100mg once a day
  • metformin 1g twice a day

Issues identified

The hospital discharge summary lists the amlodipine and doxazosin as ‘new medicines’. What factors would you consider in a post discharge medication review with the patient?