Orthostatic Hypotension in Parkinson's Disease

1. ORTHOSTATIC HYPOTENSION IN PARKINSON’S DISEASE
ADE WIJAYA, MD – NOVEMBER 2019

2. PARKINSON’S DISEASE
Tremor Bradykinesia
Rigidity Postural Instability
Motor Symptoms

3. THE NON-MOTOR SYMPTOMS OF PARKINSON’S DISEASE
 Pain
 Fatigue
 Low blood pressure
 Restless legs
 Bladder and bowel problems
 Skin and sweating
 Sleep
 Eating, swallowing and saliva control
 Speech and communication issues
 Eye problems
 Foot care
 Dental health
Mental health issues
 Mild memory and thinking problems
 Anxiety
 Dementia
 Depression
 Hallucinations and delusions
Parkinsons.org.uk

4. ORTHOSTATIC HYPOTENSION
A BP drop of 20 mm systolic or 10 mm diastolic within 3 min of standing
30-50 % of Parkinson’s Disease patients (half of them asymptomatic)
Fall
D.C. Velseboer, R.J. de Haan, W. Wieling, D.S. Goldstein, R.M. de Bie, Prevalence of orthostatic hypotension in Parkinson's disease: a systematic review and meta-analysis, Park. Relat. Disord. 17 (2011) 724e729.
J.A. Palma, J.C. Gomez-Esteban, L. Norcliffe-Kaufmann, J. Martinez, B. Tijero, K. Berganzo, H. Kaufmann, Orthostatic hypotension in Parkinson disease: how much you fall or how low you go? Mov. Disord. 30 (2015)

5. PRECIPITATING FACTORS
Postprandial
Physical
exercise
Raised
ambient
temperature
J.A. Palma, J.C. Gomez-Esteban, L. Norcliffe-Kaufmann, J. Martinez, B. Tijero, K. Berganzo, H. Kaufmann, Orthostatic hypotension in Parkinson disease: how much you fall or how low you go? Mov. Disord. 30 (2015) 639e645.
Peripheral
Vasodilatation
Reich SG. Treatment of Orthostatic Hypotension in Parkinson’s Disease. InTherapy of Movement Disorders 2019 (pp. 51-54). Humana, Cham.

6. PATHOPHYSIOLOGY & CLINICAL PRESENTATION
Degeneration of the peripheral autonomic nervous system
light-headedness, dizziness, feeling about to faint, and syncope in response to sudden postural change
Goldstein DS. Dysautonomia in Parkinson’s disease: neurocardiological abnormalities. Lancet Neurol 2003;2:669–676.
Arbogast SD, Alshekhlee A, Hussain Z, McNeeley K, Chelimsky TC. Hypotension unawareness in profound orthostatic hypotension. Am J Med 2009;122:574–580.
Shaw BH, Claydon VE. The relationship between orthostatic hypotension and falling in older adults. Clin Auton Res 2014;24:3–13.

7. ASYMPTOMATIC ORTHOSTATIC HYPOTENSION
 Review patient’s medications, including Parkinson’s Disease medications, especially dopamine agonists
 Non-pharmacological treatments
 Education; avoid precipitating factors
Reich SG. Treatment of Orthostatic Hypotension in Parkinson’s Disease. InTherapy of Movement Disorders 2019 (pp. 51-54). Humana, Cham.

8. NON-PHARMACOLOGICAL TREATMENTS
 Reduction or elimination of medications known to
lower BP (including those for PD as well as
nonneurologic conditions)
 Avoid large meals especially high carbohydrate
meals
 Eat frequent small meals
 Minimize alcohol
 Avoid situations that increase core body
temperature such as hot environments, hot baths
or showers, or saunas
 Become familiar with the earliest symptoms of OH
and sit or lay down immediately
 Use of isometric exercise to transiently increase BP
(flexing buttocks or thighs)
 Increase water intake (up to 2 l per day)
 Increase salt intake (equivalent 1–2 tablespoons)
either by adding
 additional salt to food or via high-salt soups or
vegetable drinks
 Prop the head of the bed 30°
 Use an abdominal binder
 Avoid prolonged sitting or lying down
 Encourage exercise (recumbent bicycle)
Reich SG. Treatment of Orthostatic Hypotension in Parkinson’s Disease. InTherapy of Movement Disorders 2019 (pp. 51-54). Humana, Cham.

9. PHARMACOLOGICAL TREATMENT
Reich SG. Treatment of Orthostatic Hypotension in Parkinson’s Disease. InTherapy of Movement Disorders 2019 (pp. 51-54). Humana, Cham.
Second line treatments: indomethacin, methylphenidate, yohimbine, desmopressin, octreotide, and atomoxetine

10. SUPINE HYPERTENSION
 Treatment’s side effect
Treatment
 Avoiding pharmacotherapy of orthostatic hypotension within 5 hours of bedtime
 Having patients prop up the head of the bed
 Taking a carbohydrate snack before bed
 Captopril, clonidine, hydralazine, losartan, or nitroglycerine patch, near bedtime (if needed)

11. SUMMARY
 Orthostatic hypotension is one of the most common non-motor symptoms of Parkinson’s Disease
 Increase risk of fall
 Non-pharmacological vs pharmacological treaments
 Supine hypertension

12. THANK YOU