Kenneth M. Madden, MSc, MD, FRCP, VITALITY (Vancouver Initiative to Add Life To Years) Group, Department of Medicine, University of British Columbia, Vancouver, BC.

Orthostatic hypotension (OH), while not itself a disease, is an important physical finding in the setting of unexplained syncope or falls. All antihypertensive medications directly interfere with the normal cardiovascular responses (increased venous return, tachycardia, and vasoconstriction) to orthostatic stress. Regular screening for this condition in older adults with hypertension, as well as careful titration of antihypertensive medications, can greatly improve both mortality and quality of life in this vulnerable population.
Keywords: orthostatic hypotension, postural vitals, antihypertensives, syncope, geriatric medicine.

Maxime Lamarre-Cliche, MD, FRCPC, MSc, Institut de Recherches Cliniques de Montréal, Université de Montréal, Montréal, QC.

Syncope is a frequent cause for emergency consultation and hospital admission; it is also an indicator of reduced survival rate among older adults. The differential diagnosis may be large, but bradyarrhythmias, neurocardiogenic syncope, carotid hypersensitivity syndrome, and orthostatic hypotension are the more frequent causes. Good history-taking and physical examination usually orient the diagnosis and testing strategy. In working with older patients, great care must be taken in assessing comorbidities and concomitant medications as they can exacerbate syncopal symptoms. A multidisciplinary and dedicated approach to syncope increases the diagnostic yield and rapid management of patients.
Key words: syncope, orthostatic hypotension, arrhythmia, neurally mediated syncope.

Margaret Grant, MD, FRCPC, Geriatrician and Medical Director, Geriatric Assessment Unit, Credit Valley Hospital, Mississauga, ON.

This article focuses on the treatment of orthostatic hypotension (OH) in the elderly. OH is a common problem that can affect an elderly person's function and quality of life. A careful history and physical examination must be done to make an accurate diagnosis and to determine the causes of OH. Treatment should focus on the causes of OH. Both nonpharmacological and pharmacological interventions are reviewed.
Key words: orthostatic hypotension, fludrocortisone, midodrine, octreotide, erythropoietin.

Margaret Grant, MD,
Geriatric Medicine Resident, University of Toronto, Toronto, Ontario

Definition and Prevalence

In response to the confusion surrounding the existence of multiple definitions of orthostatic hypertension (OH), a consensus statement was developed to standardize the meaning of this medical condition. OH is defined as a reduction of systolic blood pressure (BP) of at least 20 mm Hg, or a reduction of diastolic BP of at least 10 mm Hg within 3 minutes of standing or lying on a tilt table at an angle of at least 60 degrees.¹ The prevalence of OH in the elderly ranges from 5 to 33 %.^2-4 This variability may be the result of different definitions used and the range of populations considered, from frail older nursing home patients to healthy older people living in the community. The prevalence of OH can be as high as 50% in frail older nursing home patients.²

In a study by Ooi et al., which looked at nursing home patients' BP taken at 8 different times, OH was found to be variable depending on the time of day, with a higher prevalence just before breakfast.