Overview
Dr. Mitch Miglis, an autonomic and sleep disorder specialist at Stanford, led the Palo Alto Parkinson's support group meeting focusing on orthostatic hypotension (OH) in Parkinson's disease, covering its diagnosis, management, and related questions from attendees.
Introduction to Orthostatic Hypotension in Parkinson's
- Orthostatic hypotension is a drop in blood pressure when standing, common in 30–50% of Parkinson’s patients.
- OH can cause symptoms like dizziness, fainting, blurred vision, headaches, cognitive changes, and fatigue.
- OH often goes unrecognized and may be asymptomatic or only present with falls.
Causes and Diagnosis
- Causes include neurological (Parkinson's, MSA, Lewy Body dementia) and non-neurological factors (dehydration, heart failure, anemia, medications).
- Diagnosis involves measuring blood pressure lying flat and after standing for three minutes, looking for a sustained drop (≥20 mmHg systolic).
- Home monitoring is recommended, and an autonomic lab can conduct advanced testing if needed.
Impact and Importance of Treatment
- OH increases risks of falls, hospitalizations, and mortality in Parkinson’s patients.
- The focus of treatment is on improving symptoms and reducing falls, not on normalizing blood pressure.
Non-Medication Management Strategies
- Raise the head of the bed about 30 degrees at night to prevent supine hypertension.
- Use compression garments, preferably abdominal binders, to reduce blood pooling.
- Maintain 2 liters of water daily and use rapid water intake to acutely raise blood pressure.
- Increase dietary salt intake to about 2 teaspoons per day.
- Engage in seated or recumbent exercise; avoid treadmills, and use counter maneuvers (crossing legs, squatting) if symptoms occur when upright.
Medication Treatments
- First-line medications include midodrine and droxidopa; fludrocortisone is also used but has more side effects.
- Medications are timed to avoid increasing nighttime blood pressure; avoid last dose within four hours of bedtime.
- Beta-blockers and diuretics can worsen OH and may need to be adjusted.
Special Considerations and Related Issues
- Postprandial hypotension (after meals) is managed by smaller meal sizes, limiting simple carbs, and potentially using midodrine before meals.
- Delayed OH can occur and may require extended monitoring.
- Heart rate response helps differentiate neurogenic OH; lack of appropriate heart rate increase indicates neurogenic cause.
- Vertigo is differentiated by being movement-triggered and not specifically related to standing.
Access to Care and Testing
- Both autonomic specialists and experienced neurologists or cardiologists can manage OH in Parkinson’s.
- Stanford accepts new referrals and provides a range of autonomic function tests beyond blood pressure measurement.
Research Update: Long COVID and Autonomic Issues
- Long COVID can lead to autonomic dysfunction, including postural tachycardia syndrome (POTS), sometimes associated with deposition of Parkinson’s-related proteins in young patients.
- Ongoing research investigates possible links between viral infections, autonomic dysfunction, and the development or worsening of Parkinson’s disease.
Decisions
- Emphasize symptom-driven treatment for OH rather than solely targeting blood pressure numbers.
Action Items
- TBD – Robin: Distribute Dr. Miglis's slides and the orthostatic blood pressure log to attendees.
- TBD – Attendees: Track and record blood pressure at home, including before and after standing.
Recommendations / Advice
- Review medications for drugs that lower blood pressure and consult your doctor if symptomatic.
- Implement lifestyle adjustments before starting medications; escalate to medications if symptoms persist.
- See a specialist if OH is severe, frequent, or unresponsive to first-line management.
Questions / Follow-Ups
- Consider further evaluation if symptoms persist despite home management.
- Reach out to your physician or an autonomic specialist if you have high fall risk or complex medication needs.