Transcript for:
Orthostatic Hypotension in Parkinson's

all right welcome everyone we're so glad to have you join our Palo Alto so-called Palo Alto virtual Parkinson's support group meeting this month our last meeting of the year and we actually have three speakers today our first main speakers going to be talking for um well talking for about 40 minutes or so and then answering questions and we have um Dr miglas for up to an hour of his time today so we're glad to have him uh our first speaker is Mitch miglas he is um an autonomic disorder specialist at Stanford in neurology and he's also a sleep disorder specialist so he knows a lot about a couple of the issues that plague people with Parkinson's disease and similar disorders and I also noted online that um that uh Dr miglas is involved in the long covid efforts research efforts so that's very interesting too maybe you could say a bit about that towards the end of the talk or something and I see that I need to fix a chat so I will fix the chat and um if anyone has questions use the chat once I get it working or submit through the Q a box and and I will interrupt uh Dr miglas's talk to ask him certain questions so thanks for joining us Dr Mig list and everyone called in today thanks okay thank you Robin okay so um thank you for the introduction and um so today I am going to speak on a common issue in Parkinson's is um orthostatic hypotension and kind of managing blood pressure issues um and orthostatic hypotension is just the fancy medical term for meaning your blood pressure drops more than it should when you stand um so a lot of patients with Parkinson's have this maybe 50 percent uh some some patients also have big swings in blood pressure highs and lows and we can get into that um so before getting into what happens when the process doesn't work correctly it's important to understand what normal is so so normally when we stand up there is almost a liter of blood so it's a good amount of blood maybe of a sixth of our or a fifth of our total circulation is um distributed from most of it is in the stomach area uh and the upper in the Torso area and it gets distributed into the legs so all that blood kind of goes into your your legs but the body has mechanisms in place to make sure that the blood pressure stays fairly constant and so we don't faint when we stand up and so we call this the barrel reflex basically there are areas in the brain and blood vessels in the brain and in the neck that sense these changes in pressure and they'll send signals to blood vessels in your in your legs to squeeze down to pump that blood back up to increase your heart rate so the blood circulates up to your brain when you stand and you don't faint um and so when this doesn't happen correctly we have this condition called orthostatic hypotension or we can abbreviate it oh and uh oh is defined by a drop in your blood pressure uh systolic so that's the top number by at least 20 points you can also meet this criteria if the bottom number drops at least 10 points the top number is usually more important if the top number is correlated more with the blood flow to the brain and a lot of the symptoms that you might have so usually when we're seeing patients really focusing on that top number and so that top number should not drop more than 20 points um when you stand but it's important to note that this implies that the drop is sustained so it's normal for that pressure to drop right away when you stand but it should normalize within you know at least 30 seconds and definitely within a few minutes so there's a cut off here that if the blood pressure drops and it stays low for at least three minutes that's abnormal um so if you're testing your blood pressure at home if any of you have seen us in our Clinic we have a blood pressure log we give um we recommend doing your first reading actually laying flat and we'll get into this and then you'll stand and stand for three minutes and check it again because if the pressure drops right away but it rebounds normal but if at three minutes it's at least 20 points below where you started that's not normal that's orthostatic hypotension um so they're all different causes of oh and not all of them are Parkinson's disease so the more common causes are um other medical issues heart failure being dehydrated being anemic and as as we age it's it's quite common five percent is a low estimate some people have estimated it's up to 20 percent um once you get about you know over age of 65 and there's a lot of reasons for this um increased varicose veins decreased muscle mass medications that patients are on low blood medicines at lower blood pressure all of these can cause drops in blood pressure um so there's a few ways we can help distinguish those more medical causes from causes like Parkinson's more neurological causes it's also important to recognize that not everyone with orthostatic hypotension has symptoms and especially in Parkinson's sometimes if you have symptoms it's not easy to recognize those symptoms um some patients will have a drop in blood pressure but they they won't have any symptoms and some people will have really severe symptoms so this condition can be asymptomatic can be without symptoms and we really only treat it if if there are symptoms associated so it's important to look for it and probably when you see your Parkinson's specialist they do these measurements of your blood pressure sitting and standing but if your pressure does drop we're only going to treat it if you have symptoms or if you have frequent Falls that's another kind of red flag that it could be related to your blood pressure if you do have symptoms what are the common ones um well definitely dizziness lightheadedness I feel like you're about to faint some people do faint your vision could get blurry black out white out um loss of you know peripheral vision other symptoms that people don't know so much about but these are also pretty common are what we call coat hanger headaches so that's sort of um pain in the shoulders and the neck area and this is due to decreased blood flow to these large muscles in your in your neck um shortness of breath when you stand sometimes chest pain some people get more cognitive slowing and trouble thinking this is pretty common and fatigue if your fatigue is is much worse when you're standing and it gets a lot better when you sit down or lay down then you want to make sure you don't have orthostatic hypotension so you know we call all these symptoms orthostatic intolerance so it it can be lightheadedness but it can also be these kind of more vague symptoms of fatigue or shortness of breath or just not feeling well and if you have symptoms like this that are obviously worse when you're standing and you lay down they they get better go away um this is something you want to look for any questions about this the symptoms um I'll just keep going but if anyone has questions feel free to just write those out we can stop at any point um somebody asked about this um you talked about if the fatigue is worse when standing then they should get the orthostatic hypertension change somebody mentioned that standing itself for a long time uh you know seems to be problematic their legs start to hurt and they they don't feel well if they're standing for a long time and is that normal yeah it's it's not normal I mean I think that that could it's not necessarily um going to be caused by a drop in blood pressure but it's enough of a concern given how common this is I would definitely do some blood pressure measurements and again I would check first check blood pressure laying flat get that reading and also write down your heart rate and then stand try to stand in place for three minutes and check your blood pressure and your heart rate again and do that once a day for a week different times of day are good usually this problem is going to be worse in the morning you know when you're more dehydrated but get some measurements in the evening and afternoon and once a week and then bring that to your doctor I mean if you have a symptom like that yeah um so this can be diagnosed at home with these home blood pressure measurements you don't need to come in and do fancy testing but um you know we do this testing in in the autonomic lab where you know we measure blood pressure with a little finger monitor we do tilt table tests and this is common we'll see the blood pressure drop from so normal blood pressure 120 over 85 pretty quickly on upright positioning it's going to drop down to 68 over 55 um what this is showing on the top this is a measurement of blood flow in the brain in this particular patient and this is meant to show that blood flow definitely drops when the blood pressure drops so the cerebral blood flow goes down but um it doesn't go down as much as it would in say like a 20 year old with this degree of blood pressure dropped it didn't have any medical problems the the brain and Parkinson's um in patients that have this low blood pressure issue chronically it seems to adapt so the body preserves blood flow to the brain at the expense of the rest of the body so your pressure in your arm it's not the same as the pressure in your brain and patients with chronic orthostatic hypotension are able to do a lot of things that you know wouldn't be possible in someone who didn't have this adaptive process because their brain has been you know adapting to this for so long um they're shunting blood flow more to the brain and away from the rest of the body so this may be why you know we sometimes see these huge drops in blood pressure but patients don't notice symptoms or they're not so mild not so severe is because of this kind of preservation of blood fluid of the brain that happens so again there's there's two types of of oh there's the non-neurologic or non-neurgenic and then there's the neurogenic the non-neurogenic causes which also are really common I think in the uh population of Parkinson's just due to age and other medications so you always want to look for these things make sure you're not anemic make sure you're staying hydrated um if you have cardiac conditions that can contribute adrenal insufficiency is pretty rare your doctors would probably include in and check check that there'd be other features varicose veins can cause it and then if you're if you have this problem the first step is going through your medications and if you're on any medicine to lower your blood pressure that would either be lowered or stopped and that would also include include nitrates um you know things like Viagra those sorts of medications and even some antidepressants like tricyclics these are things like Nortriptyline amitriptyline so we get this all the time this is real common patients have high blood pressure most of their lives develop Parkinson's develop orthostatic hypotension and then the first thing we do is take them off of you know one or two of these anti-hypertensives you know so again what causes this condition well you know the Parkinson's disease is caused by deposition of this protein of alpha synuclein in the brain and that causes all of the the motor symptoms but that protein also gets deposited in peripheral nerves and including the nerves that control the release of chemicals that keep your blood vessels doing what they're supposed to do and so the protein is deposited in these um autonomic blood vessels that release this chemical norepinephrine or noradrenaline that chemical binds to your blood vessels and causes constriction when you stand so the Parkinson's protein causes breakdown of this release of the chemical so the blood vessels don't constrict blood pressure drops and you know again I mentioned the prevalence it's about 30 to 50 percent of patients with Parkinson's have this condition this is also orthostatic hypotension is also a feature of the other you know Parkinson's likes conditions like Lewy Body dementia and MSA so very very common um and it's important to recognize because it's really a source of a lot of um you know morbidity a lot of uh you know worsening of quality of life and also mortality patients with Parkinson's that have this orthotic hypotension they're in the hospital more they have more Falls and because of that there's you know greater risk of complications from those Falls and and death and um you know the the hospital related costs are um two to three times higher in Parkinson's patients that have oh versus those that don't have oh and it's it's also very treatable so that's why it's just important to recognize if you have it um you know it can be treated and you know thus it can you know lead to significant Improvement in other neurological functions so you know when to suspected if you're having frequent Falls which can be due to other things in Parkinson's but that should always cue you into you know looking at your blood pressure any of those symptoms that we discuss that are worse when you're standing um and then also if you're if you have any other comorbidities like heart disease or diabetes or kidney disease and if you're on any medications that can lower your blood pressure you always want to think about this and I see on the first bullet point there is the word syncope if you could Define that and and say what it means in in this and yeah thank you so syncope means fainting um so any fainting uh you want to make sure that it's not due to orthostatic hypotension fainting is can be you know normal uh in certain circumstances it's um about one-third of the population can faint or has fainted the most common cause of painting is called vasovagal syncope that's just this reflex that happens um sort of the body's response to stress that happens very quickly but people can also faint from orthostatic hypotension which is more of a gradual decrease in blood pressure it just kind of keeps going down the longer you're standing and then you faint usually that doesn't happen with orthostatic hypotension because it's a gradual decrease and by the time people are getting close to fainting they're recognizing symptoms and they'll sit down but yes people can have syncope from it which means fainting thank you okay so how do we evaluate this so we get all these symptoms we think of this this might be it might be an issue we do these blood pressure measurements so measure supine which is laying flat and then measure it after you've been standing for three minutes and and then there's a couple other blood tests that we usually do these are standard tests your primary would do mostly just making sure you don't have anemia um B12 level that's something we always check for like everything neurological um so make sure your B12 level is okay and make sure your thyroid's okay but there's not a lot of other blood tests that we do and then if you have access to autonomic testing like at Stanford that can be useful to just sort of quantify it and do the Tilt test and then we also do other breathing tests that measure autonomic function but you know it's not always necessary if you just do the measurements at home and you're seeing that you obviously have this blood pressure drop so it's not just low blood pressure so almost everyone that has orthostatic hypotension also has high blood pressure when they're laying flat so those centers in the brain that control the blood pressure um they're also not working correctly when you're laying flat so they should be lowering pressure when you're flat and then increasing pressure when you're upright but they're not working correctly because at Parkinson's and so what you'll have is when you when you lay flat like when you're sleeping your pressure will be high so we call this supine hypertension and the first step in treating this is is try to raise your head of the bed at night and I'll show you a slide on this but we always recommend raising the head of the bed by around 30 degrees and to lower blood pressure while you're sleeping and this can also help your morning blood pressure from dropping so much so what can happen is if your pressure is high at night that's going to push more sort of fluid out of your your blood vessels and you're going to end up you know urinating more of that fluid in the morning and your blood pressure will drop more so if you can keep your nighttime blood pressure more in the normal range your morning pressure is not going to drop so much so that you know there's a couple reasons to to treat this if if this is going on okay so really the important things you know how do we manage this um again the goal is not to tally normalize the blood pressure that's never going to happen it's really to improve symptoms that you're having and quality of life and reduce Falls and all that if you don't have symptoms we don't treat it all right so skip this so yeah so really before we use medications first steps are Elevate the head of the bed it's really best if you can you can get an electric bed um you know just to raise the head up in the past the old school method was putting something under the head of the bed like like bricks or telephone you know books when they used to make those and um or like risers to get the whole bed up but then you tend to slide down the bed so if you can afford an electrical bed where just the head goes up that's the best uh compression garments um I wouldn't recommend prescription grade intense compression stockings they're really uncomfortable they're really hard to get on with Parkinson's so usually just um knee-high like over-the-counter athletic socks can be useful if if you're really symptomatic the best compression is an abdominal binder so you just buy these velcro binders like for low back pain you can get you know like ten dollars on Amazon and you just put that around your your belly and just kind of keep it a little tight and so most of the blood that goes into your legs is in your in your abdomen so it'll just kind of keep that blood from you know pooling as much um fluid the goal is around two liters of water a day another really helpful sort of tip is um drinking water quickly so you know boluses of water you know have to be about half a liter uh maybe six to eight ounces of water um will also be okay so if you if you drink that quickly especially if it's cold it's going to increase your pressure by up to 30 points top number so you know the the staying hydrated throughout the day is one one component but then also you can drink water very quickly and that'll give us sort of um rapid bolus effect and you can almost use that as a medication like in the morning if you're able to you know drink some water quickly before you get out of bed if you're lightheaded in the morning that can help and it has to be water you know it's not an electrolyte solution if this is actually a reaction in the stomach that happens to the water itself if you drink it quickly and then salt this is the only time that you know doctors are recommending to increase your salt but um Salt's going to help keep more of that water in your blood blood vessels and you want to aim for about two teaspoons of salt per day to the diet so two teaspoons of table salt um and then exercise so strengthening your legs you know exercise is important important in Parkinson's disease um anything you can do to keep your leg muscles strong is going to help pump blood up to the head but um I'll show you a slide on that so this is just you know showing the head of the bed this is the picture on the left was from I think one of the first Publications on this from I think the 1940s and this is how I used to do it and uh this is a much more comfortable way to do it now so so exercise so um if you have orthostatic hypotension your blood pressure is going to drop when you exercise and I've seen patients you know Unfortunately they are referred after they fainted you know on a treadmill in the gym you really want to avoid treadmills if you have this but um the point is with normally blood pressure goes up when you exercise but if you have orthostatic hypotension it's going to drop and so you just have to be a little careful when you're exercising um it's it's definitely better to do things where you're seated you know stationary bike rowing machine or in a pool so if you're in a pool you also have the um the pressure of the water which is going to increase your blood pressure and you might be able to do more and be less symptomatic if you have really severe oh and then they're what we call counter Maneuvers which is basically squeezing your muscles so the best thing you can do if you're if you're feeling like like you could faint is to sit down or lay down but in some situations you might not be able to do that so the best thing you you can do is maybe cross your legs and squeeze your leg muscles um or squat down some patients if they're in the grocery store and they feel like they're gonna faint they can't sit down they'll squat down and pretend like they're looking at something you know so um these things will increase your blood pressure but you know they're obviously temporary maneuvers so any questions about the non sort of medication treatments for this somebody asks it used to be that you if you felt faint you sit down and put your head between your knees this person says I don't see a picture of that yeah yeah that no that's true um I I don't think I don't know why they didn't include that maybe because yeah it might be a little unsteady if with your head between your knees squatting especially if you have other kind of balance issues from Parkinson's so if you can do that that's that's fine um if you don't have you're not going to fall down but the best position is really just laying on your back and putting your legs up right and the second best is squatting probably and then the third best is crossing your legs like that and um one thing I have seen uh previously uh I don't know if this is considered a counter maneuver or not but uh doctors often advise to pump the pump the ankles before standing up to get I guess maybe get blood moving up the leg um is that considered a counter maneuver I guess you wouldn't really do that if you felt faint because you're already seated yeah um it's not a counter maneuver but it yeah it will start the blood circulation a little bit more in your calves it's probably gonna have a minor effect it's you know just the calves you know so really it's a lot of this is the is the quads and the you know the glutes and those muscles that you're trying to activate so okay somebody says my mother has had acute oh for the last 45 days that included several Falls and up to 10 oh incidents per day she has just been released to Skilled Nursing from her fourth hospitalization but ptot don't want her to leave the bed because of the fall risk are there exercises and options for bed-bound people yeah that's really tough yeah the physical therapists they never wanna touch our patients because you yeah either high or low blood pressure and they get really scared um she probably needs I mean she definitely needs medication I think to that's at that point you know it sounds like it's pretty severe so you know I'll get into medications next and um she really needs medication to increase it first so she can get out of bed but I mean the pts would be the best to kind of answer that question um you know they're probably some pretty basic uh core exercises and things she could do but it's not going to really help dramatically I mean first step is to use medication and then get out of bed and do the conditioning yeah okay thank you yeah um so I think that question just yeah kind of summarized this slide is why do we want to treat this is because the symptoms lead to Falls which leads to hospitalizations which leads to deconditioning which then leads to um fear of falling and then it's this vicious cycle that we that we want to prevent so this is a really really busy sort of technical slide but um this just kind of shows all the different medications we use for this if you want to look on the right here with this blood vessel here the most common medicines probably called mitogen and this medicine binds to The receptors in the blood vessels and causes to constrict and this is a this is a good medicine it's usually the first one we start it's shorter acting so it's going to last like three hours at a time so usually take it two to three times a day other common one you'll see is called fluidicortisone or fluorine f and that's a once a day long-acting drug and that causes retention of more salt so it's just going to increase the volume in the in the system um longer acting so there's a greater problem with that high blood pressure at night that supine hypertension um but also a a decent option draxidopa is the newest drug called droxydopa or northera it's more expensive but it's recently gone generic so it's become less expensive now and this is probably the best drug overall because it's it's the cleanest it's converted to the chemical that causes the blood vessels to constrict um it's really similar to mitogen it's two to three times a day dosing um and so typically we'll get to try monogram first because it's easily accessible and then try to think about doxy dopa and kind of see how much that's going to cost um under the insurance plan and then finally there is Pareto stigmine or mestinon um this is a good drug it's just not as powerful as the other ones and it's going to increase Upstream sort of chemicals that are eventually converted to that norepinephrine that causes the constriction foreign again sort of older School drug approved in 1996 um acts about three hours at a time side effects are higher blood pressure at night um the more common ones patients notice it can cause an itching or a tingling in the scalp which because it causes Goose bump sensation it can sometimes cause urinary retention that can be an issue in Parkinson's and sometimes it causes headache androxydopa approved in 2014 and again a lot of this is sort of more scientific stuff you don't need to know all of this it's very similar to monitoring in a dosing side effects are pretty similar doesn't cause the urinary issues or the Goosebumps it can cause headache and then higher blood pressures at night so um a lot of doctors get really nervous about either high or low blood pressures in uh in patients with this problem really we're we're really focusing on the low blood pressure I mean the priority is to increase that pressure when you're standing so you're not miserable and you're not falling and you're not fainting and then we kind of accept that there's going to be a little more risk of this higher blood pressure when you're laying flat um but there have been many studies and it seems like all of the major medical complications of this condition are related to the low blood pressure and then yes the high blood pressure can increase some risk of kidney issues and heart issues long term but it's orders of magnitude kind of lower than all those risks associated associated with the blood pressure drops so again to try and reduce those risks of high pressure we raise the head of the bed um and then sometimes will even give a short-acting medicine to lower the blood pressure at night and that that can be done as well um so you know if your doctors are really kind of nervous about these medications again the emphasis is that there's not been a lot of studies showing great risk of the supine hypertension it's all of the problems are related to the uh the orthostatic hypotension the low blood pressure one question or one person pointed out that their family member takes HCTZ or diuretic water pill what are your thoughts about those yeah I mean not good if you have um orthostatic hypotension so you should stop that if um if they have orthostatic hypotension as far as using that at bedtime um if you have supine high blood pressure it that's reasonable to do but it's going to probably cause you to go to the bathroom you know more often at night which is already a problem so they're probably better drugs if you were going to pick something to just give as needed at night um something like um clonidine or labetalol are ones that we use yep okay let me see I think I had oh no that's it thanks and so then the other point if you're taking one of these medications uh like mitogen or droxydopa is um obviously because it increases blood pressure and because there's this greater risk of supine hypertension or high blood pressure you don't want to give the last dose within four hours of bedtime so usually you know if it's three times a day we're dosing it first thing in the morning around lunch time and then maybe later afternoon and then again this is mentioning you can give these shorter acting medicines to lower blood pressure at bedtime if needed um fluticortisone that one that I said that is long-acting and it increases salt absorption probably has the most side effects it can cause swelling in the ankles it can cause low potassium it it is increased increases risk of complications generally so probably because it's real long-acting and um so this is usually something that you don't want to be on first first thing I mean it can be okay to take but you know if your doctor prescribes this first thing you know you you want to maybe ask about Alternatives and mitogen or droxy dopa are probably better stigma and again this can be a good drug it's usually an add-on so like with mitogen it works pretty well in combination because it's not as strong by itself it's really good also if you have really slow motility like gastroparesis or you know slow um emptying constipation because it's going to speed that up and and that's one of the side effects is diarrhea but if you're constipated that can be a useful side effect so yeah that's um those are all my slides and I think the point is that this is a really common complication the symptoms can be vague at times and you really want to sometimes you have to keep a diary and just really see you know are the symptoms related to standing and just being on your feet and then when in doubt there's really a low threshold to um to do blood pressure measurements and then I can um maybe even put the link to our log in the chat we have a blood pressure log on our website that you can download and then if you're seeing consistently that your top number is dropping 20 30 plus points and you have symptoms with that then you want to bring that to your doctor you want to go through your medications make sure you're not taking those drugs that'll make this worse you want to increase your fluid and salt use some compression garments Elevate head of the bed and if that's not working you have you know three or four different medications that usually we can get the blood pressure under pretty good control so patients aren't super symptomatic and it's and you know the fall risk related to this is is a non-issue um so yeah with that I'll stop there and go through questions okay I have a few more questions for you um somebody asks how high can the blood pressure be before worrying about oh to take medications to bring down the blood pressure above 170 above 200. yeah I usually tell patients 180 top number 180 um if it's not coming down within five minutes because you know part of this problem is with with these diseases there's just so much fluctuation you might check it five minutes later and it's going to drop considerably so if it's still 180 after five minutes I would make sure you have a prescription for like short acting anti-hypertensive that you could take in that situation so we do that a lot something like clonidine for instance so patients will just have that as a backup if if they're in that situation okay um somebody says my husband's blood pressure drops sometime after standing not immediately that can also happen um it's not always within the first three minutes there's something called delayed orthostatic hypotension that's happens after the first three minutes and you know the effects can be the same the important point is also is it is it sustained so is that just dropping and then a minute later it comes back up that's normal but if it's at least three minutes of abnormal then it's then it's abnormal so you also I mean you want to do a follow-up blood pressure reading make sure it's at least a sustain drop um probably before you treat it and what was sustained mean then over some number of minutes yeah and that's not defined in any guideline but I think most most of us uh think of sustain as three minutes so the last thing that yeah abnormal for at least three minutes okay and that's for the delayed orthostatic hypertension it's for yeah and I mean that sustained is in the definition of classic normal orthostatic hypotension but that's just built into how we measure it by just just checking the pressure at three minutes if it's if it's still abnormal at three that means it's it's been sustained since you stood up okay yeah all right I got it it would seem to me that this um what you call delayed orthostatic hypertension has got to be very confusing for families and perhaps even for clinicians because [Music] um it seems like everything we're talking about it has oh oh well it could be this like there seems to be caveats for everything I just don't know how families or clinicians can can diagnose these things if there are you know subcategories I guess yeah I think practically the point is no doctor is going to have time to measure the blood pressure have you stand for more than three minutes in the office and you're probably never going to be diagnosed with delayed oh in a doctor's office who's not an autonomic specialist and we only really diagnose it on a tilt table test because we go for 10 plus minutes so you know I mean the point is if you're feeling symptomatic check your blood pressure and just you know you want to look for Trends there because all these symptoms can have other causes and um the measurement's pretty simple but you just have to do it consistently and look for patterns and so I put the I put the link there in the chat to the blood pressure log so you can download that and that's a good thing you can just bring that to your doctors if if you know you're noticing a trend okay sounds good I've got a few more questions somebody asks what about heart rate with orthostatic hypotension yes that's a very good question I didn't go into the the sort of nerdy details with that because it's a little more academic but it can be useful so recently this has been something that we're using to distinguish you know neurogenic say from Parkinson's from the non-neurogenic causes like from dehydration so um because the Parkinson's protein is deposited these peripheral nerves it's also deposited in those nerves that control heart rate in the heart and so the heart can't speed up when the blood pressure drops so you can actually calculate the ratio for every 20 points the blood pressure drops actually sorry for every for every 10 points the blood pressure drops the heart rate should increase by 20 Beats so if your heart rate is not going up that much when your blood pressure drops a lot that is consistent with neurogenic oh and that's always the case in Parkinson's disease so that's something to be aware of if you're on a beta blocker so if you're on like you know metoprolol or something that's also going to blunt your whatever heart rate response that you have and it's going to make orthostatic hypotension even worse so you definitely don't want to be on beta blockers if you have oh unless you absolutely need them for something else right okay um somebody asked at what blood pressure level would you have the patient not walk around all depends on symptoms so there's no number that I would say is an absolute number it all depends on how you if you're symptomatic if if you're if you can walk then you can walk I mean if um if you fall in you know your your fall risk and even you can't recognize the symptoms before you fall then I'd say that's a problem but but otherwise you know like I mentioned the blood pressure and the arm that you're measuring is not the same as in the brain the brain is is preserving that blood flow and it's going to be much higher in the brain than it is in the arm so all depends on the symptoms okay and what percentage of people are a Sim ilar that's a good question I don't think anyone's studied that but um there was a study where they they did tilt table tests and a good percentage of those patients had Parkinson's um I want to say up to at least a third of patients wow either way asymptomatic or they didn't recognize the symptoms maybe it was cognitive slowing or little shortness of breath but they weren't really correlating that with blood pressure [Music] that's good it's a very reasonable question I think how can you tell if someone is having orthostatic hypertension or vertigo due to other causes yeah infertigo is really common with this as well um so vertigo first of all it's going to be more likely to come out when you're sitting as well as standing so it's not orthostatic vertigo is going to be more triggered by head movements whereas oh is not vertigo I mean the the classic description of it it's more of a movement or spinning versus orthostatic hypotension is more of lightheadedness or woozy sensation so that's always how I ask about it and the duration can be similar I mean both can last from from SEC you know seconds or longer I mean typically vertigo is more shorter acting you know me lasting like meaning seconds or so and then um it's consistently triggered more by movement of the head and less by just standing okay uh someone asked can you talk about the co-occurrence of oh with afib and how whether that impacts treatment options yeah oh these are great questions because I've actually preparing a manuscript looking at oh in in Rim behavior disorder which is a bit different but we found that's amazing like really surprisingly there's a very strong correlation with oh and afib and about 25 percent of patients with with neurogenic oh AFib and there is some literature that supports this connection because afib is it could be related to breakdown of these autonomic nerves in the heart so I think that's uh that's a correlation that's not really in the literature much and it's probably a real thing um how do we treat it I mean we still kind of treat it independently like your cardiologist is going to do the treatments for afib and then we're still going to use the same drugs for oh and the drugs that we use are not going to interfere with the cardiologist treatment of AFib I mean if they use beta blockers that might be a problem but um the drugs that we use are not going to interfere with afib treatment okay um speaking of that if someone has oh would they and Parkinson's disease would they be advised to see an autonomic Specialist or a cardiologist or how how would you determine which sort of specialist is the best I mean whoever you can get in to see or whoever's in your area because there's not there's not many of us there's not many autonomic neurologists um you know an autonomic doctor would be the best because this is what we treat day in and day out but most cardiologists are pretty familiar with with it um some a lot of neurologists a lot of Parkinson's you know movement Specialists treat this so probably your Parkinson's doctor has familiarity with all of these medicines that I talked about and they could prescribe it as well right okay um and is it possible to be seen at Stanford you mentioned you sort of winced at the concept of making an appointment somebody making an appointment is it possible to be seen at Stanford oh yeah definitely I mean we have be the we probably see the most autonomic patience of any you know Center in the nation um so there's there's five five doctors in our division and um yeah we're all always accepting new patients so you know your doctor just needs like with any referral at Stanford they just need a standard referral and it'll come in and um sometimes we'll do the autonomic testing as part of that sometimes we'll just do the visit first and then do the testing but yes definitely are open okay and you said um and you don't always do the tilt table test you'll do it if certain conditions warrant it uh what other sorts of autonomic testing are done besides blood pressure testing yeah so we'll do um test called the valsalva maneuver which measures this reflex that the Tilt is also measuring that bear reflex where you blow into a tube basically and we see how your blood pressure changes um we do deep breathing to look at your heart rate variability that's looking at the the Vegas uh parasympathetic nerve in the heart and then we do a test of sweating with these little capsules on your arm and leg that measure the sweat response and the small nerves in the skin most patients with Parkinson's disease have reduced sweating and they have um it's probably due to that protein being deposited and breaking down those nerves um so that's a common thing that's abnormal in the testing whether that we're going to do anything about it probably not um so sometimes we'll get referrals where the doctor's not sure if someone has Parkinson's disease or if they have like MSA and sometimes there can be features on subtleties in these autonomic tests that can distinguish one versus the other but if you pretty clearly have Parkinson's and your your home blood pressure logs are showing or the static hypotension you probably don't need to go through all that testing okay and um let's see there was a question that just came by a second ago oh um what uh somebody asked about uh postprandial hypotension so the so the loss of blood pressure control after eating or when when someone's eating could you speak to that and say is that related to orthostatic hypotension as well yeah it totally related um some people have that more than others and you know in you know Parkinson's the these nerves that affect digestion are also impaired and so you get kind of slow digestion and that can be a factor so um yes postprandial hypotension can be a big problem some people can faint from it and you know the first thing is obviously to reduce the size of the meals limit the simple carbohydrates so simple carbs are the worst because you get most blood flow to your gut and then caffeine can help so if you have a little caffeine Maybe probably like 30 minutes before you you eat that can be helpful but often we use mitotrin there's mitogens that short acting so like five milligrams of midadron maybe 30 minutes before a meal that's probably the most common you know treatment that uh that I would prescribe for that okay and again you probably only prescribe if the if the if there is fainting or if there's some strong symptoms yeah if there's symptoms yeah right um let's see oh could you uh we have just a few more minutes before we need to let you go uh could you just say something briefly about the long covid research that you're involved in that sound kind of interesting okay what do you want to know well what does it have to do with either sleep or autonomic issues well yeah I mean um minutes or less yeah well you know I don't know if you've been following the popular news but um there's another condition that we probably the most common condition that we see an autonomic Clinic is postural tachycardia syndrome that's not what you have if you have Parkinson's disease that's usually a condition of younger women but you know people develop this really fast heart rate and they can have all the symptoms that patients with oh have and usually they're worse um but it's thought of more as a condition of like automatic hyperactivity constant fight or flight it's always the opposite of oh is like failure of everything and the pots is like overactivity of everything and so um it's you know it can be a common relatively common complication with long covid um and we don't know why that is but you know part of it could be autoimmunity you know covet activates certain antibodies that cause these autonomic problems um it could be just persistent inflammation from the virus so I mean basically we're doing autonomic testing um we're doing skin biopsy in these patients very interesting as we're seeing that on the skin biopsy patients have the Parkinson's protein in the skin uh and this was an unexpected finding and it's um making me rethink you know how sensitive these skin biopsies are for for Parkinson's parkinsonian process I think you it might be that certain viruses can trigger inflammation that could lead to deposition in this protein um and that might be a totally different sort of pathology than a degenerative you know process right and you know if there's a link I mean there's also been reports of patients with Parkinson's you know having long covet and getting getting much much worse or patients totally you know developing Parkinson's after covid and so um I think there is some connection with the virus you know either triggering accumulation of these proteins or causing kind of neuronal injury either at a peripheral or even a brain level um it could be related to Parkinson's disease but you know that's something we'll repeat the biopsy see if it clears um but it's been it's about 50 of the pots patients we biopsy have this protein and they're about 20 to 30 years old wow fascinating I mean it could this could lead eventually to some discoveries that would help Parkinson's disease yeah I mean if um the role of viruses in accelerating degenerative disease I think is right I mean in the uh you know the um the Spanish flu and you know there there are these reports you know if you know in in the movie Awakenings is all based on um potentially post-viral parkinsonian you know issues so it's something that's been around for a while it's yeah it's not really well understood right right okay great well thank you so much Dr miglas appreciate it and if you could send me your slides um and I will share those online and I also have um I've copied over the um the orthostatics log that Dr migler shared and I'll make sure everybody receives that as well so thank you so much for joining us thank you enjoyed it okay thanks Robin bye