Geriatric Syndrome
Orthostatic Hypotension: Diagnosis & Treatment
Orthostatic hypotension (OH) — defined as a sustained drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing — is present in up to 30% of older adults and is a major reversible cause of falls, syncope, and cognitive symptoms. Causes are usually multifactorial: medications (diuretics, alpha-blockers, nitrates, TCAs, antipsychotics), volume depletion, autonomic dysfunction (Parkinson's, diabetes, multiple system atrophy), and deconditioning. This guide covers proper bedside measurement technique (supine for 5 minutes, then immediate, 1-minute, and 3-minute standing readings), the workup for neurogenic OH, a structured medication review with deprescribing recommendations, non-pharmacologic measures (slow position changes, increased salt and fluid intake, compression stockings, head-of-bed elevation), and pharmacotherapy options including midodrine and droxidopa. Includes specific falls-prevention counseling.
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Geriatric Syndromes · CV/Autonomic
Orthostatic Hypotension
Most common cause of syncope in older adults · Medications cause it · Treat the cause.
Assessment
How to identify in clinic
- Orthostatic vitals: BP and HR lying → sitting → standing at 1 min and 3 min
- Positive = SBP drop ≥20 mmHg or DBP drop ≥10 mmHg within 3 min of standing
- Ask: "Do you feel dizzy when you stand up?" "Have you fainted or almost fainted?"
- Check orthostatics at every visit in patients with falls, dizziness, or polypharmacy
Common causes
- Medications (#1 cause) — antihypertensives, alpha-blockers, diuretics, nitrates, TCAs, opioids, antipsychotics
- Dehydration / volume depletion
- Autonomic neuropathy (diabetes, Parkinson's, Lewy body dementia)
- Adrenal insufficiency
- Prolonged bed rest / deconditioning
- Post-prandial hypotension (BP drops after meals)
Management
Non-pharmacologic (first-line)
- Medication review and reduction — deprescribe offending agents
- Increase fluid intake — 1.5–2 L/day if no restriction
- Increase salt intake (if no CHF) — 6–10 g/day
- Rise slowly: sit on bed edge 1–2 min before standing
- Compression stockings (waist-high more effective)
- Elevate head of bed 10–20°
- Small, frequent meals (reduces post-prandial drop)
- Avoid alcohol
Medications (if refractory)
- Midodrine 2.5–10 mg TID (alpha-1 agonist) — avoid at bedtime, avoid in supine hypertension
- Fludrocortisone 0.1–0.2 mg daily — volume expansion, caution with CHF/hypokalemia
- Droxidopa — for neurogenic orthostatic hypotension (Parkinson's)
Avoid
- Aggressive BP lowering in patients with symptomatic orthostasis
- Target SBP 130–150 in frail patients — not <120
Refer & Document
When to refer
- Cardiology — syncope with suspected cardiac cause, refractory orthostasis
- Neurology — suspected autonomic failure (MSA, Parkinson's, Lewy body)
- Endocrinology — suspected adrenal insufficiency
Documentation must include
- Orthostatic vitals (lying/sitting/standing with timing)
- Symptoms with position changes
- Medication review and changes made
- Fall history
- Interventions ordered
- Follow-up plan with repeat orthostatics
Dangerous Pitfall
Over-treated hypertension is the most common medication-induced cause of orthostatic hypotension and falls. A frail 85-year-old with SBP 110 on three antihypertensives is more likely to fall and fracture a hip than to have a stroke. Relax BP targets in frail patients — SBP 130–150 is safer.
Evidence sources
- · AAS Consensus Statement on Orthostatic Hypotension 2011
- · AGS Beers Criteria 2023
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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