Appropriate management for an 82-year-old patient experiencing a drop in blood pressure upon standing (orthostatic hypotension, OH) involves a comprehensive approach prioritising non-pharmacological strategies first. Initial steps include identifying and avoiding triggers, educating the patient to recognise prodromal symptoms, and advising postural adjustments such as sitting before standing to reduce symptoms and falls risk 1. Ensuring adequate hydration is important, with encouragement to increase fluid intake if feasible, although this may be limited by mobility, continence, heart failure, or chronic kidney disease 1. Dietary salt supplementation may be considered to expand plasma volume and reduce symptoms, but evidence is limited and should be tailored individually 1. Regular physical activity is recommended to improve autonomic function and vascular tone 1.
Additional non-pharmacological measures include the use of physical counter-pressure manoeuvres (e.g., leg crossing, muscle tensing) and compression garments, especially abdominal compression, to reduce venous pooling and improve venous return; these are second-line options supported by limited evidence 1. Head-up tilt sleeping may be considered to prevent nocturnal polyuria and maintain plasma volume 1.
Medication review is critical, particularly in elderly patients, to identify and reduce or stop drugs that may worsen OH, such as diuretics, beta-blockers, calcium-channel blockers like amlodipine, and alpha-1 blockers like prazosin, which are potentially inappropriate in persistent postural hypotension due to increased risk of syncope and falls 1,5,11. Blood pressure targets should be individualised considering age, frailty, and comorbidities, with clinical judgement guiding treatment intensity 1,3.
If symptoms persist despite lifestyle modification and medication review, referral to specialist care is advised for further assessment and management, which may include autonomic function testing and consideration of pharmacological treatments such as fludrocortisone or midodrine. However, these drugs have limited evidence in the elderly and carry risks such as supine hypertension and heart failure, so specialist input is essential 1.
Overall, management should be holistic, aiming to reduce falls risk through multifactorial interventions including strength and balance training, home hazard assessment, and medication optimisation 4. Recent literature supports these approaches and emphasises bridging pathophysiology with practical strategies, reinforcing the importance of non-pharmacological management as first-line in older adults with OH (Owen and Frith, 2025; Fantin et al., 2025).
Key References
- CKS - Blackouts and syncope
- CKS - Hypertension
- NG136 - Hypertension in adults: diagnosis and management
- CG161 - Falls in older people: assessing risk and prevention
- Amlodipine SmPC
- Furosemide SmPC
- Hydrochlorothiazide SmPC
- Tolazoline SmPC
- Bosentan SmPC
- Sildenafil SmPC
- Prazosin SmPC
- Methyldopa SmPC
- (Fantin et al., 2025): How to effectively treat arterial hypertension in elderly individuals?
- (Owen and Frith, 2025): Strategies for Non-Pharmacological Management of Orthostatic Hypotension in Older People: Bridging Pathophysiology and Practice.