Imagine if you will for a moment that you are a nurse working the night shift at the local nursing home. After a long day of cleaning your house and preparing your first Thanksgiving feast for your brand-new in-laws who will be staying at your house for the first time, you are looking forward to a relatively quiet evening. You make your first rounds, checking on all of your patients. You complement that Mrs. Jones on having raised such a thoughtful son who now sends her a bouquet of flowers each week, reminding yourself to pick up some Zyrtec on the way home for your own son. You check Mr. Stein’s bedside drawer and remove the Snickers bar that he is trying to sneak, despite previous admonitions by his diabetic counselor. You calmly agree, again, with Mrs. Mond that “they do keep it too warm in here at night” and gently fold her blanket down around her feet, smiling at the hot pink bedsheets she recently received from her twelve-year-old granddaughter. You pause for just a moment outside of Mr. Deter’s room, allowing yourself a brief moment of mourning for the recent passing of the man who kept his sense of humor even during the last stages. Just as you are about to sit for a brief moment to work on charting, you hear a commotion in Mr. Peters’ room. Rushing in, you find Mr. Peters slumped on the floor next to his bed, a look of frustration and confusion on his face. Helping him to his feet, you do a quick mental review of the past two weeks, recalling three similar episodes on your shift and wondering if any other nurses have charted similar episodes. So much for your relaxing evening.
Now, imagine you are Mr. Peters. After a tedious afternoon of Thanksgiving crafts with the group of home-schooled children who visit each Wednesday, “I love those kids and those crafts sure do help with the missing of my own little Abby and Jaxon, but those moms. Oy, some of them can be so overbearing. I feel for those teachers whenever they let those kids out from under their smothering apron,” you think to yourself as you set your newest book, The Canon, on the nightstand. “I do love that Natalie Angier; she sure does make all that science mumbo-jumbo fun to read. Calling her daughter a ‘DNA carrier’ indeed!” Chuckling to yourself, you remember that you left your glass of ice water on the bathroom counter, and decide you might as well get it now so as to not stub your toe at three in the morning. “That old Mrs. Mond is loony as a Minnesota bird, but I sure agree that it is hot in here. Maybe that night nurse should put on a few pounds for the insulation and they could turn it down a few degrees in here.” Harrumphing, you swing your stiff legs over the side of your bed and push up with your arm, “damned physical therapy,” fully intending to retrieve your water and get some sleep. “I wonder if Mr. Stein will give me his mashed potatoes at dinner tomorrow, all those extra carbs for his diabetes.” Suddenly, you find yourself on the floor, staring up at the night nurse. “What the sam-hill just happened here?”
Although Mr. Peters may not be aware of how he ended up on the ground, the night nurse must be able to quickly and accurately assess the situation and discover the best course of action. While it is obvious from the look of confusion and his position that Mr. Peters has suffered an episode of syncope, or fainting, it is not immediately obvious why this is so. After aiding her patient back into his bed and retrieving his glass of water, the night nurse’s brain is just beginning to spin. She will do another quick round, checking in more carefully on the rooms to the immediate left and right for any commotion-related upset, and then settle in to review Mr. Peters’ recent chart notes in an attempt to begin unraveling the mystery of his falls. After flipping through only a few pages, the night nurse discovers her answer: orthostatic hypotension. Now, all she needs to do is convince Mr. Peters to slow down a little, and everything should be just fine.
Orthostatic hypotension – a physical finding, not a disease – is most accurately defined as a decrease in a person’s blood pressure – at least 20 mm Hg systolic or at least 10 mm Hg diastolic – within three minutes of a postural change from supine to standing. Most patients first present with frustrating symptoms and from there undergo a series of tests before a final diagnosis is given. The symptoms typically occur immediately after standing, and most frequently include a feeling of dizziness or lightheadedness, bodily dissociation and generalized numbness, blurred or diminished vision, and syncope (fainting). When a patient presents with the symptoms of orthostatic hypotension, her general practitioner will call for a number of diagnostic tests in order to narrow down the list of possible causes as well as to confirm the diagnosis.
While the first test may be done immediately and in-office – a simple comparison of a blood pressure reading taken while the patient is in a supine position, with a second blood pressure reading taken after having the patient stand – many of the other tests are referred out. The patient may be instructed to monitor her own blood pressure throughout the day for an extended period of time in order to evaluate if the blood pressure changes may be related to eating or chronic fatigue. Blood tests may be recommended to check for low blood sugar levels, anemia, and dehydration, all three of which may further decrease an already low blood pressure. An electrocardiogram may be performed, to non-invasively check for irregularities in heart rhythm. An echocardiogram is another non-invasive test that may be performed, and it will supply a more detailed image of the heart structure through ultrasound and video imaging. In addition, the patient may be given a stress test in order to monitor the heart functioning during times of increased stress; this stress may be added to the patient’s heart through a prescribed exercise regimen during the test or by the administration of selected drugs for the duration of the test. A tilt table test may be recommended; during this test, the patient is strapped to a table that tilts at dramatic angles so that the blood pressure may be monitored at varying positions from supine to upright. Finally, the patient may be given a halter monitor to wear for an extended period of time, up to one month, to allow for either continuous or intermittent monitoring of the patient’s blood pressure and heart rhythms.
While it is important to remember that orthostatic hypotension is a physical finding and not defined as a disease, it is important for the patient’s physician to encourage thorough testing in an effort to find the cause of the patient’s episodes. In the most general sense, the cause of orthostatic hypotension is always the same – when a person changes positions from supine to standing, gravitational forces cause the blood to pool in the lower extremities, resulting in a lower blood pressure. Baroreceptors in the aortic arch and carotid bodies register the lowered blood pressure and cause an autonomic response through both activation of the sympathetic division (increased heart rate and vasomotor tone in the arteries, veins, and the heart) and inhibition of the parasympathetic division (vagal inhibition will allow an increased heart rate) to rapidly return the blood pressure to its homeostatic level. While this response typically occurs so quickly and seamlessly that a healthy person will experience no negative effects from the temporarily lower blood pressure, any disruption from baroreceptors to autonomic system effector organs can cause an episode in which a person presents with symptoms of orthostatic hypotension. There are occasions when simply being overexposed to heat will cause symptoms, because a person’s blood vessels will have dilated in an effort to release the excess body heat, and so more blood will pool in the lower extremities and more constriction will be required to maintain the blood pressure during a positional change.
The important deviations between patients presenting with orthostatic hypotension are the underlying reasons, and many important factors must be considered. Although age is an easy factor to list, as the excitability of baroreceptors and other autonomic system nerves and effector organs may decline with age, there are many other factors which may play additional roles. A quick check of a patient’s medications may provide some insight, especially if a patient is taking medications to control high blood pressure, beta blockers, Viagra, or has a history of narcotic abuse. A patient who is dehydrated, even mildly, will have less water in their body and so will be unable to maintain the normal/high blood pressure of their supine position. Several heart problems, including an extremely low heart rate and heart valve problems, may cause a disrupted autonomic response because of the inability of the heart to properly circulate blood within the cardiovascular system. Diabetes, especially when undiagnosed, may be an underlying factor as the increased urination can lead to dehydration and there may be nerve damage in the baroreceptors. Finally, there are a number of other disorders that may cause disrupted autonomic responses, which include but are not limited to Parkinson’s disease, bulimia and anorexia, and multiple system atrophy.
After a finding of orthostatic hypotension can be definitively given to a patient, there are some medications available for management of the symptoms, but more often there are lifestyle changes that are strongly recommended. The listing of medications includes those that increase fluid retention or vasoconstriction, as well as stimulant drugs or benzodiazepines. Because the possible side effects of any drug must be considered both by the physical before prescribing as well as by the patient before taking the medication, it is often the simple lifestyle changes that play the most important role in decreasing the effects of orthostatic hypotension. Patients are advised to change positions more slowly, even pausing for a moment to dangle their legs in a seated position before standing upon waking, to allow more time for proper baroreceptor stimulation and autonomic nervous response. Most patients are encouraged to ensure adequate fluid intake to prevent dehydration and to keep blood fluid levels up, and many are encouraged to eat smaller, more frequent meals so that the blood supply in the stomach is more steady and less likely to pull dramatically larger amounts from the rest of the body for digestion and absorption. Some patients are also encouraged to increase their sodium intake, although this must be considered carefully due to the possible risk of inducing hypertension. Although it must be carefully monitored, it may be advisable to try altering prescribed medications either by switching amounts, times, or even types of drugs. While many patients do not readily accept them, compression stockings may be recommended, as they will help to compress the veins of the lower extremities much as in the treatment of varicose veins. A more readily accepted recommendation may be to increase caffeine intake, with some suggesting up to three cups of strong coffee each morning. Finally, once a person is able to recognize her own symptoms of orthostatic hypotension, she can quickly adjust her body positioning when she begins to feel light-headed in order to help avoid syncope, and she can consciously avoid positions that impede her blood flow, such as sitting crossed leg or with sharply bent knees for prolonged periods.
Having imagined both the experience of the night nurse and Mr. Peters during his most recent syncope episode, let your mind wander once more to the office of Mr. Peters’ general practitioner as she is explaining the tests and lifestyle changes that she is recommending.
“No, Mr. Peters, ortho-static hypo-tension. It means that when you stand up too fast, all of your blood rushes to your feet and your heart can’t pump it back up to your head quickly enough. That is why you keep passing out when you stand up so fast.”
“Well, this never happened at my house. Only since my wife died and I moved into this crazy place because my kids won’t let me live in their spare bedroom.”
“Well, it is different for you to live here. I know that you were always worried about your electric bill at home, and you kept the furnace turned pretty low, right?”
“Yeah, you all should listen to that crazy Mrs. Mond and keep it cooler here, too. Maybe if you didn’t use so much of that electricity for heat then you could pony up the extra money for some decent cable TV channels.”
“Yes, Mr. Peters. I do want you to be more aware of when you are in a hot room, because you are going to get more light-headed in a hot room than you are in a cold room. Your body has to work harder to tighten up your blood vessels when the room is too warm, and you are going to feel the effects of the delayed response time in your blood pressure. This is why you keep fainting.”
“I’m no young girl! I’m not fainting. You said it yourself – symkobe or whatever.”
“Yes, Mr. Peters, syn-co-pe. You will have to make sure to get up more carefully, especially when the room is warm.”
“Those physical trainer people you bring in here, they are trying to make me get up faster. I knew they were just blowing smoke to get paid. Pretty boys saving up to buy fast cars. I know their story!”
“Yes, Mr. Peters, I know that you have been doing some conditioning for your arthritis recently, and I want you to continue following that regimen. However, I just want you to move a little more slowly when you are getting out of bed.”
“Are you telling me, a seventy-two-year-old man to move more slowly?”
“Yes, Mr. Peters. I am also telling you that I want you to make sure that you are drinking enough water every day. You know how hot it gets here in Arizona, so you need to keep your fluid intake high.”
“Dry heat. Better than that swamp they call Florida!”
“Yes, Mr. Peters, I do prefer our dry heat. But, do you think that you can do those two things for me while we get you tested? Stand up more slowly and drink more water?”
“Yeah. Drink more water and then stand up slowly to go to the john every five minutes. How slowly do you want me to get up?”
“Just a comfortable slow, Mr. Peters, and just until we get a few tests done.”
“Just a few tests! I counted at least three that you want me to do! Who’s going to pay for all these tests, that Obama with his universal health care?”
In attempt to avoid this political minefield, you turn your attention to the lab script on your desk and write the orders for ECG, EEG, and blood tests. “Yes, Mr. Peters, just a few tests.”