Editorials

14. Maley M, Worley P, Dent J. Using rural and remote settings in the undergraduate medical curriculum. Medical Teaching 2009; 31: 9678. 15. Stott D, Langhorne P, Knight PV. Multidisciplinary care for elderly people in the community. Lancet 2008; 371: 699700.

Age and Ageing 2011; 40: 292293 doi: 10.1093/ageing/afr036 Published electronically 31 March 2011

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Non-pharmacological treatments for orthostatic hypotension

In a recent issue of Age and Ageing, Fan et al. report negative results in a randomised controlled trial on the use of sleeping in the head-up position (SHU) in the treatment of orthostatic hypotension (OH) [1]. We ask if this treatment or other non-pharmacological therapies should be recommended for use in elderly patients? Postural or Orthostatic Hypotension is a common clinical problem affecting elderly people. It affects approximately 20% of people over 65 years rising to just over a quarter aged over 85 years [2]. Dened as a fall in blood pressure of 20 mmHg systolic or 10 mmHg diastolic within 3 min when standing from supine [3], it been associated with falls, previous myocardial infarction and transient ischaemic attacks as well as systolic hypertension, ECG abnormalities and carotid stenosis [2]. Standing from supine and its associated blood pressure changes require an effective neurohumoral response with functioning renal and cardiovascular systems. Pooling of approximately 5001,000 ml of blood in the capacitance vessels of the pelvis and legs and the resulting drop in blood pressure reduces ring of carotid and aortic baroreceptors. Messages relayed via the nucleus tractus solitarius result in reex reduction in vagal tone and sympathetic activation of -adrenergic receptors. Peripheral vasoconstriction and increased stroke volume results in increased cardiac output [4]. Disruption of any of these systems may lead to symptoms associated with OH. Causes of OH in the elderly are generally divided into primary causes of autonomic dysfunction such as Parkinsons disease and multiple system atrophy, and secondary causes such as diabetes, stroke, CKD, infections and certain treatments for hypertension. Importantly older people will have many risk factors that predispose to OH, such as vascular stiffening [5] and decreased baroreceptor sensitivity [6]. Salt and water loss associated with nocturnal polyuria leading to intravascular volume depletion is a particular problem when autonomic failure is present [7] hence treatments that aim to correct this are potentially effective. Overall management of OH requires a careful geriatric assessment in conjunction with allied health colleagues. Avoiding precipitating factors such as sudden postural change, large meals, hot baths, alcohol and culpable vasodilating medications forms part of the initial treatment strategy. The role of modern antihypertensives in exacerbating OH is controversial. It has been demonstrated that the incidence of OH is reduced after long-term antihypertensive treatment of all classes [8]; however, those that act by peripheral vasodilatation may well exacerbate symptoms especially in the short term. Non-pharmacological methods for treating OH form an important part in limiting blood pressure reduction on standing. Liberal addition of salt to the diet with the addition of salt tablets aiming for a minimum intake of 150 mmol per day is important to correct salt depletion due to polyuria and poor oral intake [9]. Although exercise can exacerbate symptoms, a programme of moderate exercise training has been shown to improve orthostatic tolerance and symptoms [10]. Abdominal binders, if tolerated are more effective than stockings and work by reducing venous pooling in the splanchnic circulation [11]. Physical manoeuvres that help to raise blood pressure by increasing venous return and increasing peripheral resistance include crossing legs on standing, squatting or bending forwards with the hip exed [12]. SHU was rst described by MacLean and Allen in 1940 in a group of patients with pure autonomic failure who demonstrated signicant improvements in symptoms [7]. The main physiological response to SHU seems to be the reduction in nocturnal polyuria. A decrease in renal arterial pressure due to the legs sitting below the heart leads to activation of the reninangiotensin pathway and vasopressin release [13]. Studies demonstrating the efcacy of this treatment up to now have included only small numbers (less than 12) in younger patients (under 65) with primary autonomic failure [1416]. Generally higher degrees of head-up tilt were used (1012) in these studies than is commonly used in practice [17]. Fan et al. have demonstrated in this trial that despite promising results from observational studies, in a heterogeneous group of older people effectiveness of SHU is more variable [1]. Older people with impairments of other homeostatic mechanisms and not just the autonomic system will be less able to mount an appropriate

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Editorials
haemodynamic response to raising intravascular volume. It is interesting that difculties were noted in maintaining adequate uid hydration in the setting of this monitored trial. This implies that recommending increased uid intake alone is likely to be ineffective as an overall treatment for OH and may explain in part the lack of a signicant effect of SHU. In those who do not respond, or those where raising intravascular volume is potentially risky such as heart failure, therapies that aim to reduce peripheral pooling such as stockings, abdominal binders and physical manoeuvres might be more appropriate. Individualised exercise training should be recommended where symptoms and physical ability allow, swimming being one such example. This trial highlights a number of areas that remain unexplained. The aetiology of OH and range of co-morbidities were not reported. Sub-group analysis in future studies might identify cohorts that could benet from SHU therapy. The degree of head-up tilt likely to be effective remains uncertain. Elevation of ve degrees seems to reect common practice [17] and patient tolerability; however, most trials have used higher degrees of head-up tilt, and tolerability of higher elevations is yet to be formally investigated. The effect of antihypertensive agents that may directly interfere with the presumed physiological mechanism of SHU, such as diuretics and ACE inhibitors, remains unclear. Overall this study has successfully challenged previous assumptions on the effectiveness of SHU with a wellconducted randomised control trial. With so many unanswered questions, it would be a shame that a potentially effective and relatively safe non-pharmacological measure should be completely discarded at this juncture. As the procedure has no proven benet in elderly community-dwelling people, it should not be recommended routinely; however, it should remain within the armoury of OH therapies for those with profound autonomic failure and little cardiovascular co-morbidity where some benet may be seen. Where side effects of raising intravascular volume are of concern, other non-pharmacological measures should be considered.
PHILIP THOMPSON1,2, JULIET WRIGHT1,2, CHAKRAVARTHI RAJKUMAR1,2,* 1 Academic Department of Geriatrics, Brighton and Sussex Medical School, Audrey Emerton Building, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK 2 Brighton and Sussex University Hospital Trust, Brighton, UK Tel: (+44) 1273 523360; Fax: (+44) 1273 523366 Email: c.rajkumar@bsms.ac.uk *To whom correspondence should be addressed orthostatic hypotension: and open randomised controlled trial. Age Ageing 2011; 40: 18792. 2. Rutan GH, Hermanson B, Bild DE et al. Orthostatic hypotension in older adults: the Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension 1992; 19: 50819. 3. American Autonomic Society and the American Academy of Neurology. Consensus statement on the denition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Neurology 1996; 46: 1470. 4. Low PA, Singer W Update on the management of neurogenic . orthostatic hypotension. Lancet Neurol 2008; 7: 4518. 5. Lakatta EG, Mitchell JH, Pomerance A. Human aging: changes in structure and function. J Am Coll Cardiol 1987; 10 (2 Suppl A): 42A7. 6. Hogikyan RV, Supiano MA. Arterial alpha-adrenergic responsiveness is decreased and SNS activity in increased in older humans. Am J Physiol 1994; 266(5 pt 1): E71724. 7. MacLean A, Allen E. Orthostatic hypotension and orthostatic tachycardia; treatment with the "head-up" bed. J Am Med Ass 1940; 115: 21627. 8. Masuo K, Mikami H, Ogihara T et al. Changes in frequency of orthostatic hypotension in elderly hypertensive patients under medications. Am J Hypertension 1996; 9: 2638. 9. El-Sayed H, Hainsworth R. Salt supplementation increases plasma volume and orthostatic tolerence in patients with unexplained syncope. Heart 1996; 75: 13440. 10. Mtinangi BL, Hainsworth R. Increased orthostatic tolerance following moderate exercise training with unexplained syncope. Heart 1998; 80: 596600. 11. Denq JC, Opfer-Gehrking TL, Giuliani M et al. Efcacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res 1997; 7: 3216. 12. Ten Harkel ADJ, Van Lieshout JJ et al. Effects of leg muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure. Clin Sci 1994; 87: 5538. 13. Bannister R, Sever P, Gross M. Cardiovascular reexes and biochemical responses in progressive autonomic failure. Brain 1977; 100: 32744. 14. Van Lieshout JJ, Ten Harkel DJ, Wieling W. Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res 2000; 10: 3542. 15. Ten Harkel ADJ, Van Lieshout JJ, Wieling W. Treatment of orthostatic hypotension with sleeping in the head-up tilt position, alone and in combination with udrocortisone. J Intern Med 1992; 232: 13945. 16. Cooper VL, Hainsworth R. Head-up sleeping improves orthostatic tolerance in patients with syncope. Clin Auton Res 2008; 18: 31824. 17. Fan CW, Coakley D, Walsh JB et al. Postal Questionnaire Survey: the use of sleeping with the head of the bed tilted upright for treatment of orthostatic hypotension in clinical practice. Age Ageing 2006; 35: 52932.

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References
1. Fan CW, Walsh C, Cunningham CJ. The effect of sleeping with the head of the bed elevated six inches on elderly patients with

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