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Aging and disease
Review Article |
Parkinson Disease and Orthostatic Hypotension in the Elderly: Recognition and Management of Risk Factors for Falls
Peter A. LeWitt1,*, Steve Kymes2, Robert A. Hauser3
1Henry Ford Hospital and Wayne State University School of Medicine, West Bloomfield, MI 48322, USA
2Lundbeck, Deerfield, IL 60015, USA
3University of South Florida Parkinson’s Disease and Movement Disorders Center, Parkinson Foundation Center of Excellence, Tampa, FL 33613, USA
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Abstract  

Parkinson disease (PD) is often associated with postural instability and gait dysfunction that can increase the risk for falls and associated consequences, including injuries, increased burden on healthcare resources, and reduced quality of life. Patients with PD have nearly twice the risk for falls and associated bone fractures compared with their general population counterparts of similar age. Although the cause of falls in patients with PD may be multifactorial, an often under-recognized factor is neurogenic orthostatic hypotension (nOH). nOH is a sustained decrease in blood pressure upon standing whose symptomology can include dizziness/lightheadedness, weakness, fatigue, and syncope. nOH is due to dysfunction of the autonomic nervous system compensatory response to standing and is a consequence of the neurodegenerative processes of PD. The symptoms associated with orthostatic hypotension (OH)/nOH can increase the risk of falls, and healthcare professionals may not be aware of the real-world clinical effect of nOH, the need for routine screening, or the value of early diagnosis of nOH when treating elderly patients with PD. nOH is easily missed and, importantly, healthcare providers may not realize that there are effective treatments for nOH symptoms that could help lessen the fall risk resulting from the condition. This review discusses the burden of, and key risk factors for, falls among patients with PD, with a focus on practical approaches for the recognition, assessment, and successful management of OH/nOH. In addition, insights are provided as to how fall patterns can suggest fall etiology, thereby influencing the choice of intervention.

Keywords elderly      falls      neurodegeneration      neurogenic orthostatic hypotension      Parkinson disease      treatment     
Corresponding Authors: Peter A. LeWitt   
About author: These authors contributed equally to this work.
Just Accepted Date: 03 October 2019  
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Peter A. LeWitt
Steve Kymes
Robert A. Hauser
Cite this article:   
Peter A. LeWitt,Steve Kymes,Robert A. Hauser. Parkinson Disease and Orthostatic Hypotension in the Elderly: Recognition and Management of Risk Factors for Falls[J]. Aging and disease, 10.14336/AD.2019.0805
URL:  
http://www.aginganddisease.org/EN/10.14336/AD.2019.0805     OR     http://www.aginganddisease.org/EN/Y0/V/I/0
CauseOHnOH
Medications

·Dopaminergic agents

·Antidepressants (tricyclic antidepressants)

·Anticholinergics

·Antihypertensives

·Diuretics

·Nitrates

·Phosphodiesterase inhibitors

·Vasodilators

·Negative inotropic/chronotropic agents

·Central sympatholytics

·Renin-angiotensin system antagonists

·nOH may be exacerbated by medications that cause OH
Clinical etiologies

·Hypovolemia

∘Dehydration

∘Bleeding

·Impaired cardiac output/cardiac pump failure

∘Cardiac arrhythmia

∘Aortic stenosis

∘Heart failure

·Venous pooling

∘Prolonged recumbency or standing

∘Postprandial dilation of splanchnic vessel beds

∘Heat exposure

∘Fever

·Primary neurogenic causes
∘Sympathetic noradrenergic denervation
·Parkinson disease
·Pure autonomic failure
∘Intact sympathetic noradrenergic innervation
·Multiple system atrophy ?
·Dopamine beta-hydroxylase deficiency (intact innervation but norepinephrine deficiency)
·Secondary neurogenic causes
∘Peripheral neuropathies
∘Spinal cord problems
Table 1  Causes of OH and nOH [24-26].
Common·Postural lightheadedness or dizziness
·Syncope/presyncope
·Visual disturbance
·Sensation of blacking out
·Falls with or without syncope
Less common·Orthostatic cognitive dysfunction
·Mental dulling
·Generalized weakness
·Neck pain or discomfort in the suboccipital and paracervical region [“coat hanger” distribution)
·Fatigue
·Nausea
·Headache
·Dyspnea
Table 2  Symptoms of OH and nOH [13,24,26,27]*.
Screening Questions*
1.Have you fainted/blacked out recently?
2.Do you feel dizzy or lightheaded upon standing?
3.Do you have vision disturbances when standing?
4.Do you have difficulty breathing when standing?
5.Do you have leg buckling or leg weakness when standing?
6.Do you ever experience neck pain or aching when standing?
7.Do the above symptoms improve or disappear when you sit or lay down?
8.Are the above symptoms worse in the morning or after meals?
9.Have you experienced a fall recently?
10.Are there any other symptoms that you commonly experience when you stand up or within 3-5 minutes of standing up that get better when you sit or lay down?
Table 3  Screening Questions for Suspected OH/nOH [26].
Figure 1.  Impact of falls and fall risk in patients with PD and nOH. nOH=neurogenic orthostatic hypotension; PD=Parkinson disease [36,55-57].
InterventionsAddress OH/nOH SymptomsAddress General Fall Reduction in PD
Physical counter-maneuvers [37,87,89]·Leg crossing with active muscle tensing
·Bending forward, arms crossed over the abdomen
·Squatting
·Lower-body muscle tensing after squatting
Compression garments [26,87,89]·Abdominal or full-body compression garments
Other [24,26,89]·Sleeping with elevation of the head end of the bed (6-9 inches)
·Liberal intake of salt, up to 10 g of sodium/day
·Adequate hydration (target 2-3 L/day)
·Oral water bolus (500 mL)
Assistive devices/safety measures for general fall reduction [37,86]·Walking frames
·Canes that can be folded into a tripod chair
·Handrails
Physical therapy or symptoms of PD that may affect fall risk [77,78,85]·Vestibular training, Lee Silverman Voice Training BIG (LSVT-BIG)
Table 4  Non-pharmacologic Interventions That May Reduce OH/nOH Symptoms or General Fall Risk in PD.
MedicationLevel of Evidence [99]Comments
Droxidopa [26,91]A·FDA approved for symptomatic nOH
Midodrine [37,90]A·FDA approved for symptomatic OH
Fludrocortisone [37]C·First-line monotherapy for OH
·Full benefit requires high dietary salt and adequate fluid intake
Octreotide [37]C·May be used 30 minutes before a meal to reduce postprandial OH
Pyridostigmine [26]C·For patients with less severe symptoms with residual sympathetic function
Ephedrine [37]N/A·Considered GPP but no clear evidence for use in OH
Yohimbine [37]N/A·Considered GPP but no clear evidence for use in OH
·Has been used in refractory OH
Dihydroergotamine [37]N/A·Considered GPP but no clear evidence for use in OH
·Has been used in severe OH
Desmopressin [37]N/A·Considered GPP but no clear evidence for use in OH
Erythropoietin [37]N/A·Considered GPP but no clear evidence for use in OH
·Recommended in anemic patients
Indomethacin [37]N/A·Considered GPP but no clear evidence for use in OH
·Has been used in severe OH
Table 5  Pharmacologic Treatments for nOH/OH.
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