New Horizons in orthostatic hypotension

Area of Science:

• Gerontology
• Cardiovascular Medicine
• Clinical Pharmacology

Background:

• Orthostatic hypotension (OH) is a prevalent and disabling condition linked to increased morbidity and mortality.
• Existing evidence on OH predominantly comes from younger populations with chronic neurological diseases, creating diagnostic and management uncertainties in older individuals.

Purpose of the Study:

• To review recent and emerging evidence on the diagnosis, management, and prognosis of orthostatic hypotension in older persons.
• To provide an overview of updated diagnostic criteria and therapeutic strategies for OH in the geriatric population.

Main Methods:

• A narrative review of recent studies, emerging therapies, and relevant regulatory updates.
• Synthesis of current literature on OH diagnosis, non-pharmacological and pharmacological treatments, and prognostic factors in older adults.

Main Results:

• Revised diagnostic criteria for OH now include blood pressure drop duration, initial/delayed OH, and OH with hypertension.
• Non-drug therapies and Comprehensive Geriatric Assessment are first-line; evidence on withdrawing causative medications is inconsistent.
• Midodrine is the only UK-licensed OH medication; atomoxetine and droxidopa are emerging but need more evaluation. Increased mortality risk from OH is less evident in older individuals.

Conclusions:

• New diagnostic criteria for OH in older adults reduce uncertainty, though evidence on antihypertensive withdrawal remains conflicting.
• Non-drug therapies are primary, with fludrocortisone considered before midodrine. Emerging treatments like droxidopa may gain prominence.
• Orthostatic hypotension remains a significant concern in the elderly, necessitating tailored diagnostic and management approaches.