Orthostatic Hypotension in Parkinson Disease

Abstract

neurons are also affected. 7,8 Autonomic dysfunction in synucleinopathies occurs at all stages of the disease and occasionally is its only manifestation. 9Among the most debilitating manifestations of autonomic dysfunction in PD is orthostatic hypotension (OH), which is a sustained fall in blood pressure (BP) on standing. The current definition of OH, based on expert consensus, 10 is a fall of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP within 3 minutes of standing or upright tilt. OH can impair perfusion to organs above the heart, most notably the brain, resulting in symptoms of tissue hypoperfusion. Symptoms can be very disabling, have a profound impact on a patient's quality of life, and increase morbidity and mortality. 11,12 In PD and other synucleinopathies, OH is neurogenic (nOH), i.e., due to reduced norepinephrine release from postganglionic efferent sympathetic nerves, resulting in defective vasoconstriction when assuming the upright posture (Figure 1). 10 Complicating nOH management is arterial hypertension when supine (SH), which occurs in up to 50% of patients with efferent baroreflex failure. 13,14 When recognized, nOH can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, non-pharmacological approaches, and pathophysiology-based drug therapy are key to an effective management.Here we review the epidemiology, evaluation, and management of nOH, with emphasis on patients with PD, summarize the non-pharmacologic and pharmacologic treatment strategies, and provide practical advice on the management of patients with this debilitating condition.

Rivastigmine in Parkinson's Disease Dementia with Orthostatic Hypotension

“…Although this represented a post hoc analysis of studies not designed to target or evaluate the symptoms of OH, the data presented here suggest a potential role of rivastigmine as an adjunct treatment strategy for OH in PD, particularly given the high prevalence of this nonmotor manifestation and the limited treatment options available. 24,25 Further studies are warranted to validate these findings and determine the role of other cholinesterase inhibitors on OH, a common contributor to cognitive impairment in synucleinopathies.…”

Autonomic Function in Patients With Parkinson’s Disease: From Rest to Exercise

“…Orthostatic hypotension (OH) affects approximately 50% of the patients with PD and the prevalence may be higher when considering asymptomatic OH ( Palma et al, 2015 ). Noteworthy, OH is often used as a clinical indicator of sympathetic nervous system dysfunction ( Goldstein et al, 2015 ; Kaufmann et al, 2020 ; Palma and Kaufmann, 2020 ). Central lesions in the brainstem are thought to mediate the sympathetic dysfunction in PD ( Metzger and Emborg, 2019 ), as showed by Braak and colleagues through analysis of the regional distribution of α-synuclein immunoreactive structures in the brain of 110 subjects ( Braak et al, 2003 , 2004 ; Braak and Del Tredici, 2010 ).…”

Autonomic Dysfunctions in Parkinson’s Disease: Prevalence, Clinical Characteristics, Potential Diagnostic Markers, and Treatment

“…OH, according to the consensus statement, is defined currently as sustained drop of systolic blood pressure of at least 20 mm·Hg or diastolic blood pressure of at least 10 mm·Hg within 3 minutes upon sitting or head-up tilting of at least 60 degrees [ 25 ]. OH in PD is considered to be neurogenic, resulting from degeneration of postganglionic efferent sympathetic neurons in baroreflex cycle [ 26 ]. Therefore, OH in PD patients should be carefully differentiated from nonneurogenic OH caused by decreased pumping capacity of the heart and intravascular volume loss or redistribution.…”

“…While for PD patients with severe symptomatic OH, pharmacological and nonpharmacological interventions should be applied in combination to achieve better symptom relief. Nonpharmacological interventions include correction of aggravating factors, such as those mentioned above in nonneurogenic OH, and behavior guidance includes increased water and salt intake, lying with head elevated, wearing waist-high tight stockings, and recumbent exercises [ 26 ]. Medications include drugs restoring vascular tone, such as midodrine, and drugs that increase water and salt retention, such as fludrocortisone [ 14 ].…”

“…Ambulatory blood pressure monitor may be applied to achieve a better balance between OH and supine hypertension. The treatment of OH in PD and achievement of a compromise between OH and supine hypertension is discussed in detail in a recent review by Palma and Kaufmann [ 26 ].…”