Feature Article

Assessing and managing postural hypotension

Josephine Harris, Zbigniew Gieroba, Andrew E Russell



Nonpharmacological measures alone may be sufficient to manage postural hypotension once underlying causes have been identified and treated and, if possible, contributing medications discontinued.

Key Points

  • Postural hypotension (i.e. a drop in blood pressure on standing of at least 20 mmHg systolic and/or 10 mmHg diastolic) is common in older people but often asymptomatic.
  • Common causes include hypovolaemia, medication (including diuretics, vasodilators, levodopa, tricyclic antidepressants and major tranquillisers), neuropathy (often due to diabetes) and other neurological conditions, and cardiac disease. Ageing itself affects the cardiovascular response to standing.
  • A fall in blood pressure without an increase in heart rate suggests a neurological cause.
  • Treatment is aimed at reducing symptoms rather than achieving and maintaining a specific blood pressure.
  • Patient education is vital and nonpharmacological measures such as ensuring adequate fluid and salt intakes and elevating the head of the bed can be beneficial.
  • If pharmacological therapy is required, fludrocortisone is the usual first line agent but is likely to exacerbate heart failure and hypokalaemia. Other agents may also be used, particularly in specialist centres and for severe cases of neurogenic postural hypotension.