Get dizzy standing up? How to manage Orthostatic Hypotension

From the desk of
Robb Wolf
ScienceGet dizzy standing up? How to manage Orthostatic Hypotension

About one in five adults over the age of 60 have orthostatic hypotension (OH). To be clear, this is an entirely different condition than postural orthostatic tachycardia syndrome (POTS). For folks with orthostatic hypotension, standing up does not cause rapid heartbeat (tachycardia), but it does cause a rapid and temporary drop in blood pressure (hypotension).

The root of orthostatic hypotension typically relates to an issue with the nervous system. When someone stands up, blood briefly pools in the lower half of the body. The nervous system is meant to quickly intervene to shuttle blood back to the brain, but in this case it’s a bit late to the race. Lightheadedness, dizziness, and even fainting can follow, leading to increased fall risk—and falls can be a big deal for older adults.

Untangling the causes of orthostatic hypotension can be tricky, since causes can range from neurodegeneration and cardiovascular disease to drug side effects. But thankfully, management is oftentimes more straightforward. For example, proper hydration with fluids and sodium increases blood volume, which is one way to help keep blood pressure stable.

I’ll cover other natural treatments for orthostatic hypotension as well as pharmacologic options in this article. First, though, let’s define the condition.

What Is Orthostatic Hypotension?

When someone has orthostatic hypotension, their blood pressure drops after standing up from a sitting or lying position. Specifically, within 3 minutes their blood pressure drops by a minimum:

  • 20 mmHg systolic (when the heart muscle contracts and pumps blood from the chambers into the arteries)
  • OR 10 mmHg diastolic (when the heart muscle relaxes and allows the chambers to fill with blood)

As blood pressure drops, blood pools in the lower extremities away from the brain. Common symptoms include dizziness, loss of balance, lightheadedness, and fainting.

Less common symptoms include blurred vision, trouble concentrating, weakness or fatigue, chest pain, pain in the lower extremities, headache, or shortness of breath.

Consequently, many of these symptoms increase fall risk, a formidable cause of mortality in older folks. Orthostatic hypotension is also associated with a higher risk of cardiac and cerebrovascular conditions (like heart attack, stroke, atrial fibrillation), though it’s hard to pinpoint what causes what.

Orthostatic Hypotension Diagnosis

There are 2 main tests for orthostatic hypotension:

  1. Have the patient move from lying down to standing (at a normal pace).
  2. The tilt table test (strap the patient to a horizontal table and tilt them upright 60 degrees)

In both tests, medical professionals monitor for a significant drop in blood pressure (and patient-reported symptoms) over the following 3 minutes, and longer for changes in heart rate. These tests also help eliminate conditions that mimic orthostatic hypotension. For example, if the patient’s heart rate increases by at least 30 bpm on the tilt table, that’s potentially indicative of postural orthostatic tachycardia syndrome (POTS). But if heart rate decreases as blood pressure falls after 10 minutes, it may be a condition called neuro-cardiogenic syncope, a fainting spell that occurs when the body overreacts to certain triggers, like intense emotion, the sight of blood, extreme heat, dehydration, a long period of standing or intense pain.

A good clinician will examine the whole picture: blood pressure, symptoms, medical history, and risk factors such as age, medications, and more. Beyond diagnosis, they’ll also want to investigate what’s causing the orthostatic hypotension itself.

What Causes Orthostatic Hypotension?

When you stand up, blood pools in the lower half of your body (think inertia – though your body moves, your blood stays closer to where it was for a moment). Consequently, a part of the sympathetic nervous system called the baroreceptor reflex (the body’s reaction to a change in pressure) kicks in to return blood to the upper half of your body. As a result, the heart pumps more powerfully, veins constrict, blood pressure normalizes, and voila: you don’t get dizzy.

But with orthostatic hypotension, a link in this chain of events is often broken. It could be a neurological break in the nervous system (like an impaired baroreceptor reflex), low blood volume (common for endurance athletes), or a heart issue which hinders the transport of blood to your brain. It could also be the side effect of certain medications.

With this in mind, the primary causes of orthostatic hypotension make sense. These include:

  • Neurodegenerative conditions such as Parkinson’s disease or peripheral neuropathy due to diabetes, vitamin B12 deficiency, or amyloidosis
  • Low blood volume (hypovolemia) due to dehydration, low sodium status, low iron, or high blood sugar
  • Cardiovascular diseases that affect heart function
  • Lack of physical conditioning
  • Alcohol consumption (alcohol inhibits the constriction of blood vessels)
  • Medications such as blood pressure-lowering drugs, SSRIs (antidepressants), beta-blockers, and diuretics that can cause dehydration

On the last bullet point, many people over 60 take a cocktail of pharmaceuticals. The adverse effects of these drugs are a good place to look for causes of sit-to-stand drops in blood pressure.

Managing Orthostatic Hypotension Naturally

After ruling out drug side effects, you have several options for treating orthostatic hypotension. I suggest starting with the low-risk, holistic choices before addressing pharmacologically.

One common sense approach is to avoid sudden transitions to the standing position. Instead of leaping up off the couch or out of bed, sit poised for a few moments to give your baroreceptor reflex time to activate. Elevating your head also reduces the risk of dizziness upon rising. Other simple strategies to stave off blood vessel constrictions include routine low-level exercise, limiting alcohol, avoiding tensing-up, and not crossing your legs immediately upon standing.

There’s also evidence that extremity compression mitigates orthostatic hypotension. In one controlled study of 21 older adults with orthostatic hypotension, compression bandages around the abdomen AND legs led to significantly fewer incidences of low blood pressure after a tilt table test.

The last orthostatic hypotension treatment option I’ll cover is hydration. For starters, it’s well-publicized that dehydration (low net body water) can cause dizziness and low blood pressure—so hydrating effectively can help alleviate symptoms of orthostatic hypotension. In one study, people with orthostatic hypotension drank about 16 ounces of water. After 35 minutes, their standing systolic blood pressure increased from 83 mmHG to 114 mmHG.

Few people realize the crucial role sodium plays in determining blood volume. “Many patients who have inadequate control of [orthostatic hypotension] have an inadequate salt intake,” state the authors of one review paper. We need more rigorous investigation into the effectiveness of sodium in treating orthostatic hypotension, but the current data suggest that higher salt intakes improve the condition.

My evidence-based recommendation is for folks to get 4–6 grams of sodium per day as a baseline. If you can’t get it through diet alone, use an electrolyte drink like LMNT to bump up your salt status.

Pharmacology for Orthostatic Hypotension

If holistic strategies don’t improve your condition, your doctor may recommend pharmacology. The main drugs to treat orthostatic hypotension include:

  • Fludrocortisone, a type of steroid that increases sodium retention and remains a first-line therapy.
  • Midodrine, a blood pressure medication that raises standing systolic blood pressure, but whose 1996 FDA approval has been under review due to efficacy concerns.
  • Pyridostigmine, a muscle strengthener that stimulates the nervous system, kickstarting the baroreceptor reflex in folks with orthostatic hypotension.

Keep in mind, however, that these medications come with side effects. [Queue the Big Pharma TV commercial rattling off a long list of afflictions while a gleeful geriatric plays with grandkids.]

Personally, I’d start with exercise, sodium, compression, and other natural methods to treat your symptoms. Then move on to more aggressive treatments, such as pharmacology, if your situation ensues.

One last thing: Please forward this article to anyone who might benefit. Sharing this information can help others manage the complications of this frustrating condition.

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