Orthostatic Hypotension

🍽️ Postprandial hypotension is a common but under-recognised cause of dizziness, syncope, and falls in older adults. It refers to a significant drop in blood pressure within 2 hours of eating, especially after carbohydrate-rich meals. ⚠️ It is particularly relevant in the elderly, in those with neurodegenerative disorders, diabetes, or cardiovascular disease, and may be asymptomatic.

📖 About

• ⬇️ Defined as a systolic BP drop ≥20 mmHg (or to <100 mmHg) after meals.
• 👵 Most frequent in older adults, especially with Parkinson’s disease, diabetes, heart failure, or CKD.
• 🧠 Often presents as dizziness, near-syncope, falls, but may be silent.

🧬 Aetiology

• 🍲 Gastric distension + release of vasodilatory gut peptides → ↑ splanchnic pooling.
• ⚡ Impaired baroreflex sensitivity (ageing, HTN, neurodegenerative disease).
• 📉 Inadequate sympathetic compensation or vascular responsiveness.
• 🧪 Insulin-mediated vasodilation after high-carbohydrate meals.

🩺 Clinical Features

• ⏱️ Occurs within 30–120 minutes after eating.
• 🍞 Worse after large carbohydrate meals or 🍷 alcohol.
• 😵 Symptoms: dizziness, weakness, blurred vision, syncope, falls.
• 🚶 May cause embarrassment as often happens in public/social settings.

📊 Comparison: Postprandial vs Orthostatic Hypotension

🔎 Investigations

• 📉 Serial BP monitoring before and after meals (supine/standing).
• 🩸 Bloods: FBC, U&E, LFTs, TFTs, glucose, cortisol if Addison’s suspected.
• 🫀 ECG ± CXR to exclude other causes of syncope/hypotension.

💊 Management

• 🍽️ Dietary: Small, low-CHO meals; avoid large portions and alcohol.
• 💧 Water bolus: 400–500 mL within 5 minutes before meals.
• 🚶 Postural: Rise slowly after meals; avoid strenuous activity soon after eating.
• 🩱 Abdominal binders: Reduce splanchnic pooling before outings/events.
• 💦 Maintain hydration.
• 💊 Pharmacological (specialist): – Caffeine ☕ (sympathetic stimulation) – Octreotide (somatostatin analogue) – Vasopressin analogues – NSAIDs (rare; caution due to renal/GI risk)

🧾 Clinical Case Examples

Case 1 – The Fainting Lunch 🥪
An 82-year-old woman with Parkinson’s disease collapses after a large pasta lunch. Paramedics record BP 85/50 mmHg, which improves after lying flat. 👉 Diagnosis: Postprandial hypotension. 👉 Management: Education on small, low-CHO meals, hydration, rise slowly after eating.

Case 2 – Recurrent Falls 👵
A 76-year-old man with diabetic autonomic neuropathy has repeated unexplained falls. Clinic BP is normal, but 30 min after a sandwich his systolic BP falls by 25 mmHg. 👉 Diagnosis: Postprandial hypotension in diabetes. 👉 Management: Pre-meal water bolus, diet modification, consider abdominal binder for outings.

Case 3 – Medication Interaction 💊
A 70-year-old man with heart failure on carvedilol reports dizziness after Sunday roasts. Ambulatory BP monitoring shows repeated post-meal systolic drops. 👉 Diagnosis: Postprandial hypotension, worsened by beta-blockers. 👉 Management: Review beta-blocker dosing/timing, advise small frequent meals.

Case 4 – Asymptomatic Drop 📉
A 68-year-old woman with CKD is found on routine geriatric assessment to have a 25 mmHg post-meal BP fall, but she denies any dizziness. 👉 Diagnosis: Asymptomatic postprandial hypotension. 👉 Management: Monitor, lifestyle advice; intervene if symptoms/falls develop.

Case 5 – The Social Collapse 🍷
A 74-year-old man collapses at a wedding reception after a heavy meal with wine. In ED, BP is 90/55 mmHg, ECG normal. 👉 Diagnosis: Postprandial hypotension triggered by alcohol and large meal. 👉 Management: Patient education, avoid alcohol-heavy meals, encourage hydration.

🌟 Teaching Pearls

– Always ask about the timing of symptoms in relation to meals. – Consider in older patients with falls or “funny turns” where orthostatic hypotension has been excluded. – Think about medication timing (beta-blockers, vasodilators, insulin). – Water bolus therapy is a simple, effective first-line measure.

📚 Reference

• Orthostatic Hypotension: Management of a Complex, but Common, Medical Problem