Blood pressure was continuously monitored during standardized standing and meal tests, after starting mg b. Seventeen age- and sex-matched healthy subjects served as controls.
Postprandial hypotension, but not orthostatic hypotension, was more common in elderly parkinsonian patients than in healthy subjects. Therapy with mg b. OH and PPH can cause dizziness, lightheadedness, weakness, blurred vision, falls, or loss of consciousness 2. Antiparkinsonian medication can impair autonomic or cardiovascular compensatory mechanisms and thereby aggravate orthostatic and postprandial BP decreases 3 6 8 9. In the treatment of elderly parkinsonian patients, levodopa in combination with a peripheral decarboxylase inhibitor is the most frequently used medication 10 Although it is known that levodopa, whether or not in combination with a peripheral decarboxylase inhibitor, can worsen OH 3 12 13 14 , the effect of levodopa on PPH in elderly patients is unknown.
However, the risk of OH, PPH, and related symptoms underscores the importance of diagnosing and preventing these syndromes in elderly patients. We hypothesized that elderly parkinsonian patients, who are already at higher risk of OH and PPH than healthy elderly subjects, would show worse orthostatic and postprandial BP decreases during levodopa therapy. This hypothesis implicates careful evaluation and adjustment of a patient's cardiovascular comedication in case of OH or PPH during levodopa therapy.
This study quantified systemic hemodynamic responses during standing and after eating for elderly parkinsonian patients and healthy elderly subjects. We evaluated heart-rate HR responses to standing and a Valsalva's maneuver, and orthostatic BP responses as parameters of autonomic function.
Elderly patients with clinically diagnosed Parkinson's disease or parkinsonism were recruited from the clinic and outpatient clinic of the Department of Geriatric Medicine, University Medical Center Nijmegen, and the Department of Neurology, Rijnstate Hospital, Arnhem, in The Netherlands. Eligibility required a clinical diagnosis of Parkinson's disease or parkinsonism according to the U. Exclusion criteria were drug-induced parkinsonism, use of neuroleptic medications with the potential to cause parkinsonism, use of high-dose antiparkinsonian medication, and diabetes mellitus.
Since we considered it unethical to withdraw therapy for patients on high-dose antiparkinsonian therapy, our study comprised only elderly parkinsonian patients with an indication for levodopa therapy in a relatively low mg b. All consecutive potential participants from our clinic and outpatient clinic were approached and informed about this investigation via a letter or consultation.
We had to approach 50 patients during a period of 1. Many patients refused to participate because the study involved a period without effective pharmacological therapy.
Seventeen patients 8 men, 9 women; mean age, The latter group included a patient with symptoms suggestive of progressive supranuclear palsy and a patient with symptoms suggestive of multiple system atrophy. These medications were withdrawn for at least 1 week before entering the study.
Eight subjects had not previously used any antiparkinsonian medication. Thirteen of these patients led an active and independent life, regularly performing physical exercise such as walking and cycling, but 4 patients needed help for daily care.
In addition, we included 17 age- and sex-matched healthy subjects mean age, These subjects had a medical history free of cardiovascular, pulmonary, renal, endocrinological, and neurological disorders; did not use medications; and led an active and independent life.
All were in good physical health and regularly performed physical exercise. All subjects had a normal, balanced diet without salt, carbohydrate, or fat restrictions. They gave their written informed consent to this study, and the investigation was approved by the ethics committees for research on human subjects of the University Medical Center Nijmegen and the Rijnstate Hospital in Arnhem, The Netherlands. BP was measured at the middle finger of the nondominant hand unless the dominant hand showed less tremor than the nondominant hand.
The finger used was kept at heart level at all times. The BP signal was recorded with a sample frequency of Hz. Before the study, randomization was performed according to the balanced allocation method, incorporating sex, presence of comorbidity or use of comedication with cardiovascular effects, hypertension, and signs of autonomic dysfunction as dichotomous covariates On the days of testing, the subjects arrived at the hospital in the morning after an overnight fast and withdrawal of all medication from midnight the previous night.
After instrumentation and a rest period of 10 minutes in a sitting position, the subjects performed a Valsalva's maneuver in a sitting position by blowing into a mouthpiece attached to a manometer. The subjects were instructed to maintain an expiratory pressure of 40 mm Hg for 15 seconds. They breathed normally after the release. Valsalva's maneuver was repeated at least once after a rest period of at least 1 minute. After the Valsalva's maneuvers, the subjects assumed a supine position for at least 15 minutes, after which they stood up within 15 seconds and remained standing for 10 minutes.
Patients were asked about possible symptoms during standing and after the meal; the symptoms were noted and classified in a severity score from 0 to 4. A score of 0 represented no symptoms; a score of 1 represented tiredness or sleepiness; 2 represented dizziness, lightheadedness, or restlessness; 3 represented severe weakness, feeling unsteady, feeling miserable, nausea, or vision changes; and a score of 4 involved speaking disturbances, decline in the level of consciousness, syncope, or falling.
Finally, the parkinsonian state was evaluated by administration of the item motor portion of the Unified Parkinson's Disease Rating Scale UPDRS form, which metrically established bradykinesia; gait disorder or postural reflex impairment, or both; rigidity; and tremor Each item was assessed with a severity scale ranging from 0 to 4, and the maximum total severity score was Movements were limited as far as possible during the tests.
Autonomic function was determined on the basis of HR variability during Valsalva's maneuver, and HR variability and BP changes during standing. The HR variability in the Valsalva tests was expressed as the ratio of the maximum tachycardia to the maximum bradycardia induced by the maneuver during the 30 seconds following the release of the strain Valsalva ratio The highest Valsalva ratio was accepted.
Baseline values were defined as the last 1-minute averages before the posture change from a supine to upright position. During the meal tests, 5-minute averages of the variable changes were calculated and baseline values were defined as the last 5-minute average values before the meal ingestion.
The dependence of average postural or postprandial changes in BP on baseline BP levels, the autonomic function determined by HR and BP parameters, and the stage and severity of parkinsonism was evaluated by Pearson correlation tests. Age and resting BP and HR levels were similar in the 17 healthy elderly subjects and the 17 elderly parkinsonian patients Table 1. Therefore, the results are presented as total-group means for both treatments.
Two parkinsonian patients were unable to stand up within 15 seconds and remain standing without help and without disturbing the BP measurements. Therefore, the standing test was performed for 15 parkinsonian patients and for 17 healthy subjects.
Nine patients had mild to severe symptoms during standing: 3 experienced dizziness or restlessness score of 2 ; 4 felt weak, unsteady, or miserable, or had nausea or vision changes score of 3 ; and 2 felt unable to stand or had a decline in the level of consciousness score of 4. These 2 patients had to sit down after 4 and 6 minutes of standing, although OH was not present in one of them at that time.
Only 2 healthy subjects had mild symptoms; they felt tired upon standing score of 1. The symptom score was not significantly related to the BP changes for either group.
Five parkinsonian patients felt tired or sleepy score of 1 ; 2 experienced dizziness, lightheadedness, or restlessness score of 2 ; 1 patient felt weak, miserable, and had vision changes score of 3 ; and 1 patient started speaking indistinctly and had lowered consciousness score of 4 after the meal. All healthy subjects performed standardized Valsalva's maneuvers of 35 to 40 mm Hg. Five parkinsonian patients were not able to perform reliable Valsalva's maneuvers because of functional restrictions, 3 patients were not able to produce an expiratory pressure exceeding 20 to 30 mm Hg, and 9 patients performed maneuvers of 30 to 40 mm Hg.
The orthostatic BP changes were not significantly different between the two groups. The frequencies of the two phenomena were not related to each other. Relations between postural BP changes and age, autonomic function variables, or stage or severity of parkinsonism were not found. There are also other causes. Your GP may be able to recommend treatment to ease the symptoms of low blood pressure. Blood pressure varies throughout the day, and is affected by different factors, such as temperature, digestion of food, and general wellbeing.
There is medication for constipation, which you should take as prescribed. For example if you are getting dressed, you could do this in slow stages, sitting down. Learning to adapt and change the way you do things can be difficult, but it can lower the risk of potential problems, and help you stay independent. Ask for help, or use other strategies and aids to get things from a lower level. Again, this takes a bit of adjustment, but can be worth it.
Speak to an occupational therapist for more advice. Move slowly from lying to sitting to standing as blood pressure is naturally lower in the morning. An occupational therapist or other health professional can advise you on this so speak to them if you are unsure. Caffeine can increase the risk of dizzy spells when you get out of bed.
This is because it is dehydrating and can make you want to urinate more at night. Digesting food takes blood from your brain to your stomach and can cause people to feel faint after a large meal. Etilefrine 5—10 mg was used in 15 PD patients to increase blood pressure upon standing mean increase of 4.
Fluoxetine 20 mg was used in a pilot study including 14 PD patients, reducing the drop in blood pressure in 11 mmHg and improving orthostatic symptoms Montastruc et al.
For treating supine hypertension, it has been recommended to use nitroglycerine patches 0. Orthostatic hypotension is a common and challenging symptom affecting PD patients. The neurodegenerative process is responsible for damaging the autonomous nervous system, but anti-parkinsonian treatments could enhance the symptoms derived from it.
Current therapeutical strategies include non-pharmacological and pharmacological measures aimed to favor baropressor responses or to increase blood volume. There is insufficient evidence to recommend any specific treatment for the PD-related autonomic failure.
Therefore, it should be individualized for the individual patient. Studies addressing the underscored questions related to OH in PD are needed. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Abassi, Z. Cardiovascular activity of rasagiline, a selective and potent inhibitor of mitochondrial monoamine oxidase B: comparison with selegiline.
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