Post written by Dr. Bradley Hiner
All of us have at one time or another have stood up too fast and experienced a sudden feeling of lightheaded dizziness. Usually this lasts just a matter of a few moments and then it passes. Some people have experienced a different kind of dizziness called vertigo. This is a sense of things going around and around, like on a merry-go-round. Still others use the word “dizziness” to describe a feeling of being off-balance or unsteady on their feet.
Each of these 3 kinds of dizziness has unique features that allow the neurologist to get to the bottom of the cause, as the causes are different for each and the treatments are different for each. Let’s talk about the one that is often overlooked in Parkinson's disease: low blood pressure upon standing.
“Doctor, I get dizzy spells!”
Mr. G has had parkinsonism for over 5 years now and is on a number of medications. Recently he has noted that whenever he gets up from a chair or out of bed, that within moments he feels dizzy. I always ask, “if you couldn’t use the word “dizzy”, how would you describe the sensation?”. He responded that he gets very lightheaded, almost faint feeling, and that if he didn’t sit back down he might actually “go out”. On some occasions, he has noted dimming of vision, or a sudden queasy feeling. His wife reports that sometimes he “looks pasty and pale” and she wonders if he is having a heart attack or stroke. Some patients note this is worse in the morning, after a meal, or after exertion. Taking a hot shower or bath makes it worse, as can doing physical activities like yardwork on a hot day.
The answer can be found doing a simple blood pressure (BP) and pulse check with the patient laying down and then standing. Orthostatic hypotension (OH), or simply put, low BP upon standing, is a common problem in Parkinson’s disease. Normally when we stand up there may be a brief drop in BP, but our autonomic nervous system makes adjustments and prevents it from falling too low. Unfortunately in PD those reflexes are often impaired, and to make matters worse PD medications can all contribute to low BP especially the dopamine agonists like ropinirole (Requip) and pramipexole (Mirapex). A drop in BP from laying to standing of 30 points systolic (the top number) or more means that this person indeed has OH, and we may need to do something about it.
This may mean making some changes:
- Eliminate if possible any medications that can contribute to low BP. Sometimes, if it’s o.k. with the patient’s internist, we can decrease or stop medications used to treat high BP. Many medications can contribute to low BP upon standing, so we want to regularly review the patient’s medication list.
- If there are no contraindications (like heart disease), we often increase dietary sodium (salt) and increase fluid intake. All too often PD pts. don’t take in enough fluids, and we recommend six or more 12 oz glasses of water or juice daily.
- Sleep with the head of the bed elevated. Sometimes using extra pillows is enough, but in more severe cases we recommend that the head of the bed actually go up on blocks 8-10 inches. This seems to have a beneficial effect on the kidney’s control of BP.
- Compression stockings. These are not the “white stockings”, sometimes called TED or anti-embolism stockings that are commonly used after surgery. We need something stronger. One brand name is Jobst stockings, and we recommend medium compression thigh-high style.
- Be aware of those situations that are likely to provoke low BP, like excessive heat, prolonged sitting or standing, drinking alcohol, dehydration, during illness or after prolonged bedrest.
- Patients may choose to avoid activities that involve straining, such as heavy lifting. Prolonged coughing, straining at stool, and even vigorous singing or playing a wind instrument may cause a drop in BP.
- When first getting up in the morning, sit on the edge of the bed before standing and flex leg muscles by wiggling the feet and march in place or contract thigh and calf muscles (tighten kneecaps and buttocks) to diminish blood pooling in the legs after standing.
- Should the patient feel faint, the best thing to do is to sit and lean forward, or better yet, lay down and elevate the feet. This helps to restore normal blood flow to the brain.
- Medications: there are a number of good medications to help with low BP. Florinef, midodrine and others can effectively prevent this from happening.
We are fortunate here at Froedtert and the Medical College to have access to sophisticated testing of the autonomic nervous system. Should a patient have severe orthostatic hypotension (low BP), we may want to take a look at how the autonomic nervous system is working. This involves a series of simple tests of heart rate, blood pressure and sweat function. The results allow us to determine if the patient has straightforward Parkinson’s disease or one of the “Parkinson-Plus” syndromes, like Multiple Systems Atrophy or Shy-Drager syndrome, that can mimic PD.
Watch for my next blog in which I’ll discuss the other autonomic dysfunctions that can be part of a Parkinson’s patient’s challenges. In the meantime, please don’t disregard episodes of “dizziness” or “lightheadedness.” Exercise the cautions listed above and consult your neurologist to get the right diagnosis and treatment strategy.