Orthostatic Hypotension-What do I need to know?

Mar 21, 2017

Chad Speth

Primary Care Provider


Eating disorders have the highest death rate of any of the psychiatric illnesses. They affect every organ system in the body. As I stated in my first post, many of the symptoms of an eating disorder go unrecognized by healthcare professionals. Increased awareness of the effects of eating disorders on the body is vital to helping those who suffer with eating disorders get the help they need.

An important health concern in eating disorder populations is orthostatic hypotension. In order to understand this problem, it will define a couple of terms.

First, the medical term orthostatic means to “be caused by an upright position.”

Next, hypotension is defined as “an abnormally low blood pressure.”

The diagnosis of orthostatic hypotension is defined as at a 20 mm/Hg fall in systolic blood pressure and at 10mm/Hg fall in the diastolic pressure. It is often accompanied by orthostatic tachycardia. Tachycardia means an increased heart rate. With orthostatic hypotension the heart rate can increase by as much as 30-40 beats per minute or more. Orthostatic hypotension can severely impact a patient’s health and lifestyle.These disruptive symptoms occur with postural changes such as going from sitting or lying to standing. Symptoms can range from a mild “head rush”, dizziness, seeing black spots to loss of consciousness and passing out. Studies show that the presence of orthostatic hypotension represents an increase in risk of cardiac or heart related deaths and death from all causes (Mechanisms, causes, and evaluation of orthostatic hypotension, 2015). Testing for orthostatic vital sign changes and recognition of the problem is extremely important.

You may be wondering…what causes orthostatic hypotension? Normally, when we stand, the force of gravity pulls on our blood. The brain is a very sensitive organ and cannot tolerate drops in blood flow well. If it does not have adequate blood supply, even for a few seconds, we feel a sensation of dizziness. With decreased blood flow to the brain, our vision can become altered and we may even get a “black” sensation in our vision. If blood flow to the brain drops too much then we will pass out. Normally our autonomic nervous system signals our heart to increase the force of contraction to overcome gravity. The blood vessels in our legs and abdomens also contract in order to keep more blood flow to the brain. In the presence of an eating disorder, these mechanisms can be significantly impaired resulting in vital sign changes consistent with orthostatic hypotension.

In a patient diagnosed or who might be suspected to have an eating disorder, a medical provider should assess vital signs that include postural changes. The provider should first obtain a blood pressure and heart rate while the patient is laying down. They person should then sit or stand for a minimum of 2-3 minutes. It is best is to wait 5 minutes after sitting or standing for the most accurate readings. Though this can be somewhat time consuming in a busy outpatient office, hospital floor or emergency department, if an eating disorder is suspected or present these vital signs are a very important part of the medical exam. Valuable information can be gathered from orthostatic vital signs that can determine the treatment needs of the patient or give clues to behavior or underlying pathologic processes in the body.

It is incumbent on healthcare providers to determine the cause(s) of orthostatic hypotension and prescribe appropriate treatment. There are several potential causes of these vital sign abnormalities. Eating patterns including dietary restriction and lead to malnutrition can cause these vital sign changes. Other eating disordered behaviors may include: fluid restriction resulting in dehydration, purging through vomiting, diuretic (water pills) and laxative abuse. As with most medical conditions, there are other conditions not related to eating disorders that can cause similarly abnormal vital signs. Other conditions include: nervous system problems, dehydration from other causes, bleeding, vomiting and diarrhea. These should be ruled out by the medical provider. In patients with eating disorders, it is most likely that the vital sign abnormalities are a result of eating disorder behaviors and should signal need for intervention.

Treatment of orthostatic hypotension should focus on the underlying cause. Patients with eating disorders require interruption of contributing behaviors. Most will require nutritional stabilization. This may include a period of weight restoration followed by weight maintenance. Fluid imbalances such as dehydration should also be corrected. Patient who are quite ill may require hospitalization or care in a residential setting depending on the severity of symptoms. A referral to a cardiologist may also be warranted.

In addition to nutrition and fluids, patients may require electrolyte fluids such as Gatorade or Powerade. It is not uncommon to give patients salt tablets to increase retention of fluid in the blood vessels. This increases the intravascular volume of the blood and therefore increases blood pressure. At other times an oral medication such as Florinef may be used to increase blood pressure. It is important for patients and families to understand it can take time for the vital signs to normalize, even with effective treatment. Sometimes orthostatic vital signs can last for months after a patient has begun treatment. Most patients heal and vital signs generally return to normal. Nearly all patients feel better physically after they have interrupted the behaviors that led to the development of orthostatic hypotension.

The orthostatic vital signs are a serious sign in a patient with an eating disorder. They should not be taken lightly or readily dismissed by patients, families and healthcare providers. When providers and families understand this, doors are opened for patients to be able to get the treatment they need. The good news is that there is hope for healing provided patients get adequate treatment over a long enough period of time. The “Treat to Outcome” philosophy at Avalon Hills works on multiple levels. Patients continue to get better and improve physically, emotionally and spiritually. I am a witness of it firsthand.

Chad Speth FNP-BC
Primary Care Provider
Avalon Hills Residential Eating Disorders Program

References:

H. Kaufmann, N. M. Kaplan. (2015, February 2). Mechanisms, causes, and evaluation of orthostatic hypotension. Retrieved from https://uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension/


Category: Medical

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