- Email: [email protected]
Postural hypotension
Postural Hypotension The many precautions and the practical steps elders can take to reduce the effects of.this condition.
rent rise in pulse rate of 20 or greater(3). And Schatz states that a consistent drop in blood pressure of 30/20 mm Hg upon rising confirms the diagnosis of orthostatic hypotension(4). Whatever the specific figures, an understanding of this condition and MARGO QUINLAN recognition of its early signs will One of the most common cardio- help health providers to assist the vascular problems of the elderly is elderly to cope with it. In many inorthostatic (postural) hypotension, stances, unfortunately, the problem or a fall in blood pressure when an cannot be eradicated, but its effects individual changes from a supine to . may be minimized. an erect position. Causes of Hypotension The gravitational change results in excessive pooling of peripheral Hypotension is in general due to venous blood in the lower extremi- one of the following four factors: ties and splanchnic bed and a re• Hypovolemia. This is generalduction in central blood volume, ly considered the cause until proven cardiac output, and cerebral blood otherwise. It may result from hemflow. This reduction in pressure is orrhage, vomiting, diarrhea, adrenusually accompanied by sweating, al cortical insufficiency, septic pallor, and nausea, and the individ- shock, or other conditions. ual may experience dizziness, con• Medication. Many drugsfusion, and disturbance in balance among them guanethidine (Ismeand gait. Syncope, the most dan- lin) phenothiazines, and methyldogerous complication, may occur. pa (Aldomet)-interfere with peAccording to Myers, about one ripheral sympathetic or catecholin every 10 individuals over the age amine activity, producing vasodilaof 65 suffers from some degree of tation. Antidepressants and sedaorthostatic hypotension(l). It can tives may also play a role, but the be detected clinically by measuring mechanism is not well understood. the brachial blood pressure within Diuretics decrease fluid volume, two minutes after a person stands thus lowering blood pressure. Medor sits up following a five-minute ications are generally thought to be period in a quiet, nonstressful re- the main cause of hypotension in cumbent position. the elderly. Mooss defines the condition as a • Impaired cardiac output. This fall in both systolic and diastolic may result from congestive heart pressures, accompanied by varying failure, arteriosclerotic heart dischanges in heart rate(2). ease, venous pooling, anemia, or Bookman says postural hypoten- cardiac tamponade. sion is a fall in diastolic pressure of • Peripheral neurologic dys20 mm Hg or more and a concur- function. Interference with sympathetic reflex mechanisms usually is associated with tumors, spinal cord Margo Quinlan, RN, MSN, is an instructor injury, amyloidosis, and alcoholic in medical-surgical nursing at 81. Elizaor diabetic neuropathies(5). The beth's Hospital. Boston, ~ass.
250 Geriatric Nursing July/August 1983
hypotension is usually accompanied by impotence and disturbances in sweating and sphincter control. Other forms of severe orthostatic hypotension, which occur with no signs of sensory/motor nerve involvement, are called primary autonomic insufficiencies. An example is Shy-Drager, or idiopathic orthostatic hypotension. In this rare condition, there is degeneration of the central or peripheral autonomic nervous structures, or both. It is a progressive disease, characterized by anhydrosis (loss of sweating), reduced norepinephrine production, ileus, and absence of tachycardia on standing, despite the marked hypotension(6). Fortunately, the Shy-Drager syndrome is not common among older adults. Compensatory Mechanisms Two major homeostatic mechanisms usually operate to stabilize blood pressure when the individual assumes an upright position: (a) the baroreceptor reflex and (b) hormonal release (see illustration). The baroreceptors are nerve endings that are sensitive, to arterial pressure changes. They are located primarily in the aortic arch and the internal carotid arteries, above the bifurcation. When one stands, the drop in pressure causes the baroreceptors to excite the vasoconstriction center in the medulla and inhibit the vagal center via afferent nerve fibers. This stimulates the sympathetic nervous system to increase the rate and strength of heart contractions and to constrict the peripheral vessels. In the hormonal reaction, the second major compensatory mechanism, epinephrine, norepinephrine, and antidiuretic hormone
(ADH) are released, and the reninangiotensin mechanism is activated. The latter also stimulates . the secretion of aldosterone. Epinephrine and norepinephrine, secreted by the adrenal medulla in response to stimulus from the sympathetic nervous system, excite the heart and produce vasoconstriction, particularly of the skin vasculature. The release of ADH, which is manufactured in the hypothalamus and stored in the posterior pituitary gland, increases water reabsorption from the collecting tubules of the kidneys, thus increasing blood volume. ADH or vasopressin (which contains vasopressor and ADH hormone activity) also constrict blood vessels, thus increasing peripheral vascular resistance and raising blood pressure. The renin-angiotensin system is activated by hypovolemia, which
thostatic hypotension in the elderly. Since they are extremely sensitive to antihypertensive agents, special care is taken when hypertension is being treated with these drugs(7). As an example, when temperature rises, either environmentally or internally because of an infection, the elderly may experience a fall in blood pressure. Finnerty has suggested that the dosage of an antihypertensive . medication be reduced when an elderly person goes from a cold to a warm climate-a Florida vacation for instance(8). The drug of choice for treating symptomatic orthostatic hypotension is fludrocortisone (FlorineO 0.1 to 0.5 mg daily. (Asymptomatic hypotension usually is best left untreated.) Florinef increases fluid volume initially and potentiates the vascular actions of circulating norepinephrine. In one study, 18 of 23
The goal in treating orthostatic hypotension is to maintain normal blood pressure when a person rises, by decreasing venous pooling and increasing peripheral and cerebral perfusion.
__
--_._---~,_. ._.~,----~---------~~,-
induces the juxtaglomerular cells in the kidneys to secrete renin. Renin then catalyzes the conversion of a plasma protein, renin substrate, into angiotensin I. Angiotensin I forms angiotensin II in the presence of the converting enzyme in the lungs. Angiotensin II is a potent vasoconstrictor, particularly for the arterioles and, to a lesser extent, the veins. It also stimulates the adrenal cortex to release aldosterone. Angiotensin II has an additional effect on the body's fluid volume, for it acts on the kidney to increase the retention of salt and water. This property of angiotensin II is similar to that of aldosterone. Drug Therapy A clear understanding of the effects of medication and diet is necessary in any effort to reduce or-
patients with diverse causes of orthostatic hypotension responded favorably to Florinef(9). It is contraindicated in patients with overt heart failure, however, because it induces fluid retention and raises recumbent blood pressure. Other drugs have also shown promise in the treatment of orthostatic hypotension. Tyramine supplemented with a monoamine oxidase inhibitor such as isocarboxazid (Marplan) or phenelzine sulfate (Nardil) has been used with some success(lO). Tyramine releases norepinephrine from the postganglionic nerve endings, and the MAOI prevents the destruction of the norepinephrine. Indomethacin (Indocin) has been moderately helpful for hypotensive patients who have Parkinson's disease(l I). Indocin's effect is attributed to its inhibition of the synthesis of pros-
taglandin and other vasodilators. If a medication is suspected as the cause of orthostatic hypotension, the patient should not discontinue the drug without first consulting a physician, because it is often possible to reduce the side effects by changing the dose or time of day for taking it. If dehydration or diuresis is a contributing factor, increasing fluid and salt intake, which will expand the extracellular fluid volume, may be beneficial. Alcohol is to be avoided because it may aggravate postural hypotension(12). What the Patient Needs to Know When assessing a patient's knowledge of his or her medications, one can not assume, for instance, that an elderly person knows the purpose, dose, and side effects of each drug to be taken. In addition, the person needs to know the measures necessary to prevent or diminish. the side effects. Does he realize the importance of adequate food and fluid intake to maintain electrolyte balance when taking diuretics? Is he familiar with the symptoms of orthostatic hypotension? Does he know that nitroglycerin should not be taken when one is in a standing position, because the resultant vasodilatation may cause fainting? The goal in treating orthostatic hypotension is to maintain normal blood pressure when a person rises, by decreasing venous pooling and increasing peripheral and cerebral perfusion. If patients can learn to mitigate the effects of postural hypotension, they can be more inde~ pendent and less likely to injure themselves. Patient education is focused on how individuals can modify their life-style in order to deal with orthostatic hypotension on a day-today basis. An effective way to prevent orthostatic hypotension is to maintain muscular and vascular tone through activity. When skeletal muscles contract, they compress the veins and increase blood return to the heart. Similarly, deep inspiration facilitates venous return by increasing the gradient pressure
Geriatric Nursing July/August 1983251
between peripheral veins and the vena cavae. In the Hospital A patient who is confined to bed should perform range of motion exercises every four hours and pedal exercises and deep breathing hourly, unless contraindicated. Before standing, he should first roll slowly to the side, then gradually sit up while taking deep breaths. If a
inch blocks under the head of the bed. This raises the upper body, thus decreasing renal artery pressure and stimulation of renin release(13). A second and possibly more important measure---one that compensates for decreased muscular activity-is the wearing of elastic stockings, with the maximal pressure applied distally. The correct stocking size is determined by mea-
crease pooling of venous blood. Elastic stockings are contraindicated in the presence of congestive heart failure, because they produce an added strain on the heart by increasing the volume of blood returning to the atria. The elderly should also avoid intense heat-hot baths, electric blankets, and heating pads, for instance-because this enhances vasodilatation and induces venous stasis. They should
COMPENSATORY MECHANISM FOR ORTHOSTATIC HYPOTENSION The response, as shown in the scIIema, returns the blood pressure 10 normal and restores homeostasis.
,.---------1: ~
BLOOD PRESSURE
:I--------~
~
BARORECEPTORS
~
SYMPATHETIC NERVOUS SYSTEM
~
t EPINEPHRINE and
NOREPINEPHRINE
I
(adrenal medulla)
tVASOCONSTRICTION
I
RENIN (kidney)
~
ANGIOTENSIN 1
'\ tCARDIAC OUTPUT
I
HYPOTHAlAMUS
~
POSTERIOR PITUITARY
~
~
tANTIDIURETIC HORMONE
ANGIOTENSIN "
'WATER RtTENTION
(lung) - - - - -
tAlDOSTERONE
tBLOOD VOlUME
\ tVASOCONSTRICTION
(adrenal cortex)
/
tSODIUM {ETENTlON
t'l~ t~i~ -I t BLOOD PRESSURE 1;....- ----.:..------.....: cane, walker, or any other assistive device is used, it should be readily accessible. The patient is taught not to sit for extended periods and to be sure that the call bell is within reach to summon assistance. Health providers and families should use a relaxed unhurried approacq when encouraging the elderly to walk. Two physical measures are helpful in reducing orthostatic hypotension. The first is to place 8-to-12-
252 Geriatric Nursing July/August 1983
suring the length of the limb and diameter of calf and thigh. The nurse emphasizes to the elderly that the stockings are to be worn when they are recumbent. (It is less critical to wear them when exercising, because skeletal muscles are then contracting.) Patients are encouraged to remove the stockings twice a day and inspect the skin. Before the stockings are reapplied, the legs are elevated above heart level for at least 15 minutes to de-
stay out of intense midday heat or wear wide-brimmed hats. In warm, dry environments it is advisable to increase fluid intake to compensate for loss through sweating. Orthostatic hypotension is most likely to occur when a person rises from a nap or night's sleep, one to two hours after taking antihypertensive medications, and after heavy meals. If the person feels faint, it is best to sit down, immediately lower the head below heart
level, or lie flat. This person should not undertake unnecessary activity like walking to a telephone or a neighbor for assistance, since this may induce total syncope. Unless contraindicated for other causes, there is no reason why elderly persons should not continue routine household activities like sweeping, light cleaning, vacuuming, and bed making. Not only will this foster the individual's selfesteem and independence, but the moderate muscular exercise involved may lessen attacks of orthostatic hypotension. Proper body mechanics are called for, of course, and the hypotensive individual should refrain from heavy cleaning, lifting, strenuous activity, or any action involving the Valsalva maneuver, which occurs when one holds his breath and bears down against a closed glottis. This maneuver increases intrathoracic pressure, which in turn diminishes venous return and adequate filling of the right atrium (14). The Valsalva occurs when a person strains to defecate. If the individual with orthostatic hypotension suffers from constipation, moderate exercise, high fiber diet, and liberal fluid intake are encouraged to ease elimination. Stool softeners may be required. At Home Patients need to learn the precautionary measures they should use at home. It helps if the nurse is familiar with their life-style and home environment. Practical instructions include: • When arising, hold on to sturdy, fixed objects such as a table, bureau, or handrail. • Do not depend on light furniture or objects on wheels for support. • Do not make twisting movements or climb on stepladders or chairs. • When engaged in sedentary activities-knitting, reading, watching TV-sit in a rocking chair. Gentle rocking is an excellent way to improve your circulation. • When standing to cook or iron,
sit down in the rocker occasionally. If you iron while seated on a kitchen stool, stand up frequently. The rooms at home should be well-lit and the floors free of worn carpets, throw rugs, and slippery surfaces. Long telephone or electric extension cords are inadvisable. All stairs require handrails that are easily grasped and extend to the bottom step. Light-reflecting, nonskid strips on the stair edges will help prevent falls. The residence should be clear of unnecessary materials, like seasonal items not in current use. Stairs, paths of travel, and closets should be kept clean. Shoe bags and drawer dividers are helpful in keeping
Precautions include the use of proper body .mechanics and moderate exercise, avoidance of sudden bending or straining, and taking life at an even pace.
frequently used articles or mementos and souvenirs handy. The two most hazardous living areas-the kitchen and bathroom-require special attention. The kitchen articles that are used most frequently can be stored at waist height or slightly above to prevent sudden bending over or hyperextending the head to see items on a hig}1 self. When storage cabinets are deep, Lazy Susans and sliding trays will make supplies and utensils more accessible. Dropped objects should be picked up immediately with long-handled tongs,' and spills wiped up-preferably with a· longhandled mop. Hostess and utility carts are useful to store or carry heavy appliances. Accidents due to hypotension frequently occur in the bathroom. To prevent falls, men should sit on
the toilet when voiding. A raised toilet seat and the installation of handrails promote safety. If the top of the wall mirror is tilted, it's possible to sit as one shaves or applies cosmetics. Patients should be alerted ·to the possibility of micturition syncope-sudden vasodilation, intensified by standing, upon the release of intravesicular pressure. Individuals may also need counseling in regard to activities outside of their home. If they take a bus, subway or train, for instance, it is advisable to wait until the vehicle comes to a complete stop before rising to exit. Preferably, they will stay home on snowy or rainy days. If they must go out, nonskid footwear is essential. They may need to be cautioned against overburdening themselves with large, heavy bags when shopping. Such a practice not only keeps them from seeing where they're going but also creates the possibility of the Valsalva maneuver. If elderly persons with orthostatic hypotension remind themselves to avoid rushing, and develop a slower, even pace of daily activities, this will enable them to 'remain active members in the community. References \. Myers. M. G. Postural hypotension and diu· retic therapy. Can.Med.J. 119:1061, Sept. 23, 1980. 2. Mooss. A. N., and Sketch, M. H. Orthostatic hypotension: evaluation and therapy. Hosp.Med. 15:16, Dec. 1979. 3. Bookman, L. B., and Simoneau, J. K. Early assessment of hypovolemia: postural vital signs. J. Emerg. Nurs. 3:43-45, Sept.-Oct. 1977. 4. Schatz, 1. J. Current management concepts of ouhostatic hypotension. Arch.lntern.Med. 140: 1152-1154. Sept. 1980. 5. Mooss and Sketch, Op.cil.. p. 17. 6. Isselbacher, K. J., and others. Harrison's Principles of Internal Medicine. 9th ed. New York, McGraw-Hili Book Co., 1980, p. 178. 7. Finnerty, F. A., Jr. Hypertension in the elderly: special considerations in treatment. Postgrad.Med. 65:121, May 1979. 8. Ibid. 9. Schatz, op.cit.. p. 1153. 10. Nanda, R.N., and others. Treatment of neurogenic ouhestatic hypotension with a mono oamine oxidase inhibitor and tyramine. Lancet 2:1164·1167,1976. II. Abate, G., and others. Elfect of indomethacin on postural hypotension in Parkinsonism. Br.Med.J. 2:1466-1468, Dec. 8, 1979. 12. Mooss and Sketch, op.cit.• p. 2 \. 13. Schatz, op.cit.• p. 1153. 14. Isselbacher and others, op.cit.• p. 79.
Geriatric Nursing July/August 1983253
rent rise in pulse rate of 20 or greater(3). And Schatz states that a consistent drop in blood pressure of 30/20 mm Hg upon rising confirms the diagnosis of orthostatic hypotension(4). Whatever the specific figures, an understanding of this condition and MARGO QUINLAN recognition of its early signs will One of the most common cardio- help health providers to assist the vascular problems of the elderly is elderly to cope with it. In many inorthostatic (postural) hypotension, stances, unfortunately, the problem or a fall in blood pressure when an cannot be eradicated, but its effects individual changes from a supine to . may be minimized. an erect position. Causes of Hypotension The gravitational change results in excessive pooling of peripheral Hypotension is in general due to venous blood in the lower extremi- one of the following four factors: ties and splanchnic bed and a re• Hypovolemia. This is generalduction in central blood volume, ly considered the cause until proven cardiac output, and cerebral blood otherwise. It may result from hemflow. This reduction in pressure is orrhage, vomiting, diarrhea, adrenusually accompanied by sweating, al cortical insufficiency, septic pallor, and nausea, and the individ- shock, or other conditions. ual may experience dizziness, con• Medication. Many drugsfusion, and disturbance in balance among them guanethidine (Ismeand gait. Syncope, the most dan- lin) phenothiazines, and methyldogerous complication, may occur. pa (Aldomet)-interfere with peAccording to Myers, about one ripheral sympathetic or catecholin every 10 individuals over the age amine activity, producing vasodilaof 65 suffers from some degree of tation. Antidepressants and sedaorthostatic hypotension(l). It can tives may also play a role, but the be detected clinically by measuring mechanism is not well understood. the brachial blood pressure within Diuretics decrease fluid volume, two minutes after a person stands thus lowering blood pressure. Medor sits up following a five-minute ications are generally thought to be period in a quiet, nonstressful re- the main cause of hypotension in cumbent position. the elderly. Mooss defines the condition as a • Impaired cardiac output. This fall in both systolic and diastolic may result from congestive heart pressures, accompanied by varying failure, arteriosclerotic heart dischanges in heart rate(2). ease, venous pooling, anemia, or Bookman says postural hypoten- cardiac tamponade. sion is a fall in diastolic pressure of • Peripheral neurologic dys20 mm Hg or more and a concur- function. Interference with sympathetic reflex mechanisms usually is associated with tumors, spinal cord Margo Quinlan, RN, MSN, is an instructor injury, amyloidosis, and alcoholic in medical-surgical nursing at 81. Elizaor diabetic neuropathies(5). The beth's Hospital. Boston, ~ass.
250 Geriatric Nursing July/August 1983
hypotension is usually accompanied by impotence and disturbances in sweating and sphincter control. Other forms of severe orthostatic hypotension, which occur with no signs of sensory/motor nerve involvement, are called primary autonomic insufficiencies. An example is Shy-Drager, or idiopathic orthostatic hypotension. In this rare condition, there is degeneration of the central or peripheral autonomic nervous structures, or both. It is a progressive disease, characterized by anhydrosis (loss of sweating), reduced norepinephrine production, ileus, and absence of tachycardia on standing, despite the marked hypotension(6). Fortunately, the Shy-Drager syndrome is not common among older adults. Compensatory Mechanisms Two major homeostatic mechanisms usually operate to stabilize blood pressure when the individual assumes an upright position: (a) the baroreceptor reflex and (b) hormonal release (see illustration). The baroreceptors are nerve endings that are sensitive, to arterial pressure changes. They are located primarily in the aortic arch and the internal carotid arteries, above the bifurcation. When one stands, the drop in pressure causes the baroreceptors to excite the vasoconstriction center in the medulla and inhibit the vagal center via afferent nerve fibers. This stimulates the sympathetic nervous system to increase the rate and strength of heart contractions and to constrict the peripheral vessels. In the hormonal reaction, the second major compensatory mechanism, epinephrine, norepinephrine, and antidiuretic hormone
(ADH) are released, and the reninangiotensin mechanism is activated. The latter also stimulates . the secretion of aldosterone. Epinephrine and norepinephrine, secreted by the adrenal medulla in response to stimulus from the sympathetic nervous system, excite the heart and produce vasoconstriction, particularly of the skin vasculature. The release of ADH, which is manufactured in the hypothalamus and stored in the posterior pituitary gland, increases water reabsorption from the collecting tubules of the kidneys, thus increasing blood volume. ADH or vasopressin (which contains vasopressor and ADH hormone activity) also constrict blood vessels, thus increasing peripheral vascular resistance and raising blood pressure. The renin-angiotensin system is activated by hypovolemia, which
thostatic hypotension in the elderly. Since they are extremely sensitive to antihypertensive agents, special care is taken when hypertension is being treated with these drugs(7). As an example, when temperature rises, either environmentally or internally because of an infection, the elderly may experience a fall in blood pressure. Finnerty has suggested that the dosage of an antihypertensive . medication be reduced when an elderly person goes from a cold to a warm climate-a Florida vacation for instance(8). The drug of choice for treating symptomatic orthostatic hypotension is fludrocortisone (FlorineO 0.1 to 0.5 mg daily. (Asymptomatic hypotension usually is best left untreated.) Florinef increases fluid volume initially and potentiates the vascular actions of circulating norepinephrine. In one study, 18 of 23
The goal in treating orthostatic hypotension is to maintain normal blood pressure when a person rises, by decreasing venous pooling and increasing peripheral and cerebral perfusion.
__
--_._---~,_. ._.~,----~---------~~,-
induces the juxtaglomerular cells in the kidneys to secrete renin. Renin then catalyzes the conversion of a plasma protein, renin substrate, into angiotensin I. Angiotensin I forms angiotensin II in the presence of the converting enzyme in the lungs. Angiotensin II is a potent vasoconstrictor, particularly for the arterioles and, to a lesser extent, the veins. It also stimulates the adrenal cortex to release aldosterone. Angiotensin II has an additional effect on the body's fluid volume, for it acts on the kidney to increase the retention of salt and water. This property of angiotensin II is similar to that of aldosterone. Drug Therapy A clear understanding of the effects of medication and diet is necessary in any effort to reduce or-
patients with diverse causes of orthostatic hypotension responded favorably to Florinef(9). It is contraindicated in patients with overt heart failure, however, because it induces fluid retention and raises recumbent blood pressure. Other drugs have also shown promise in the treatment of orthostatic hypotension. Tyramine supplemented with a monoamine oxidase inhibitor such as isocarboxazid (Marplan) or phenelzine sulfate (Nardil) has been used with some success(lO). Tyramine releases norepinephrine from the postganglionic nerve endings, and the MAOI prevents the destruction of the norepinephrine. Indomethacin (Indocin) has been moderately helpful for hypotensive patients who have Parkinson's disease(l I). Indocin's effect is attributed to its inhibition of the synthesis of pros-
taglandin and other vasodilators. If a medication is suspected as the cause of orthostatic hypotension, the patient should not discontinue the drug without first consulting a physician, because it is often possible to reduce the side effects by changing the dose or time of day for taking it. If dehydration or diuresis is a contributing factor, increasing fluid and salt intake, which will expand the extracellular fluid volume, may be beneficial. Alcohol is to be avoided because it may aggravate postural hypotension(12). What the Patient Needs to Know When assessing a patient's knowledge of his or her medications, one can not assume, for instance, that an elderly person knows the purpose, dose, and side effects of each drug to be taken. In addition, the person needs to know the measures necessary to prevent or diminish. the side effects. Does he realize the importance of adequate food and fluid intake to maintain electrolyte balance when taking diuretics? Is he familiar with the symptoms of orthostatic hypotension? Does he know that nitroglycerin should not be taken when one is in a standing position, because the resultant vasodilatation may cause fainting? The goal in treating orthostatic hypotension is to maintain normal blood pressure when a person rises, by decreasing venous pooling and increasing peripheral and cerebral perfusion. If patients can learn to mitigate the effects of postural hypotension, they can be more inde~ pendent and less likely to injure themselves. Patient education is focused on how individuals can modify their life-style in order to deal with orthostatic hypotension on a day-today basis. An effective way to prevent orthostatic hypotension is to maintain muscular and vascular tone through activity. When skeletal muscles contract, they compress the veins and increase blood return to the heart. Similarly, deep inspiration facilitates venous return by increasing the gradient pressure
Geriatric Nursing July/August 1983251
between peripheral veins and the vena cavae. In the Hospital A patient who is confined to bed should perform range of motion exercises every four hours and pedal exercises and deep breathing hourly, unless contraindicated. Before standing, he should first roll slowly to the side, then gradually sit up while taking deep breaths. If a
inch blocks under the head of the bed. This raises the upper body, thus decreasing renal artery pressure and stimulation of renin release(13). A second and possibly more important measure---one that compensates for decreased muscular activity-is the wearing of elastic stockings, with the maximal pressure applied distally. The correct stocking size is determined by mea-
crease pooling of venous blood. Elastic stockings are contraindicated in the presence of congestive heart failure, because they produce an added strain on the heart by increasing the volume of blood returning to the atria. The elderly should also avoid intense heat-hot baths, electric blankets, and heating pads, for instance-because this enhances vasodilatation and induces venous stasis. They should
COMPENSATORY MECHANISM FOR ORTHOSTATIC HYPOTENSION The response, as shown in the scIIema, returns the blood pressure 10 normal and restores homeostasis.
,.---------1: ~
BLOOD PRESSURE
:I--------~
~
BARORECEPTORS
~
SYMPATHETIC NERVOUS SYSTEM
~
t EPINEPHRINE and
NOREPINEPHRINE
I
(adrenal medulla)
tVASOCONSTRICTION
I
RENIN (kidney)
~
ANGIOTENSIN 1
'\ tCARDIAC OUTPUT
I
HYPOTHAlAMUS
~
POSTERIOR PITUITARY
~
~
tANTIDIURETIC HORMONE
ANGIOTENSIN "
'WATER RtTENTION
(lung) - - - - -
tAlDOSTERONE
tBLOOD VOlUME
\ tVASOCONSTRICTION
(adrenal cortex)
/
tSODIUM {ETENTlON
t'l~ t~i~ -I t BLOOD PRESSURE 1;....- ----.:..------.....: cane, walker, or any other assistive device is used, it should be readily accessible. The patient is taught not to sit for extended periods and to be sure that the call bell is within reach to summon assistance. Health providers and families should use a relaxed unhurried approacq when encouraging the elderly to walk. Two physical measures are helpful in reducing orthostatic hypotension. The first is to place 8-to-12-
252 Geriatric Nursing July/August 1983
suring the length of the limb and diameter of calf and thigh. The nurse emphasizes to the elderly that the stockings are to be worn when they are recumbent. (It is less critical to wear them when exercising, because skeletal muscles are then contracting.) Patients are encouraged to remove the stockings twice a day and inspect the skin. Before the stockings are reapplied, the legs are elevated above heart level for at least 15 minutes to de-
stay out of intense midday heat or wear wide-brimmed hats. In warm, dry environments it is advisable to increase fluid intake to compensate for loss through sweating. Orthostatic hypotension is most likely to occur when a person rises from a nap or night's sleep, one to two hours after taking antihypertensive medications, and after heavy meals. If the person feels faint, it is best to sit down, immediately lower the head below heart
level, or lie flat. This person should not undertake unnecessary activity like walking to a telephone or a neighbor for assistance, since this may induce total syncope. Unless contraindicated for other causes, there is no reason why elderly persons should not continue routine household activities like sweeping, light cleaning, vacuuming, and bed making. Not only will this foster the individual's selfesteem and independence, but the moderate muscular exercise involved may lessen attacks of orthostatic hypotension. Proper body mechanics are called for, of course, and the hypotensive individual should refrain from heavy cleaning, lifting, strenuous activity, or any action involving the Valsalva maneuver, which occurs when one holds his breath and bears down against a closed glottis. This maneuver increases intrathoracic pressure, which in turn diminishes venous return and adequate filling of the right atrium (14). The Valsalva occurs when a person strains to defecate. If the individual with orthostatic hypotension suffers from constipation, moderate exercise, high fiber diet, and liberal fluid intake are encouraged to ease elimination. Stool softeners may be required. At Home Patients need to learn the precautionary measures they should use at home. It helps if the nurse is familiar with their life-style and home environment. Practical instructions include: • When arising, hold on to sturdy, fixed objects such as a table, bureau, or handrail. • Do not depend on light furniture or objects on wheels for support. • Do not make twisting movements or climb on stepladders or chairs. • When engaged in sedentary activities-knitting, reading, watching TV-sit in a rocking chair. Gentle rocking is an excellent way to improve your circulation. • When standing to cook or iron,
sit down in the rocker occasionally. If you iron while seated on a kitchen stool, stand up frequently. The rooms at home should be well-lit and the floors free of worn carpets, throw rugs, and slippery surfaces. Long telephone or electric extension cords are inadvisable. All stairs require handrails that are easily grasped and extend to the bottom step. Light-reflecting, nonskid strips on the stair edges will help prevent falls. The residence should be clear of unnecessary materials, like seasonal items not in current use. Stairs, paths of travel, and closets should be kept clean. Shoe bags and drawer dividers are helpful in keeping
Precautions include the use of proper body .mechanics and moderate exercise, avoidance of sudden bending or straining, and taking life at an even pace.
frequently used articles or mementos and souvenirs handy. The two most hazardous living areas-the kitchen and bathroom-require special attention. The kitchen articles that are used most frequently can be stored at waist height or slightly above to prevent sudden bending over or hyperextending the head to see items on a hig}1 self. When storage cabinets are deep, Lazy Susans and sliding trays will make supplies and utensils more accessible. Dropped objects should be picked up immediately with long-handled tongs,' and spills wiped up-preferably with a· longhandled mop. Hostess and utility carts are useful to store or carry heavy appliances. Accidents due to hypotension frequently occur in the bathroom. To prevent falls, men should sit on
the toilet when voiding. A raised toilet seat and the installation of handrails promote safety. If the top of the wall mirror is tilted, it's possible to sit as one shaves or applies cosmetics. Patients should be alerted ·to the possibility of micturition syncope-sudden vasodilation, intensified by standing, upon the release of intravesicular pressure. Individuals may also need counseling in regard to activities outside of their home. If they take a bus, subway or train, for instance, it is advisable to wait until the vehicle comes to a complete stop before rising to exit. Preferably, they will stay home on snowy or rainy days. If they must go out, nonskid footwear is essential. They may need to be cautioned against overburdening themselves with large, heavy bags when shopping. Such a practice not only keeps them from seeing where they're going but also creates the possibility of the Valsalva maneuver. If elderly persons with orthostatic hypotension remind themselves to avoid rushing, and develop a slower, even pace of daily activities, this will enable them to 'remain active members in the community. References \. Myers. M. G. Postural hypotension and diu· retic therapy. Can.Med.J. 119:1061, Sept. 23, 1980. 2. Mooss. A. N., and Sketch, M. H. Orthostatic hypotension: evaluation and therapy. Hosp.Med. 15:16, Dec. 1979. 3. Bookman, L. B., and Simoneau, J. K. Early assessment of hypovolemia: postural vital signs. J. Emerg. Nurs. 3:43-45, Sept.-Oct. 1977. 4. Schatz, 1. J. Current management concepts of ouhostatic hypotension. Arch.lntern.Med. 140: 1152-1154. Sept. 1980. 5. Mooss and Sketch, Op.cil.. p. 17. 6. Isselbacher, K. J., and others. Harrison's Principles of Internal Medicine. 9th ed. New York, McGraw-Hili Book Co., 1980, p. 178. 7. Finnerty, F. A., Jr. Hypertension in the elderly: special considerations in treatment. Postgrad.Med. 65:121, May 1979. 8. Ibid. 9. Schatz, op.cit.. p. 1153. 10. Nanda, R.N., and others. Treatment of neurogenic ouhestatic hypotension with a mono oamine oxidase inhibitor and tyramine. Lancet 2:1164·1167,1976. II. Abate, G., and others. Elfect of indomethacin on postural hypotension in Parkinsonism. Br.Med.J. 2:1466-1468, Dec. 8, 1979. 12. Mooss and Sketch, op.cit.• p. 2 \. 13. Schatz, op.cit.• p. 1153. 14. Isselbacher and others, op.cit.• p. 79.
Geriatric Nursing July/August 1983253