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Suggest Treatment For Orthostatic Hypotension
Question: Thank you for writing. Will give you an update in day or two - and seek your continued advice.
Brief Answer:
You are welcome
Detailed Answer:
you are welcome. All the best.
You are welcome
Detailed Answer:
you are welcome. All the best.
Above answer was peer-reviewed by :
Dr. Raju A.T
Since our last writing, we have seen a Geriatric and a Otolaryngology specialist. There specific findings are noted below. My question is wheter you agree with their findings.
Dr. XXXXXXX Otolaryngology
1.
Chronic orthostatic hypotension
I95.1
458.0
Ambulatory Referral to Physical Therapy
2.
Vertigo, central origin, unspecified laterality
H81.49
386.2
Ambulatory Referral to Physical Therapy
Health Advice provided. Topics discussed: diet, exercise, fall prevention, supplements and mental health concerns
Dr. XXXX, Geriatric
1. Dizziness/Gait instability
-Patient had currently been worked up for dizziness, most consistent with orthostatic hypotension. Potential causes could include dysautonomia secondary to normal aging and medication adverse effect, though primary neurologic disorder cannot be entirely ruled out. Has had previous brain MRI, ENT evaluation, as well as cardiac (unremarkable ECHO), negative carotid ultrasounds, normal B12 and TSH, all of which were unremarkable. A tilt table study was suggestive of neurocardiogenic mechanism. However, will need to adjust medications to rule out adverse reactions from medications. At this time, low concern for parkonsinism although exam notable for micrographia and mild gait changes. Will consider referral to movement disorder if patient does not improve on medication adjustments.
-Recommend continuing symptomatic support with Florinef, salt tablets, and behavioral modification including increased fluid intake. Recommend scheduling bathroom breaks to assist with urinary incontinence.
-Recommend optimizing anti-depressant medication (see below) in hopes to wean off clonazepam.
-Provided script for physical therapy for balance training.
2. Mood disorder, probable anxiety
Abnormal cognitive testing
-Currently being seen by outpatient psychiatry with good relationship. Will touch base in regards to adjusting antidepressants (increase sertraline dose vs switching to Lexapro) prior to weaning off clonazepam. Will defer to primary psychiatry.
-In addition, patient may benefit from psychotherapy as adjunct to medication therapy.
-Seems that significant stressor includes caring for elderly mother. Recommended taking 1-2 days off a week for self-care.
- MOCA score today was abnormal for age, level of education. She had impairments in executive function, concentration and verbal fluency. Certainly uncontrolled mood disorder can explain some of these deficits, also medications adverse effects. Lastly primary neurodegenerative disorder cannot be ruled out. I would favor treating better underlying mood disorder and weaning off benzodiazepines. Repeat cognitive testing in 3 months. If abnormal will refer to neuropsychiatric testing.
Other Medication recs:
-recommend discontinuing Mobic (listed under Beer's List) as patient currently does not have any arthritic pain.
-confirmed with patient and currently not taking tolterodine.
Follow up in 3 months.
Thank you for your attention.
Dr. XXXXXXX Otolaryngology
1.
Chronic orthostatic hypotension
I95.1
458.0
Ambulatory Referral to Physical Therapy
2.
Vertigo, central origin, unspecified laterality
H81.49
386.2
Ambulatory Referral to Physical Therapy
Health Advice provided. Topics discussed: diet, exercise, fall prevention, supplements and mental health concerns
Dr. XXXX, Geriatric
1. Dizziness/Gait instability
-Patient had currently been worked up for dizziness, most consistent with orthostatic hypotension. Potential causes could include dysautonomia secondary to normal aging and medication adverse effect, though primary neurologic disorder cannot be entirely ruled out. Has had previous brain MRI, ENT evaluation, as well as cardiac (unremarkable ECHO), negative carotid ultrasounds, normal B12 and TSH, all of which were unremarkable. A tilt table study was suggestive of neurocardiogenic mechanism. However, will need to adjust medications to rule out adverse reactions from medications. At this time, low concern for parkonsinism although exam notable for micrographia and mild gait changes. Will consider referral to movement disorder if patient does not improve on medication adjustments.
-Recommend continuing symptomatic support with Florinef, salt tablets, and behavioral modification including increased fluid intake. Recommend scheduling bathroom breaks to assist with urinary incontinence.
-Recommend optimizing anti-depressant medication (see below) in hopes to wean off clonazepam.
-Provided script for physical therapy for balance training.
2. Mood disorder, probable anxiety
Abnormal cognitive testing
-Currently being seen by outpatient psychiatry with good relationship. Will touch base in regards to adjusting antidepressants (increase sertraline dose vs switching to Lexapro) prior to weaning off clonazepam. Will defer to primary psychiatry.
-In addition, patient may benefit from psychotherapy as adjunct to medication therapy.
-Seems that significant stressor includes caring for elderly mother. Recommended taking 1-2 days off a week for self-care.
- MOCA score today was abnormal for age, level of education. She had impairments in executive function, concentration and verbal fluency. Certainly uncontrolled mood disorder can explain some of these deficits, also medications adverse effects. Lastly primary neurodegenerative disorder cannot be ruled out. I would favor treating better underlying mood disorder and weaning off benzodiazepines. Repeat cognitive testing in 3 months. If abnormal will refer to neuropsychiatric testing.
Other Medication recs:
-recommend discontinuing Mobic (listed under Beer's List) as patient currently does not have any arthritic pain.
-confirmed with patient and currently not taking tolterodine.
Follow up in 3 months.
Thank you for your attention.
Brief Answer:
She is having orthostatic hypotension, probably due to dysautonomia
Detailed Answer:
Hello,
Sorry for late reply.
I would focus my discussion on cardiac part. Overall, from all the symptoms there is a possibility of neurodegenerative disorder which is also called Parkinson plus syndromes and dysautonomia is frequent accompaniments.
So according to me, she is autonomic failure which is leading to ORTHOSTATIC HYPOTENSION. Because whenever one stands normally there is decreased intravascular volume, which is compensated by simultaneous vasoconstriction, which is impaired in autonomic failure. Due to this blood accumulates in the legs and there is decreased blood to heart and then to brain. This sometimes lead to further activation of vagal nerve from the heart which sometimes may lead to further decrease in pulse rate as well leading syncope or fainting which probably happened during the testing.
So in treatment, I agree with increased fluid intake, exercise and florinef. Because increasing intravascular volume will be helpful.
Drug induced cause is less likely as she is not on any such drugs.
It's important that you see neurologist or movement disorders specialist as from symptoms like handwriting changes and slowness of movement, there is possibility of underlying neurological disease which is causing all these symptoms.
Hope this helps you. Please get back if you have any doubts as my answer may not cover your entire concerns. All the best.
She is having orthostatic hypotension, probably due to dysautonomia
Detailed Answer:
Hello,
Sorry for late reply.
I would focus my discussion on cardiac part. Overall, from all the symptoms there is a possibility of neurodegenerative disorder which is also called Parkinson plus syndromes and dysautonomia is frequent accompaniments.
So according to me, she is autonomic failure which is leading to ORTHOSTATIC HYPOTENSION. Because whenever one stands normally there is decreased intravascular volume, which is compensated by simultaneous vasoconstriction, which is impaired in autonomic failure. Due to this blood accumulates in the legs and there is decreased blood to heart and then to brain. This sometimes lead to further activation of vagal nerve from the heart which sometimes may lead to further decrease in pulse rate as well leading syncope or fainting which probably happened during the testing.
So in treatment, I agree with increased fluid intake, exercise and florinef. Because increasing intravascular volume will be helpful.
Drug induced cause is less likely as she is not on any such drugs.
It's important that you see neurologist or movement disorders specialist as from symptoms like handwriting changes and slowness of movement, there is possibility of underlying neurological disease which is causing all these symptoms.
Hope this helps you. Please get back if you have any doubts as my answer may not cover your entire concerns. All the best.
Note: For further follow up on related General & Family Physician Click here.
Above answer was peer-reviewed by :
Dr. Prasad
Answered by
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