Course Authors
John E. Morley, M.D.
During the last three years, Dr. Morley has received grant/research support from Vivus, Merck & Co., Upjohn, B. Braun McGaw, Bayer Corp and Nestec, Ltd. He has also served on the Speakers' Bureau for LXN, Organon, Ross, Pharmacia & Upjohn, Glaxo Wellcome, Hoechst Marion Roussel, Searle, Merck & Co., Roche, Bristol-Myers Squibb, Novartis, Pratt, B. Braun McGaw, Pfizer and Parke-Davis.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
Mrs. A. is an 83-year-old nursing home resident. In the last month she has had two falls. Her blood pressure is 150/90 mm Hg and there is no orthostatic drop. Both falls occurred in the dining area approximately 45 to 60 minutes following lunch. She is taking a long-acting nitrate preparation for angina. Her fasting glucose is 123 mg/dl.
What is the most likely cause of her falls?
Old, as opposed to young persons, have a tendency to drop their blood pressure following a meal. This drop can be prolonged, lasting up to two hours. By definition postprandial hypotension involves a decrease in systolic blood pressure of at least 20 mm Hg following a meal (Graph A, Figure 2):
Lew Lipsitz at Harvard(1) was the first to demonstrate that this drop in blood pressure was linked to falls following a meal in nursing home residents. In addition, there is an increase in syncopal episodes in older persons with postprandial hypotension. Postprandial hypotension has also been associated with stroke, dizziness and angina.
The macronutrient in meals involved in the pathogenesis of these blood pressure drops is carbohydrate. As the postprandial decrease in blood pressure can be inhibited by the somatostatin analog, octreotide, it was postulated that this particular hypotension may be related to an excessive release of a vasodilatory gastrointestinal peptide. Recently we have identified this peptide to be calcitonin gene related peptide. Splanchnic blood pooling and impaired cardiac output in response to a meal may also contribute to postprandial hypotension.
Persons with postprandial hypotension rarely have orthostatic hypotension. However, even young persons who have autonomic neuropathy often have a combination of orthostasis and postprandial hypotension. Patients with hypertension and diabetes are at greater risk of developing postprandial hypotension.
Medications that lower blood pressure such as nitroglycerine are associated with exaggerated drops in blood pressure following a meal and a greater chance of meal-associated falls. Caffeine has been used to treat postprandial hypotension, but its efficacy is debatable.
Most falls in older persons are not associated with syncope, but are due to a variety of extrinsic (environmental) or intrinsic factors in the nursing home environment. The three major intrinsic causes of falls are proximal muscle weakness, balance problems and polypharmacy (greater than 4 medications). In addition the practitioner should also rule out orthostasis, depression and visual problems as a cause of falls. In the national FICSIT study(4), falls among community dwelling elders were best prevented by programs focusing on balance training. A particularly successful form of balance training for older persons are the basic exercises for all martial arts, such as Tai Chi.
At St. Louis University we have developed a mnemonic to help remember the causes of falls:
The MOGGEC "Safe and Sound" Risk Factors for Falls
Strength problems
Alcohol
Food associated hypotension
Environmental factors
Atherosclerotic disease (syncope)
No freedom (restraints)
Drugs
Sight problems
Orthostasis
Unsteady balance
Nocturia
Delirium