Dan Keller 0:03 Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research, the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.
Up to 60% of people with Parkinson's disease may experience a drop in blood pressure at some point when standing up from a lying or sitting position. The technical term is orthostatic hypotension, also called postural hypotension. It may be the result of the disease itself or medications used to treat PD. Individuals may experience lightheadedness, dizziness, or even fainting when it occurs. The danger is that it may cause falls and injuries, so it's important to get orthostatic hypotension under control.
The flip side is that medications used to raise blood pressure when standing can lead to high blood pressure when lying down. Fortunately, there are medication as well as non-medication related ways to treat hypotension, and working with one's healthcare provider can often achieve a good balance in blood pressure. When I spoke with Jeni Bednarek, a nurse educator at the Parkinson's Center and Movement Disorders Program at the Oregon Health and Science University in Portland, a Parkinson's Foundation Center of Excellence, she laid out the problems and offered some suggestions for alleviating orthostatic hypotension at its most basic. What should people with Parkinson's know about blood pressure and blood pressure control?
Jeni Bednarek 2:16 So the biggest thing to know about blood pressure and Parkinson's is that it can fluctuate, and that is due to the Parkinson's, but it can be made worse by Parkinson's medications. There are ways to manage it with medication and ways to manage it without medication.
The most common type of blood pressure fluctuation is low blood pressure, and that's low blood pressure when you're changing position, like going from laying down to sitting up or sitting to standing, and we call that orthostatic hypotension. But people can have hypertension—so high blood pressure—when they're laying down, and they call that supine hypertension. If you're experiencing things like dizziness, or lightheadedness, or feeling kind of unsteady when you sit up or stand up, then you definitely want to talk to your provider about, "Do you have orthostatic hypotension? Are you having blood pressure issues?"
Dan Keller 3:10 If it's just momentary, is it a big deal, or if it persists for a certain amount of time, is it a big deal?
Jeni Bednarek 3:16 I think both. Especially if you're noticing it's momentary sort of after you're taking your Parkinson's medications, that may signal that you're having issues. And definitely, if you notice it a couple of times throughout the day, or if it seems to be getting worse, then you'd want to have a chat about it and make sure that you're implementing some measures to prevent something worse, like a fall. So even if it's momentary, you know, it can get worse quickly, so you'd want to make sure you're safe.
Dan Keller 3:46 How common are these events in the course of the disease? You had mentioned it may be related to medication changes, but also, what about disease progression?
Jeni Bednarek 3:56 It's fairly common. I don't know the exact numbers, but a large number of Parkinson's patients will have issues with blood pressure fluctuations. We certainly, like everything in Parkinson's, would see more of it as disease progresses, and as you get onto those higher doses of meds, like the carbidopa/levodopa.
Dan Keller 4:15 You had mentioned the term neurogenic orthostatic hypotension. Can you break those down? Just, what does each part mean?
Jeni Bednarek 4:23 Yeah, so neurogenic just means that this is caused by your nervous system. There are different types of hypotension, and that differentiates this from different types of orthostatic hypotension, which could be caused by dehydration—that is another thing that can cause it. So, neurogenic just tells us it's neurological in basis. Orthostatic tells us it has to do with position changes, so it's when you're making those movement changes versus when you're laying down and you're hypotensive. And so we have a neurological position change, low blood pressure.
Dan Keller 4:58 Good. What are some of the symptoms someone may experience if they're experiencing neurogenic orthostatic hypotension, or NOH?
Jeni Bednarek 5:09 They would be mostly noticeable when you're changing position. They could be dizziness, you could feel lightheaded, you may be sweaty or shaky, just a feeling of unsteadiness or even sort of foggy. Those can be short in duration, or it could be longer, you know. Sometimes patients feel kind of nauseous and dizzy for a long period of time.
Dan Keller 5:31 What can patients do if they're experiencing this, and what can they do to prevent it?
Jeni Bednarek 5:36 So, if you're having symptoms of it right away, my suggestion would be, sit down if you can. The last thing we want is for it to get worse and have a fall. But if you can't sit down—like you're in line somewhere, you're at the grocery store pushing a cart and there's nowhere to sit—you can do some moves to help get that blood flowing up to your brain.
One is you can stand on your toes. You could lean forward and put your hands on your knees. You can do a squat if that's a safe thing for you to do. And the last thing is you can put one leg up on a chair or a ledge, or like if you're pushing a cart, get a leg up on the cart.
If you're able to drink water, if you drink two full glasses of water within a five-minute period, it's sort of the same as getting a liter of fluids in an IV bag. It can really fill up your tank quickly, and it can actually increase your blood pressure for the next one to two hours.
The other thing you can do, if you know this is an issue that you have and you have medication on hand, one medication called Midodrine is short-acting, and you may have instructions from your provider to take it when you're having an episode, but it does take 30 to 60 minutes to kick in.
So, for prevention, the biggest thing I tell patients is keep a full glass of water at your bedside and drink it before you get up, so get that tank full in the morning before you're up and about. Slow position changes, so no jumping out of bed and running around in the morning. Make sure you're moving nice and slow when you're changing positions.
You can wear compression garments, and they need to be thigh-high, so the knee-high compression garments don't work as well. They make thigh-high and waist-high compression garments, or an abdominal binder, which is kind of a... it's like a stretchy elastic girdle that you put on with velcro. It's not very attractive, but it works well to help get that blood flowing.
And then increased salt intake will help prevent orthostatic hypotension. You'd want to work with your provider on that, because if you have any cardiac issues, you'd need to weigh whether that was safe for you or not.
And then making sure you're drinking plenty of water. So that glass of water in the morning, a full glass of water with each dose of medication, a full glass of water with each meal.
And then we have another type of hypotension called postprandial hypotension, which is a fancy way of saying low blood pressure after eating a big meal, and everybody gets that, even without Parkinson's. So, eating smaller, more frequent meals can also help prevent it.
And then, of course, medications, working with your provider on whether or not medications would be a good option for you.
Dan Keller 8:16 Is there kind of a delicate balancing act between avoiding orthostatic hypotension and having supine hypertension? If it's good when you're standing up and then you lie down, does blood pressure go up?
Jeni Bednarek 8:30 That's a great question, because some of these medications for orthostatic hypotension can actually put you at higher risk for having supine hypertension, so there is a delicate balance, for sure.
Some things you can do if you have issues with supine hypertension—and you probably won't have symptoms of it if you have it, but you're likely monitoring your blood pressure and would know that it's happening: you can elevate the head of your bed when you sleep, that can help lower your blood pressure. You can also work with your provider on a short-acting antihypertensive, and you would take that either in the afternoon or at bedtime, so the effects would be worn off by the morning, so you wouldn't hopefully have any of it left in your system to cause hypotension in the morning.
Dan Keller 9:16 Let's talk about what you might call the opposite problem. What about high blood pressure, hypertension? Does that occur, and is it different from hypertension in most people as they get older and their blood pressure goes up?
Jeni Bednarek 9:31 Yeah, so people with Parkinson's can certainly still have hypertension. We often have patients who are on antihypertensives already, then they come and get a Parkinson's diagnosis, so it does get tricky, and that can be not linked to the Parkinson's. You may just have hypertension and have Parkinson's disease.
So, as the disease progresses, and you maybe start having issues with hypotension, you have to work with both your primary care and your Parkinson's provider on when it is time to back off on that antihypertensive, or you know, do you need to stay on it?
The one thing we see with Parkinson's patients is that supine hypertension—and that's the high blood pressure when laying down—that is part of Parkinson's disease, and is again something that is that balancing act of if you're having the hypertension when you're laying down and the hypotension when you're standing up, you'll work with your Parkinson's provider on strategies for that.
Dan Keller 10:26 Are these phenomena of high blood pressure and low blood pressure accompanying Parkinson's disease just part of the overall process where people have autonomic problems—they have constipation, and they have sweating, and things like that? Are these all part of the same constellation?
Jeni Bednarek 10:44 They are. So we know that neurogenic orthostatic hypotension is... it's not as clear with the supine hypertension what that mechanism is, but that low blood pressure is part of that autonomic dysfunction that we can see in Parkinson's.
Dan Keller 11:00 What's your advice in a nutshell to people with Parkinson's who are experiencing any of these blood pressure irregularities?
Jeni Bednarek 11:09 My biggest advice is drink a lot of water. That's going to help you in all of your different realms of health. But if you're having issues with either of them, talk to your provider. If your team has a nurse that you can talk with, that's someone who can help you work on what to do, what strategies to use, and then help you advocate with your provider if you feel like medication is needed.
Dan Keller 11:32 Very good, thanks.
For more information about hypotension and other causes of dizziness, search our website for "hypotension." A past podcast called Understanding Neurogenic Orthostatic Hypotension may be of particular interest. You can find an Expert Briefing by Dr. Rajesh Pahwa called PD and Medication: What's New that discusses orthostatic hypotension; just go to parkinson.org/eb. The specific part about hypotension begins at 14 minutes and 15 seconds. Also, if you search on the words "low blood pressure" when visiting the PD Library at parkinson.org/library, you can find a fact sheet on the topic.
On the related issue of falls, our PD Library also includes past podcasts that may be of interest. One is called Stall the Fall, and the other is titled Movement Strategies: Mobility, Falls and Freezing of Gait.
If you have specific questions on any of these topics, our helpline staff will be glad to try to find answers. News and updates about future events and resources are available by joining our email list at the bottom of our website's homepage. If you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. If you enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts or wherever you get your podcasts.
At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Till next time, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO. That's 1-800-473-4636. Thank you for listening.
