The question often comes up about how to prevent or treat orthostatic hypotension to avoid dizziness and falls. It's often due to dehydration, diabetes, Parkinson's, or drugs. Follow these steps...
Check for medications that may precipitate falls in blood pressure such as alpha- blockers (Cardura, Tamsulin, etc), diuretics and many antiparkinson's drugs (levodopa, etc). Try lowering the dose or switching to another drug. Nondrug therapies can help. Advise patients to get up slowly, increase fluid and sodium intake when possible, wear compression stockings and avoid alcohol. If nursing home patients have postprandial hypotension, suggest walking to meals and taking a wheelchair ride back to their room. When this isn't enough, use medications that increase blood pressure.
Fludrocortisone (Astonin, Cortilon) raises blood pressure by causing sodium and water retention. Be careful using it in patients with heart failure. The dose is 0.1 mg once daily, increasing by 0.1 mg weekly until trace edema occurs or a dose of 1 mg daily is reached. Monitor serum potassium, fludrocortisone can cause hypokalemia.
Midodrine (Morepress, Gutron, Midodrine) raises blood pressure by causing vasoconstriction and therefore should be avoided in patients with heart disease. It is dosed at 2.5 mg three times daily, increased by 2.5 mg weekly to a maximum of 10 mg three times daily. The morning dose should be taken first thing, and the evening dose taken not later than six o'clock to avoid supine hypertension. It can be used with fludrocortisone. Midodrine also decreases heart rate. Be careful using it with other medications that lower heart rate such as beta-blockers, digoxin, etc. Tell patients not to be surprised if they get "goose bumps", midodrine commonly causes hair to stand on end. Again, caution patients not to take midodrine less than 4 hours before bedtime to avoid HYPERTENSION when lying down.
Pseudoephedrine (Decongess SR) is another vasoconstrictor that has been used, but has less supporting data. Doses of 30 mg to 60 mg three times daily have been used. Like midodrine, it should not be taken within four hours of bedtime to prevent supine hypertension.
Caffeine is worth a try to see if it reduces hypotension. Suggest 1 or 2 cups of coffee or black tea up to 3 times a day (100 to 250 mg up to three times daily, administered as tablets or a beverage, can be recommended).
REFERENCES
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Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007 Oct;120(10):841-7. Available at: https://www.amjmed.com/article/S0002-9343(07)00363-4/fulltext
Freeman R. Clinical practice. Neurogenic orthostatic hypotension. N Engl J Med. 2008 Feb 7;358(6):615-24. Available at: https://www.nejm.org/doi/full/10.1056/NEJMcp074189