A validated test for neurogenic orthostatic hypotension at the bedside

Orthostatic hypotension in Parkinson's disease: Sit-to-stand vs. supine-to-stand protocol and clinical correlates

BACKGROUND

Screening for orthostatic hypotension (OH) is integral in Parkinson's disease (PD) management, yet evidence-based guidelines on best practice methods for diagnosing OH in PD are lacking.

METHODS

We investigated the frequency and correlates of OH, symptomatic OH, and neurogenic OH, in a large consecutively recruited PD cohort (n = 318), and compared the diagnostic performance of the sit-to-stand vs. the supine-to-stand blood pressure (BP) test. We evaluated the utility of continuous BP monitoring and tilt table testing in patients with postural symptoms or falls who were undetected to have OH with clinic-based BP measurements. Disease severity, fluid intake, orthostatic and overactive bladder symptoms, falls, comorbidities and medication history were evaluated.

RESULTS

Patients' mean age was 66.1 ± 9.5years, with mean disease duration 7.8 ± 5.5years. OH frequency was 35.8 % based on the supine-to-stand test. OH in PD was significantly associated with older age, lower body mass index, longer disease duration, worse motor, cognitive and overactive bladder symptoms and functional disabilities, falls, and lower fluid intake. A similar profile was seen with asymptomatic OH. Three quarters of OH were neurogenic, with the majority also having supine hypertension. The sit-to-stand test had a sensitivity of only 0.39. One quarter of patients were additionally diagnosed with OH during continuous BP monitoring.

CONCLUSIONS

The sit-to-stand test substantially underdiagnoses OH in PD, with the important practice implication that supine-to-stand measurements may be preferred. Screening for OH is warranted even in asymptomatic patients. Adequate fluid intake, treatment of urinary dysfunction and falls prevention are important strategies in managing PD patients with OH.

[S1 guidelines for the management of postviral conditions using the example of post-COVID-19]

These S1 guidelines are an updated and expanded version of the S1 guidelines on long COVID differential diagnostic and management strategies. They summarize the state of knowledge on postviral conditions like long/post COVID at the time of writing. Due to the dynamic nature of knowledge development, they are intended to be "living guidelines". The focus is on practical applicability at the level of primary care, which is understood to be the appropriate place for initial access and for primary care and treatment. The guidelines provide recommendations on the course of treatment, differential diagnostics of the most common symptoms that can result from infections like with SARS-CoV-2, treatment options, patient management and care, reintegration and rehabilitation. The guidelines have been developed through an interdisciplinary and interprofessional process and provide recommendations on interfaces and possibilities for collaboration.

Autonomic History, Examination, and Laboratory Evaluation

PURPOSE OF REVIEW

Autonomic disorders offer a fascinating view of the complexity of the nervous system. Their impact on human health ranges from benign to severe. Deciphering autonomic symptoms and signs draws on the cognitive skills and personal interest in the plight of patients that first attracted many physicians to the field of neurology. This article provides tools to sharpen those skills.

RECENT FINDINGS

Autonomic neuroscience and accumulated clinical knowledge have led to the categorization of autonomic disorders into specific syndromes that can be identified on the basis of clinical phenotypes and physiologic responses to standardized stimuli in the autonomic laboratory. A key development has been the ability to distinguish neurogenic orthostatic hypotension from other causes of hypotension. Quantification of sudomotor responses has proven valuable in the diagnosis of thermoregulatory disorders and small fiber neuropathies such as those related to diabetes mellitus. Increasing attention has focused on autonomic failure as a defining feature of neurodegenerative α-synucleinopathies, especially multiple system atrophy. As awareness of autonomic disorders has increased, the once obscure term dysautonomia has entered into common parlance.

SUMMARY

With appropriate knowledge and experience, neurologists can diagnose autonomic dysfunction accurately and with confidence. The opportunity to play an important role in caring for patients with autonomic disorders is worth the effort.