Postural hypotension: dizziness on standing, falls, and GP management

Postural (orthostatic) hypotension is a sustained fall in blood pressure occurring within three minutes of standing — defined by the European Society of Cardiology 2018 Syncope Guidelines as a drop of at least 20 mmHg in systolic or 10 mmHg in diastolic pressure. It is extremely common in older adults, affecting approximately 20% of community-dwelling adults aged 65 and over and up to 50% of those in residential aged care. It is a major — and often underdiagnosed — contributor to falls, fractures, syncope, cognitive decline, and cardiovascular mortality.

The condition is highly treatable. The highest-yield intervention in most patients is a thorough medication review. Most postural hypotension in older adults is caused by medications, and deprescribing or dose reduction can dramatically improve symptoms without any other intervention.

A. Core clinical — the AU general-practice framework

How to assess postural hypotension

The measurement technique matters. A single blood pressure reading immediately after rising is insufficient and misses many cases.

Lying-to-standing BP measurement:

1. Patient lies supine for at least five minutes; record blood pressure and heart rate.
2. Patient stands; record blood pressure and heart rate at one minute, three minutes, and five minutes.
3. A sustained drop of ≥20 mmHg systolic or ≥10 mmHg diastolic at any point confirms classical orthostatic hypotension.
4. Some patients only develop the drop beyond three minutes (delayed orthostatic hypotension) — the five-minute reading is necessary.

Examine for clues to the cause:

• Cardiovascular — pulse regularity (arrhythmia), volume status, heart murmurs (aortic stenosis with fixed cardiac output).
• Neurological — Parkinson’s signs (rest tremor, rigidity, bradykinesia, postural instability); peripheral neuropathy assessment (10 g monofilament, vibration sense, ankle reflexes); autonomic signs (anhidrosis, dry skin, pupillary changes).
• Skin — pigmentation in palmar creases or oral mucosa suggests adrenal insufficiency.

History:

• Symptom triggers: morning rising, post-meal, post-exercise, hot environment, hot showers, prolonged standing, alcohol.
• Severity: dizziness only, presyncope (almost blacking out), or actual syncope and falls.
• Medication review — comprehensive, including all prescribed, over-the-counter, and complementary medicines.
• Comorbidities: diabetes, Parkinson’s disease, cancer history, autoimmune disease.
• Fluid intake and dietary salt.

Investigations:

• First-line bloods: FBC, electrolytes and creatinine, glucose or HbA1c, thyroid function, B12, vitamin D, calcium.
• ECG — bradyarrhythmia, heart block.
• Selective: morning cortisol or short Synacthen test (suspected adrenal insufficiency); urinary metanephrines (suspected phaeochromocytoma in younger or refractory patients); SPEP and IFE (suspected amyloidosis in older adults); HIV serology where appropriate.
• Holter or loop recorder — if arrhythmia is suspected as a contributing cause.
• Echocardiography — if significant structural heart disease (aortic stenosis, heart failure) is suspected.
• Tilt-table testing — specialist referral only; used for delayed orthostatic hypotension, suspected POTS, or refractory unexplained syncope.

Causes of postural hypotension

Medication — most common cause in older adults:

• Alpha-blockers: prazosin, tamsulosin, terazosin (strongly associated with first-dose and sustained orthostatic hypotension).
• Multiple antihypertensives: ACE inhibitors, ARBs, calcium channel blockers, beta-blockers, diuretics — especially when newly started, recently dose-escalated, or combined.
• Antidepressants: tricyclic antidepressants (nortriptyline, amitriptyline — anticholinergic plus alpha-1 blockade), trazodone, MAOIs.
• Antipsychotics: chlorpromazine, risperidone, clozapine — alpha-1 blockade.
• Dopaminergic agents: levodopa and dopamine agonists used in Parkinson’s disease.
• PDE5 inhibitors: sildenafil and tadalafil, especially combined with nitrates.
• Opioids: centrally mediated autonomic suppression.
• Alcohol: vasodilation plus diuresis.

Volume depletion:

• Dehydration (hot weather, inadequate intake, gastrointestinal losses).
• Diuretic overuse.
• Adrenal insufficiency (Addison’s disease or relative insufficiency from steroid withdrawal).

Autonomic neuropathy (neurogenic orthostatic hypotension):

• Diabetic autonomic neuropathy — occurs in long-standing diabetes alongside peripheral neuropathy.
• Parkinson’s disease, multiple system atrophy (MSA), Lewy body dementia — autonomic failure is a core feature of MSA.
• Amyloidosis — both AL and hereditary TTR amyloid affect autonomic nerves.
• Post-COVID dysautonomia — an increasingly recognised autonomic syndrome following COVID-19 infection.
• Alcohol-related autonomic neuropathy.

Cardiac causes:

• Severe aortic stenosis or hypertrophic cardiomyopathy — fixed cardiac output cannot increase with standing.
• Bradyarrhythmia — sinus node dysfunction, high-degree AV block.
• Heart failure with significantly reduced ejection fraction.

First-line management — non-pharmacological

The RACGP Silver Book and eTG both emphasise non-pharmacological measures as the foundation of treatment:

1. Medication review and deprescribing — the highest-yield intervention: Use the STOPP/START criteria and Anticholinergic Burden Scale. Review all antihypertensives — in frail elderly patients, relaxing the blood pressure target (for example, accepting systolic 140–150 mmHg) may allow dose reduction. Consider switching tamsulosin or prazosin to an alternative. Cease unnecessary diuretics, sedatives, and anticholinergics where clinically appropriate. A Home Medicines Review (HMR, MBS item 900) by an accredited pharmacist is a valuable structured approach.

2. Fluid intake: At least 2–2.5 L daily; more in hot weather or after exercise. Dehydration substantially worsens postural hypotension.

3. Dietary salt liberalisation: 6–10 g of salt daily (approximately one to two teaspoons) supports plasma volume. This is appropriate unless contraindicated by heart failure, poorly controlled hypertension, or significant chronic kidney disease. Food-based salt is preferred to salt tablets.

4. Counter-pressure manoeuvres: Leg crossing and tensing, calf muscle contraction, handgrip, squatting, or bending forward — all increase venous return and temporarily raise blood pressure. These are particularly effective immediately before and during standing. Calf-pump exercises before rising from bed are helpful.

5. Compression garments: Knee-high or thigh-high compression stockings of at least Class II (15–20 mmHg); Class III (20–30 mmHg) for refractory cases. Abdominal binders are particularly effective for splanchnic venous pooling and are underutilised. Apply before getting out of bed in the morning; remove before lying down.

6. Positioning adjustments:

• Sit at the edge of the bed for 30 seconds before standing.
• Elevate the head of the bed 10–20 cm — this reduces overnight sodium loss and blunts morning postural hypotension.
• Avoid prolonged standing, hot showers or baths, saunas, and alcohol.

7. Post-prandial hypotension: In older adults, large carbohydrate-rich meals cause splanchnic vasodilation and can drop blood pressure significantly. Small, frequent, low-carbohydrate meals reduce this. A coffee with breakfast can provide a modest pressor effect.

8. Exercise: Recumbent or aquatic exercise avoids postural stress while improving cardiovascular conditioning. Supine cycling, swimming, and rowing are suitable options. Progressive reconditioning reduces deconditioning-related postural hypotension over weeks.

B. Evidence for pharmacotherapy — when non-pharmacological measures are insufficient

Fludrocortisone (Florinef) 0.1–0.2 mg daily: A mineralocorticoid that increases renal sodium and water retention, expanding plasma volume. AMH lists it as PBS-listed for conditions requiring mineralocorticoid replacement; its use in orthostatic hypotension is established clinical practice. Side effects — supine hypertension, hypokalaemia, oedema, and headache — require monitoring. Avoid in heart failure; use with caution in moderate-to-severe hypertension and significant chronic kidney disease. Monitor blood pressure in both lying and standing positions, electrolytes, and weight.

Midodrine 2.5–10 mg two to three times daily (last dose by 6 pm): A selective alpha-1 agonist that increases peripheral vascular resistance. PBS Authority Required for symptomatic orthostatic hypotension. Taken 30 minutes before anticipated activity or standing. Key safety point: do not take within four hours of bedtime — supine hypertension is the main concern. Side effects include pilomotor reactions (goosebumps), urinary retention, and paraesthesia. Specialist initiation is typical given the monitoring required.

Droxidopa 100–600 mg three times daily: A norepinephrine prodrug that restores sympathetic neurotransmitter tone. Available via TGA Special Access Scheme for neurogenic orthostatic hypotension in Parkinson’s disease, multiple system atrophy, and pure autonomic failure. Significant cost; specialist-only.

Pyridostigmine 30–60 mg three times daily: An acetylcholinesterase inhibitor that boosts ganglionic transmission and has a modest pressor effect with lower risk of supine hypertension than midodrine. A reasonable option for mild neurogenic orthostatic hypotension, particularly when supine hypertension is a concern. PBS General Schedule for myasthenia gravis; off-label use in orthostatic hypotension.

Evidence summary:

• Non-pharmacological measures: eTG rates these as first-line with strong evidence for medication review, salt and fluid loading, compression, and physical manoeuvres.
• Fludrocortisone and midodrine: established pharmacological options with reasonable evidence in controlled studies; both require specialist input in general practice.
• POTS management includes beta-blockers (low-dose propranolol) and ivabradine for rate control, alongside the non-pharmacological base.

C. Neurogenic orthostatic hypotension — a specific subtype

In neurogenic orthostatic hypotension, the compensatory heart rate rise on standing is absent or blunted (normally HR should rise 10–15 bpm on standing; in neurogenic OH it does not). This occurs because the sympathetic nervous system pathways are damaged or dysfunctional.

Common neurological causes in general practice:

• Diabetic autonomic neuropathy — co-occurs with peripheral neuropathy and other autonomic features (gastroparesis, erectile dysfunction, bladder dysfunction, gustatory sweating). Optimising glycaemic control may slow progression but does not reverse established autonomic neuropathy.
• Parkinson’s disease — orthostatic hypotension affects up to 50% of patients with Parkinson’s, particularly those on higher levodopa doses or dopamine agonists. Management requires careful balancing of antiparkinsonian therapy and orthostatic treatment; geriatric or movement disorder specialist input is helpful.
• Multiple system atrophy — more severe autonomic failure than Parkinson’s; droxidopa is a specific option.
• Post-COVID dysautonomia — a recognised syndrome following SARS-CoV-2 infection; predominantly younger adults; overlaps with POTS. Non-pharmacological measures are first-line; specialist autonomic neurology input for refractory cases.

D. Australian operations

MBS items relevant to postural hypotension management in general practice:

• Standard GP consultation: items 23/36/44
• 75+ Health Assessment: item 705 — includes assessment of postural blood pressure as a standard component; this alone identifies many cases in older adults
• Aboriginal and Torres Strait Islander Health Assessment: item 715
• Home Medicines Review (HMR): item 900 — accredited pharmacist reviews all medications in the patient’s home; highest-yield for polypharmacy-driven orthostatic hypotension
• Residential Medication Management Review (RMMR): item 903 — for aged care residents
• GP Chronic Condition Management Plan (GPCCMP): items 965/967 (replaced 721/723 from 1 July 2025) — eligible for chronic orthostatic hypotension with comorbidities; enables physiotherapy, exercise physiology, and occupational therapy referral for falls prevention
• ECG: item 11700
• Echocardiography: items 55113 range
• Holter monitoring: items 11600/11602

PBS pharmacotherapy:

• Fludrocortisone (Florinef) 100 mcg tablets — PBS General Schedule for adrenal insufficiency; clinical standard for orthostatic hypotension.
• Midodrine 2.5 mg, 5 mg, 10 mg tablets — PBS Authority Required (Streamlined) for symptomatic orthostatic hypotension.
• Pyridostigmine (Mestinon) 60 mg tablets — PBS General Schedule for myasthenia gravis; off-label for neurogenic orthostatic hypotension.
• Droxidopa (Northera) — TGA Special Access Scheme; not PBS-listed; significant cost; for neurogenic orthostatic hypotension in Parkinson’s and MSA.

Falls prevention integration: Postural hypotension is a Priority 1 modifiable falls risk factor per the RACGP Silver Book. Referral to a falls clinic (geriatrician-led multidisciplinary team) is appropriate for older adults with recurrent falls attributable to orthostatic hypotension.

Driving and Austroads: Austroads — Assessing Fitness to Drive 2022 classifies symptomatic orthostatic hypotension with recurrent presyncope or syncope as a potential driving restriction. Document assessment and counselling. Private vehicle driving typically requires four weeks of symptom stability; commercial vehicle licensing is more stringent. Record clearly in the clinical notes.

E. Special populations

Older adults in residential aged care: Postural hypotension affects approximately 50% of residential aged care residents. Multiple medication contributors are common. The RMMR process (MBS 903) by an accredited pharmacist is the most systematic way to identify and reduce medication burden. Compression stockings are often difficult for residents with arthritis to apply — nursing staff or carers can assist. Bed-head elevation and small frequent meals are simple environmental interventions.

Patients with Parkinson’s disease: Orthostatic hypotension and Parkinson’s disease interact in complex ways. Dopaminergic medications can worsen orthostatic hypotension, while reducing them worsens motor control. Droxidopa (norepinephrine prodrug) specifically addresses neurogenic orthostatic hypotension without worsening Parkinson’s motor features. Movement disorder specialist input is valuable.

Patients with supine hypertension and orthostatic hypotension: This paradox — blood pressure high when lying, low when standing — is a characteristic of neurogenic autonomic failure and can be exacerbated by fludrocortisone and midodrine. Management includes: head-of-bed elevation 10–20 cm; avoiding evening doses of fludrocortisone and midodrine (last dose by 6 pm for midodrine); a small carbohydrate snack at bedtime to blunt nocturnal supine hypertension through post-prandial splanchnic dilation. Treat supine hypertension only cautiously if severe (systolic above 180 mmHg) to avoid worsening standing hypotension.

Pregnancy: Supine hypotension in late pregnancy results from the gravid uterus compressing the inferior vena cava (“supine hypotensive syndrome of pregnancy”). Management is positional — left lateral recumbent position and compression stockings. Medications are generally avoided.

When to escalate

Refer or escalate when:

• Suspected neurogenic orthostatic hypotension (Parkinson’s, MSA, amyloidosis) — neurology or geriatric medicine.
• Suspected adrenal insufficiency or phaeochromocytoma as an underlying cause — endocrinology.
• Significant structural cardiac cause (aortic stenosis, heart failure, arrhythmia) — cardiology.
• Refractory orthostatic hypotension not responding to comprehensive non-pharmacological measures and initial pharmacotherapy — specialist autonomic clinic referral (major teaching hospitals).
• Recurrent falls with injury, or complex polypharmacy driving orthostatic hypotension in an elderly patient — geriatrician or falls clinic.
• POTS in a young adult — specialist autonomic neurology or cardiology.

What this article is and is not

This is general health information drawn from Australian and international clinical guidelines — Therapeutic Guidelines, RACGP Silver Book, Australian Medicines Handbook, ESC 2018 Syncope Guidelines, and NPS MedicineWise. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigation, medication adjustment, and treatment are made with your own GP and, where appropriate, specialist clinicians.

For reliable Australian patient resources: HealthDirect — Postural hypotension, Heart Foundation Australia, Better Health Channel — Low blood pressure.

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Sources cited

1. Therapeutic Guidelines (eTG) — Cardiovascular and Autonomic
2. RACGP Silver Book — Aged Care
3. ESC 2018 Guidelines — Diagnosis and Management of Syncope
4. Australian Medicines Handbook
5. NPS MedicineWise — Medication review
6. Austroads — Assessing Fitness to Drive 2022
7. Heart Foundation Australia
8. HealthDirect — Postural hypotension
9. Better Health Channel — Low blood pressure
10. MBS Online — items 705, 900, 903, 965/967