You can find out more about NPF's National Medical Director, Dr. Michael S. Okun, by also visiting the NPF Center of Excellence, University of Florida Center for Movement Disorders & Neurorestoration.
Over many years of clinical practice, I have seen many Parkinson’s disease (PD) patients visit the emergency room or clinic because of dizziness and/or syncope (passing out). In most cases, the obligatory cardiac evaluation finds no underlying factor. Many patients are referred to a vestibular physical therapist, someone who specializes in gaze and gait stabilization, to fix vertigo; however, this approach is useful for few patients. Most patients actually have orthostatic hypotension, which can be a manifestation of Parkinson’s and made worse by Parkinson’s medications.
Orthostatic hypotension is common in PD, and affects 15-50% of patients. It has been defined as a drop in systolic blood pressure of greater than 20 mmHg, or a decrease in diastolic blood pressure of greater than 10mmHg within 3 minutes of changing to a standing position. Dr. Jankovic and colleagues at the NPF Center of Excellence in Houston, TX recently published information about orthostatic hypotension in a large series of PD patients. They reviewed the records of 1,318 patients and found that symptomatic orthostatic hypotension occurred in “81% of patients with multiple system atrophy, in 18% of PD, and in 19% with non-multiple system atrophy (MSA) atypical parkinsonism.” They found that orthostatic hypotension occurred in older patients with more advanced PD, and longer disease durations.
When orthostatic hypotension is verified, patients should consider reducing or eliminating the medications that contribute to the problem, including antihypertensive medication. Dopaminergic medications (particularly the dopamine agonists) may worsen orthostatic hypotension. Non-pharmacologic strategies which may improve orthostatic symptoms include increasing fluid intake, increasing dietary salt andcaffeine, and using tight, thigh-high support stockings to prevent pooling of blood below the waist. Purchasing a hospital bed, or raising the head of a normal bed 10-30 degrees may improve standing blood pressure when performed on a regular basis over several weeks.. If needed, pharmacologic agents to raise blood pressure may be used.
Orthostatic hypotension Treatments
Fludrocortisone 0.1 mg once daily
5-10 mg three times per day; last dose should not be after 6pm to avoid supine hypertension
25-50 mg q4-6 hours
Phenylpropanolamine start 25 mg twice per day or
Do not take after dinner to avoid insomnia and supine hypertension.
Finally, some practitioners add drugs named Mestinon and Midodrine, used for myasthenia gravis, or other drug treatments. There is also a medication in clinical trials called droxidopa, L-threo-3,4,-dihydroxyphenylserine. This drug is a pro-drug of norepinephrine. The drug has been promising in MSA and cases of pure autonomic failure. Many scientists are working to discover if and how this drug may be used in PD.
The bottom line for PD patients who are passing out (syncope), or getting dizzy, especially when standing up or when changing positions, is that this may be your Parkinson’s disease, your Parkinson’s disease medications or both. Consult your doctor immediately, and have your blood pressure taken while laying down, sitting and standing. There are many potentially effective strategies that may improve your quality of life, and may also prevent dizziness and passing out.
Ha AD, Brown CH, York MK, Jankovic J. The prevalence of symptomatic orthostatic hypotension in patients with Parkinson's disease and atypical parkinsonism. Parkinsonism Relat Disord. 2011 Jun 18.
Mostile G, Jankovic J. Treatment of dysautonomia associated with Parkinson's
disease. Parkinsonism Relat Disord. 2009 Dec;15 Suppl 3:S224-32.
Okun MS, Fernandez HH. Ask the Doctor about Parkinson’s Disease. Demos Medical Publishing, 2010.
Posted: 7/1/2011 8:32:09 AM by
Browse current and archived What's Hot in PD? articles, the National Parkinson Foundation's monthly blog for people with Parkinson's written by our National Medical Director, Dr. Michael S. Okun.
Two New Therapies for Parkinson’s Disease Patients to get Excited About: Vaccines and Monoclonal Antibodies
The Importance of a Monitoring Strategy When Prescribing Dopamine Agonists: Lessons from the National Parkinson Foundation Data
Is Midlife Migraine Related to Late Life Parkinson’s Disease?
Deep Brain Stimulation for Parkinson’s Disease: NPF Congratulates Mahlon DeLong and Alim-Louis Benabid and Looks to a Bright Future in Human Neural-Network Modulation
Everything You Need to Know About Medical Marijuana and Parkinson’s Disease
The End for Levodopa Phobia: New Study Shows Sinemet is a Safe Initial Therapy for Treatment of Parkinson's Disease
Is light therapy a potential treatment modality in Parkinson’s disease?
How does the most common genetic cause of Parkinson’s Disease (LRRK2) cause Parkinson’s disease and could it be used to help develop a better therapy?
An Update on DAT Scanning for Parkinson’s Disease Diagnosis
Could Northera (Droxidopa) Be an Alternative Treatment for Low Blood Pressure and Passing Out Symptoms?
The Dream of a Pill Free Existence and the Continuous Dopaminergic Pump for the Treatment of Parkinson's Disease
Should I take Inosine to Raise my Uric Acid Levels and Treat my Parkinson’s Disease?
Could Fungus and Mold be an Important Contributor to Parkinson’s Disease?
Pimavanserin and the Hope for a Better Drug for Hallucinations and Psychosis in Parkinson’s Disease
Halting of the Creatine Study
The Importance of Identifying and Treating Caregiver Strain
Putting Parkinson’s Disease Information into the Palm of Your Hand: Parkinson’s Enters the Smartphon
What Parkinson’s Disease Patients Need to Know about H. Pylori Gastrointestinal Infections
A2A Receptor Antagonists and Parkinson’s Disease Treatment
Another Setback for Trophic Factor Treatment in Parkinson's Disease
IPX066 and What Patients Really Want in New Carbidopa/Levodopa (Sinemet) Formulations
The Weather Forecast for Parkinson’s Disease Calls for Worldwide Economic Storm
Defeating the Barriers to Implementing Exercise Regimens in Parkinson’s Disease Patients
When should you start medication therapy for Parkinson’s disease?
Neurologist Care Reduces Hospitalizations in Parkinson's Disease
A Victory in Court for Parkinson's Disease Patients who Require Ongoing Rehabilitative Therapies
Given the recent FDA announcement about Mirapex (pramipexole), should I be worried about dopamine agonists?
What about the new Parkinson’s Disease Vaccine? What should I know?
Caffeine as a Potential Treatment for Parkinson’s Disease
Time to Consider GPi DBS for Parkinson’s Disease: A Shift in the Practice of Patient Selection for DBS
A New Treatment for Parkinson’s Disease-Related Constipation
Too Many Pills: Improving Delivery Systems for Parkinson’s Disease Drugs
Measuring Quality and Assessing Depression in Parkinson's Disease
Watch out for Unexpected Obstacles if You Use a Cueing Strategy to Break Freezing of Gait in Parkinson’s Disease
Pill Color, Generic Medications and Insurance Issues: Important Medication-Related Tips for the Parkinson’s Disease Patient
Are Blood Tests for Parkinson’s Disease on the Horizon?
Placing Stem Cells in Animal Models of Parkinson’s Disease: Another Important Step
Important News for the Parkinson’s Disease Community: More Evidence that Sinemet and Madopar are Not Toxic and do Not Accelerate Disease Progression
The Case for All Parkinson’s Disease Patients to be Co-managed by a Primary Care-Neurologist Team
Scientists say Research on Brain Proteins Involved in Parkinson’s Disease is “Shaping” Up
Who Actually Takes Care of Most of the Parkinson’s Patients Worldwide: The Need for Education and the Parkinson’s Toolkit
If you are Dizzy or Passing Out, it could be Your Parkinson’s Disease or Parkinson’s Disease Medications
How Will Group Visits for Parkinson’s Disease Fit into the Future of Parkinson’s Disease Care?
Why Patients Should be Wary of Chelation Therapy for Parkinson’s Disease
Opening the Door to Gene Therapy in Parkinson’s Disease: The Need for Refinement of the Technology and Approach
Does it Matter if I Can’t Get Brand Sinemet?
Should I get a DaTscan or PET scan to confirm my diagnosis of Parkinson’s disease?
A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease
Environmental Risks for PD: Manganese, Welding, Mining, and Parkinsonism
Calling for the FDA to Revise the Eight Sinemet a Day Rule
Dry Cleaning Solvents and Potential Environmental Risks for Developing Parkinson’s Disease
Maintaining the Balance: Why Parkinson’s Disease Patients Need to Understand Drug Recalls, Withdrawals, and Safety Alerts
Shining a Light on Parkinson’s Disease: Optogenetics Has a Bright Future in Research
Poor Medication Management of Parkinson's Disease During Hospital Admissions: Patients and Families Can Improve Their Hospital-Based Management
Why Are Patches and Continuous Release Technology a Big Deal to Parkinson's?
Is the PD SURG Trial Another Surge Forward for DBS Therapy?
Cycling in PD in Those Who Can’t Walk: Is it Possible?
New iPS Stem Cells for PD: What Does it Mean?
Time for Comprehensive Care Networks for PD
Is Parkinson's Disease a Prion Disease?
Parkinson's Disease Linked to Gaucher's Disease
Brain Cells Keep Time Stamps: Implications for Parkinson's Disease Therapies
Is it Safe to Have an MRI with a DBS in Place?
Take Care of Your Bones as They Are Affected in Parkinson's Disease (Even in Men)
Is it Time to Start Paying Attention to Pain Symptoms in Parkinson's Disease Patients?
Glutathione Fails to Demonstrate Significant Improvement in PD Symptoms
Keeping an Eye on Trials Important to the Parkinson's Disease Patient
Increased Risk of Melanoma in Parkinson's Disease
Finally a DBS Expert Consensus Statement Aimed at Their True Customers: The Patients
Pesticides and Environmental Exposure in Parkinson's disease: Should We Stay Away From the Stink Truck?
Is Exercise Effective Treatment and Protection Against PD?
Why are Transplant Trials Struggling to Succeed in the Treatment of PD?
Are Monoamine Oxidase Inhibitors Disease Modifying or Neuroprotective in PD?
Update on Gene Therapy for Parkinson's Disease