MSGM Case Presentation June 2025

Title: The Geriatric Challenge of Orthostatic Hypotension: A Syndrome with Many Faces

Prepared by : Dr Khaw Mae Jane

Supervised by : Dr Elizabeth Chong Gar Mit

Case 1: Elderly with Parkinson’s Disease presenting with lethargy

Mr SYK is a 72-year-old gentleman with background history of Idiopathic Parkinson’s Disease (H&Y stage 3), hypertension, dyslipidemia and right renal stone with recurrent urinary tract infection. Premorbid clinical frailty scale (CFS) is 5, he is independent with his basic activities of daily living (bADL) but requires assistance with certain instrumental ADLs (iADL) such as cooking and household chores due to physical limitations.

He first presented to polyclinic with lethargy, loss of appetite and constipation past one week. Previous urine culture sent by polyclinic when patient complained of 1-month history of urinary frequency and nocturia revealed E. Coli ESBL producer. Otherwise, he denied fever, dysuria or abdominal pain. On initial assessment, he was hypotensive with blood pressure (BP) of 80/40mmHg, bradycardic with heart rate (HR) of 53 beats per minute but afebrile. His BP improved to 100/50mmHg after fluid resuscitation with 1 pint of normal saline. He was subsequently referred to HKL.

Medications Review:

T. Madopar HBS 125mg BD

T. Madopar 250mg/187.5mg/250mg/187.5mg QID

T. CoAprovel (Irbesartan 300mg/HCTZ 12.5mg) I/I OD

Clinical Progress:

GCS E4V5M6 and clinically dry. Repeated BP was 140/62mmHg with PR 61. Apart from clinical findings of mask-like facies, bilateral upper limb rigidity and bradykinesia, other clinical examinations were unremarkable.

Since 2 years ago, he had recurrent falls at home (1-2 episodes per year) due to imbalance during his ‘off’ period. So far, no injurious falls.

Case 2: Elderly presenting with recurrent fall complicated with subdural hemorrhage and T12 vertebral compression fracture

Mr. CCB is a 77-year-old gentleman with background history of hypertension, dyslipidemia, atrial fibrillation, pulmonary hypertension of unknown etiology (incidental finding during ECHO 19/1/2024: EF 60%, mildly dilated LA, severely dilated RA with RVSP 30-40mmHg and severe TR; refused further workup) and autonomic dysfunction (diagnosed since 2022 with positive autonomic function tests affecting sympathetic function). He is a nursing home resident since 2 years ago, with premorbid CFS of 6. Recurrent episodes of fall at nursing home especially when ambulating to toilet due to dizziness. Since March 2025, he is wheelchair bound due to worsening weakness after recurrent fall.

One week prior to admission, he had recurrent unwitnessed falls (4 episodes in total) in the bathroom. He complained of pain over swelling at occipital region,  body weakness, dizziness and loss of appetite.

Medications Review:
T. Dabigatran 150mg BD	T. Fludrocortisone 0.1mg OD
T. Bisoprolol 1.25mg OD	T. Calcitriol 0.25mcg OD
T. Perindopril 2mg OD	T. Mecobalamin 500mcg
T. Simvastatin 20mg ON

Clinical Progress:

GCS E4V5M6 and clinically dry. He was normotensive with BP 139/90mmHg, PR 86, and oxygen saturation of 99% under room air. Neurological examinations were unremarkable. He had a 2cmx2cm occipital hematoma.

His bilateral SDH was conservatively managed under Neurosurgical team. Initially, he was in hypoactive delirium which subsequently resolved. During physiotherapy, he frequently complained of dizziness on changing position from lying to sitting at edge of bed.

Case 3: Elderly with major depressive disorder on multiple psychotropics presenting with urinary retention and electrolyte imbalance

Mr. LKH is a 71-year-old gentleman with background history of hypertension, major depressive disorder with anxious distress and chronic insomnia. Premorbid CFS is 5, he is independent with his bADL but requires assistance with certain iADL such as cooking and household chores due to tremors.

Prior to admission, patient was found after 5 hours on the toilet floor with bowel incontinence. Patient complained of giddiness when attempted to pass motion in toilet, subsequently sat on the floor. No injuries sustained.

Medications Review:

T. Agomelatine 25mg ON

T. Desvenlafaxine ER 100mg ON

T. Olanzapine 10mg ON

T. Clonazepam 2mg OD

T. Atenolol 50mg OD

Clinical Progress:

GCS E4V5M6, mask-like facies with stuttering speech and frequent blinking. Bilateral upper limb symmetrical resting tremors exacerbated by movements, with no rigidity or bradykinesia. Reflexes and power assessment normal. Abdominal examination revealed distended urinary bladder, urinary catheter inserted drained 3L of urine.

Case 4: Elderly with poorly controlled Diabetes Mellitus and multisystem complications presenting with giddiness

Mr. AR is a 74-year-old gentleman with background history of poorly controlled diabetes mellitus with target organ damage (diabetic nephropathy, peripheral neuropathy) and hypertension. Premorbid CFS is 5, he is independent with his bADL but requires assistance with iADL due to physical limitations.

He complained of giddiness and appeared slow in response. Admitted from nephrology clinic in view of symptomatic hypotension - BP ranging 82-87/47-57mmHg. Dextrostix was 5. Otherwise, he denied fever and other systemic symptoms.

Medications Review:

T. Metformin 500mg BD

S/C Mixtard 22U BD

T. Amlodipine 5mg OD

T. Simvastatin 10mg ON

T. Coversyl (Perindopril 10mg/Indapamide 2.5) I/I OD

Clinical Progress:

GCS E4V5M6 with normal hydration status. Repeated BP 126/83mmHg with PR 96. Clinically cushingoid with numbness in ‘stocking-glove’ distribution. Other clinical examinations were unremarkable.

All 4 clinical cases share a common issue of orthostatic hypotension (OH) in elderly, but can you spot how each case tells a different story?

1. Can you identify the possible etiologies of OH in each case?

Try listing the relevant clues for each case under:-

• Clinical history

• Clinical examination

• Investigations

2. When comparing across all 4 cases, what differences stand out to you and how does it affect your management strategy?

• Which cases are best suited for non-pharmacological interventions alone?

• When would pharmacological treatment be justified?

3. Take a closer look at the medication lists - are any drugs potentially exacerbating OH in each case?

• What adjustments would you make to balance symptom control with overall safety, especially in fall-prone or frail patients?

References

Wahba A, Shibao CA, Muldowney JAS, et al. Management of Orthostatic Hypotension in the Hospitalized Patient: A Narrative Review. Am J Med. 2022;135(1):24-31. doi:10.1016/ j.amjmed.2021.07.030