Disclosures: Naveen Singh Khokhar, DO: Nothing to disclose

Case Description: The patient has a history of hypertension, carotid stenosis status post endarterectomy, subdural hematoma (SDH) after a fall several years ago, and a recent left sided SDH that was being monitored by Neurosurgery in the outpatient setting. During an unrelated hospital stay, the patient had developed agitation. Imaging demonstrated an enlarging previously known SDH with mass effect requiring emergent burr hole. Hospital course was complicated by labile blood pressures ranging from hypertensive urgency to near syncopal episodes. Multiple regimens were unsuccessful and definitive treatment included as needed (prn) clonidine and midodrine to control blood pressures.

Setting: Inpatient Rehabilitation Center

Patient: 80-year-old male with supine hypertension and orthostatic hypotension

Assessment/Results: During rehab course, patient had significant supine hypertension and orthostatic hypotension. This limited therapies as his baseline blood pressures were elevated, and he intermittently had near syncopal episodes with positional changes. To overcome this, moderately elevated blood pressures were permitted and prn antihypertensives were given only when systolic blood pressure was greater than 180 mmHg. Fluid status was optimized to improve orthostasis and midodrine’s use was decreased. Abdominal binder and compression stockings were used. Therapies utilized temperature contrasting baths, tilt table, and aquatic therapy to train appropriate autonomic and vasogenic responses.

Discussion: Supine hypertension with orthostatic hypotension is a condition affecting the aging population. Chronic hypertension and autonomic failure may result in poor vascular response to positional changes. This patient was on multiple antihypertensives due to his uncontrolled hypertension previously but developed syncopal episodes leading to falls and SDH. Carotid atherosclerosis also plays a role in syncopal episodes during orthostasis due to poor neuro-perfusion.

Conclusion: It may be necessary to adjust goal blood pressure ranges in an aging population with supine hypertension and orthostatic hypotension. Therapeutic modalities to train the autonomic system and vascular responses may benefit improving patient symptoms and reducing falls secondary to syncope.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rehab-dilemma-in-an-aging-population-an-extreme-incident-of-supine-hypertension-with-orthostatic-hypotension-a-case-report/