The MDTea Podcast
The MDTea Podcast
S6 E2 - Postural Hypotension
This is the MDT podcast, a podcast for all healthcare professionals working with older adults. We are a multidisciplinary team. Educating about aging md. Mtt is brought to you by the hearing aid podcast, mp focused on a different topic each week to work with you to enhance your knowledge to help you to cough to older people. WelcoMe To The second episode of the six theories of the mtt podcast. I am dr markison. I'm a consultant geriatrician down in the southeast of the uk in surrey, and I'm dr jay presson and I am a consultant geriatrician. It's in george's. This week we're going to be talking about postural hypotension. It's hypotension, hypertension, low, hypo low, and so we're gonna coming up this week we're gonna cover a little bit about the mechanisms of foster hypertension. Some of the common causes, how to take along a standing blood pressure, dah, dah, dah, when presyncope and instability might be related to low blood pressure, and then thinking about how was a multidisciplinary team, how can we look after someone with low blood pressure, preferably without using drugs. Before we get started, social media, what have you seen? What did you like? So this time I've again got a different one to last time, which is always good. So this one is by ken covinsky who's a geriatrician in the states who uses the twitter handle at jerry unscored doc and it's a paper not specific to care for their paper from the journal of american medical association jama, and it's a study looking at sleep disruptions when people are hospitalized and that the average patient loses 83 Minutes of sleeP per night compared to being at home. And you think about the effect of that that's gonna have on you when you're trying to recover from acute illness and your rates of delirium and all that sort of stuff that go along with the sleep deprivation. Eighty three minutes less sleep. Very, very grumpy. He would get particularly. Yes. And that's why we did an episode on sleep. So important. So go back and have a listen to our episode on sleep. So mine is from thea jones, geriatrician slightly up north. North north, yes. Just parkinson's, parkinson's. And she was at the fringe last year. She has taken over organizing the fringe for us this year. We organize it last year and we didn't want it to get static and stale, so there is doing it this year, which I'm really excited to see what she does. An excellent job. I'm sure. So we just say what the fringes. So the fringe was an idea that uh, you myself and winner our drought and brightened, came up with mostly youtube I have to say about the fringe to the british
Speaker 2:geriatric society and focusing a little bit on more arts and humanities rather than some of the core science topics and nurses practitioners and how do we, how are we influenced by that and how does the humanities help us to understand that and appreciate it and stay saying which is partly why we're doing the gallery. Our final feature at the end. So this has nothing to do with that or there. If you are interested. She has taken over the ets fringe twitter account now so you can follow her there. This was about, it was a nice article by the outside society and reporting on people with dementia, trialing new cutlery and the word for plates and things. That's cutlery, crockery. Yeah. So I'm a company has designed some crockery cutlery, which is less likely to break and that feels more real so it doesn't feel like plastic opaque, cheap kind of picnic feel that you might have, which, which feels a bit transient. So, um, different kinds of cups and plates and things like that, which I thought was really nice and just some of the descriptions of how they, um, what they liked about it and that kind of thing. I thought it was a really nice way to approach looking at something like this. The rest of this episode we're going to talk about postural hypertension. We are. So postural hypertension is defined as a drop in blood pressure from lying to standing of at least 20 over 10 millimeters of mercury within three minutes of stemming. I think it is. Symptomatic drop, yes. So the 20 out of 10 number means a 20 drop in systolic or attend dropping the diastolic. And it actually came from quite a small initial study, which probably wasn't sufficiently powered to recommend that, um, but it seems to be the number that has been replicated and lots of other studies have been done, uh, so it seems to work. So it's kind of been validated by other studies reproducing it. So it stands as a work and figuring that that's the kind of working values that we use. But practically I have a really high index of suspicion for postural hypotension if someone has postural symptoms are clearly related to, yeah, even if you don't catch the blood pressure. And so there are a feW other definitions for things like classic, a postural hypertension, initial postural hypotension and how to look at it in hypertensives and delayed postural hypotension, which is when someone's been standing for a bit longer. So the classic definition of, as we've said, is a 20 over 10 in the first three minutes of standing. But it's most likely to happen at about 30 seconds. Initial, which is a drop 40 over 20. And the first 15 seconds it was quite difficult to catch the beat by the blood pressure, some of that tilt table testing potentially, which probably not going to touch on kind of a separate thing. Maybe I'm quite specialized. There is a separate definition for postural hypotension and people who are hypertensive or have high blood pressures and that's because the variability can be much higher in that group. So they recommend I'm a 30 drop in systolic blood pressure rather than 20. The variability in blood pressure recordings and delayed and there isn't an agreed definition, but it's symptoms occurring after three minutes. So that can sometimes be quite quite a while afterwards. Sort of 20, 30 minutes standing desk for yes. But I found a another definition which I quite liked and it's talking about the goal of, of treating this. The practical goal is to improve the standing blood pressure so as to minimize symptoms and improve the standing time in order to be able to undertake orthostatic activities of daily living. Like walking. So postural hypotension is a common calls of postural instability and it is associated with falls. Fear of falling under reduced confidence and protection and I think we should just reference you back to the episode on dizziness that we did in the first series. Just as sort of kind of sets the scene a little bit about. This is one of the things that can cause dizziness. Yeah. Yeah. I mean it's really important to remember that the words that people use and not necessarily going to help you in in determining what this is and older adults are far more likely to use a variety of different words. They might say dizzy, light, headedness and vertigo is interchangeable terms. Whereas a younger adults are more likely to describe spinning as a, as a pure dizziness, so just being, being aware of that when you're listening to what people are saying as a rule of thumb is to try and get people away from using those. Edwards said marcy and dizzy and things. I'm trying to unpick that just a little bit more as to what exactly what they're talking about and so we just talk briefly about sync p. We didn't cover this in the business episode and we have had some requests to, but we're going to say again, there's very clear guidance on sync and we might do an episode on it in the future, but there's this quite extensive guidelines and in general, older adults should be treated the saMe if iT's cardiac syncope as a younger adulT. So the point of saying this here is to kind of say that syncope is a transient. Global cerebral hypoperfusIon tends to be transient, it's self limiting loss of consciousness anD it has a rapid onset and recovery spontaneous, coMplete and usually prompt, so you might get those symptoms from postural hypotension if your blood pressure isn't good enough to get up into the brain, but also there are lots of other causes of that group of symptoms and generally the brain is very good at maintaining a stable blood flow except to the extremes of blood pressure. So when it's very high or when it's very low. Yeah. This does, however, change as we age and the regulation, a steady blood pressure is less well controlled as we get older, which means the brain becomes more vulnerable to changes in blood pressure. Let's begin older, so things that may not have caused symptom the many younger may well do as you get older and things that caused lots of symptoms on the younger may cause even more profound symptoms as you get older, and as you said, Singapore disorders can be quite varied in their causes, so one of the. An important first step is to make sure that the person is seeing a clinician that can determine whether it's likely to be postural hypotension and rather than a simple faint or something that's more cardiac in origin, so it might be useful to talk through a typical history of someone who has postural hypertension so they would have symptoms when they stand up from lying down or sitting down that they would feel light headed. I feel like they might feel a bit faint when they stand up and should they lie down again or sit down again. Those symptoms should go away. It should not occur as an ordinary thing when sitting up from a lying position or when turning over in bed, uh, although if someone has been lying down for a long period of time, say they've had surgery or something like that, then just that small change against gravity can cause symptoms, but the symptoms will be the same feeling of lightheadedness if they laid down again, it went away. This, as a general rule of thumb though, this should never occur if you are sitting or lying and have been in that position for a reasonable period of time. So it's that change that will quite often bring on the symptoms if you've been still. It shouldn't really happen. Yeah, it's all to do with gravity. Yeah. In that circumstance, you need to look for another cause and the turning over in bed and it's more likely to be a vestibular problem. So what happens when we stand up? So when we stand, our bodies should be able to keep up or pressure the same and it should keep the blood supply to the brain. Therefore the same ad. But that requires three things to happen. It requires you to have a normal plasma volume, so you need to be well hydrated. Younger people, if they're dehydrated, can compensate mUch better. For this though, um, you need to have intact barrow receptors and reflexes and these, a little pressure sensors that sit around the body and they detect changes in pressure until the blood vessels have the need to respond to that to maintain your blood pressure and they are all over the body. And thirdly, you need a vino motor tone. And what that is is the ability of blood vessels to respond to those changes in blood flow. So you need to have enough blood volume inside you. You need to be able to detect the changes and you need to be able to respond to these changes was detected. And there are some laws that go behind that. First of all, the law for blood pressure. What is the rule for depression? What is the law? Do you mean cardiac output is stroKe volume times heart rate. That's part of it.
Speaker 1:So that's the cardiac output. So cardiac output determineS as party of blood pressure was the other bit peripheral resistance. And total peripheral resistance is presos law, which is the rate of fluid traveling through a tube. And the key bit on that is that is r to the power four. So one small change in the radius slipping up. Listeners, once more, change in the greatest, reduces the flow by four. Okay? So you need to know that. And then the cardIac output is stroke volume by heart rate. And so the way that the body can control the blood pressure is by changing the total peripheral resistance or by changing the heart rate. So when we first ended up, you get an episodes of tachycardia for short period of time and there's some people that is exaggerateD and that's, uh, the symptoms of a or the syndrome of postural associate ditech acadia, which is often occurs in younger people that feel gideon dizzy when they stand up.
Speaker 2:So what happens when we stand this, we need a higher blood pressure to overcome gravity and pump the blood to the brain, which is now for the, from the floor. So this drop in blood pressure should be recognized by those baroreceptors which sends signals to the heart, increase their rate and the cardiac output, so there's a stronger beat and to the arteries and the veins to change their tone to increase the blood pressure to reconstruction, and that's all done by the autonomic nervous system, which is part of your nervous system. Now, a really important area of blood supply for all of this is not actually the lower limbs were quite typically tend to think of this in terms of all of the fluid pools in the legs and some does that she, the biggest pool of blood is actually the abdominal blood supplies, the splanchnic and mr. Herrick vessels which has a large blood supply and has lots and lots of baroreceptors surely sensitive in that area. So. So it's a really important area in controlling your blood pressure.
Speaker 1:So thinking about those things. Therefore there are only a certain number of courses. It's got to affect your peripheral resistance. It's got to fit your cardiac output in some way, which is a manifestation of your heart rate and stroke volume. So I can only affect last thing, so acute things that can cause post hypertension protection,
Speaker 2:so keep causes tend to be secondary to dehydration, so if someone's not drunk enough, so I'm someone with decreased access to fluids in this heat wave that we've been having, someone who's overdosing, so they are on too much medication to offload fluids if they've got heart failure, perhaps if they'd been vomiting large volumes or if they have acute bleeding and political loss. Medications are another common course, so medications that alter the normal physiological responses
Speaker 1:can have a side effect of postural hypertension, so you always get one side effect for free with every medication. That's more of what it's meant to do. So if you're on antihypertensives, if it does more than that, it's a problem and that's composed
Speaker 2:postural hypertension and heart rate medication. Again, if they work too well and you go bradycardic, that affects your heart rate and therefore your blood pressure to respond and increase your heart rate as you've described. Let's keep it and then diuretics like frusemide or spironolactone or[inaudible], which may over diaries you and reduce your circulating volume over dehydrate eighth and there's often a concern about stopping antihypertensives. People are often worried about that and when you do that, you do need to take into account the likely or the reason that some bombs on it and often it's for primary or secondary prevention of cardiac or cerebrovascular disease. Using longer term outcomes as your prognosis market, you have sort of five, 10 year outcomes. There's been a couple of studies looking at the withdrawal of antihypertensives in populations of people. The first looked at these populations of people who are quite frail and older. Same, so not Just people our age and the first one was patients in nursing homes and the second one was in people who are over the age of 85 and the light and study and that will Put the references to both of those there, but essentially they support the practice of a rationalization of antihypertensives. Whilst bearing in mind the prognosIs of the person, their risk, cardiovascular risk of what they're saying is going back to that, one of those early definitions of the aim is to keep this person upright actually at that stage, if you need to do that and someone is already quite proud that you're not necessarily going to do harm. I think there is a real concern because antihypertensives had been so successful in reducing morbidity and mortality in adults and that sometimes we can be a little bit scared to stop them then when they're starting to cause problems. And these two studies show, one showed that your blood pressure being too low can affect your cognition and the other show that in the immediate phase, after stopping the hypertensive blood pressure went up bat of three months, it had gone back down to normal values that it had been on the blood pressure tablets. So another thIng that I encounter quite often is I'm sayinG to people, if something's happened to them, maybe they're a little bit too dehydrated or something like that. Um, or they've been quite unwell recently saying, you can stop it now. IT's not a drug that is acting on your day to day. It's a longer term preventative measure. As long as the values don't go up too high, you are usually safe to come off of it for a short period to get you over that acute illness and people really struggle with that mentally sometimes, but I think it's an important thing to reinforce my thing that fits in with the multiple morbidity guidelines that we talked about previously and one of our other episodes about engaging in a conversation with the person you're looking after and working with to actually go, well, what are their priorities? Is their priority to have a low blood pressure and reduce their cardiovascular risk or is their priority to be able to jump out of bed and go to answer the telephone when it rings without fainting halfway there, and that's a conversation you need to have with that person and work out what their priority is. Another cause of postural hypertension, which we often see is autonomic dysfunction, so as we mentioned, it's the autonomic nervous system that carries the signals backwards and forwards. Said, that's not working. Then you will have fluctuating blood pressure and conditions like diabetes and parkinson's disease can cause this quite often. Diabetes causes it by kind of the same way that you get to your peripheral neuropathy and diabetes. You get disruption in the small blood vessels that supply the nerves themselves and therefore you get dysfunction in those nerves and in parkinson's disease it's a slightly different mechanism, but also you get autonomic dysfunction and the medications for parkinson's disease leave a doper can also cause postural hypertension so often you get two things together and then there are the other slightly rarer conditions. So multIsystem atrophy has an autonomic component to that earlier on in much, much earlier on. Yeah, and people fall over a lot as a result of that and then you can also have, and it's rare, but you can also have a pure autonomic failure and I've seen a few people who've who've got pure autonomic failure who just have the autonomic bits if you like. So they just feel very, very faint when they stand up or even sit up. Actually, it can be really quite problematic. Quite tricky to manage and we'll come on to talking about how to manage all these things a little bit later on. It's an important part of this and diagnosis is to be able to take a good posture. Blood pressure. The most important part I think alongside a good history. Yeah, I think. Okay. Yeah. You said the royal college of physicians recognize this and made some guidance with downloads as part of the inpatient falls program that they were developing and because they recognized that this was something that the practice really varied when they looked at it a lot. So they produced some really clear guidance on how to do this. So it's quite worth getting that if it's done a bit variably where you work really simple at lanyard bits and downloadable for free. They will, um, our, you can download them and we'll put a link in the show notes. So we thought we'd just take a minute and just explain what the royal collection. I don't see this. So first of all, the first thing to do is to have a look at if you're in hospital, uh, behind the bed, if you have these things to tell you how this person mobilizes. So the first thing is to be able to see are you going to be able to stand this person up all the way, be able to stand independently and think about this beforehand before you get halfway through the procedure. So if they're going to need something to hold on to position them in such a way that they can have that. If you need a second pair of hands to get those yet for what you start, ideally you want to use a manual sphygmomanometer which is a blood pressure recording thing. um, but something is better than nothing. So an electronic one if you can. And preferably I think the electronic ones that measure the pressures they get up because I find that they record the much quicker that pump up and come down. No idea which way around you. Then this measurement. So you measured the blood pressure while they're lying down with the arm at the height of the heart, then stand them up a measure their blood pressure in the first minute and you then keeps coming up and you repeat that app three minutes. If the blood pressure is still dropping at that point, then you repeat the blood pressure and you keep checking it until it results. So this will be a minimum of three minutes if you need to go on for longer than you should do that. And if their symptoms change at any point, then repeat the blood pressure then. So if you're at two minutes and they're feeling quite light headed, do blood pressure then and it's most likely to be low at that first 30 seconds. So if you stick to one minute and three minutes, you may miss that initial low blood pressure. So be guided by the symptoms that the person has now at work are physiotherapists have been doing this and one of the things that they wanted was a quick refresher about the sounds that you listened to when you're doing blood pressure. So as you inflate the cuff, you occlude the blood vessel so there is no flow so you don't hear anything. And then as you deflate the blood vessel, at some point, suddenly you will get a starting of a flow of blood through the the vessel and that's the first noise that you hear and you hear what that is, the noisy here rather. And you hear that at the systolic blood pressure. So when you first, as you deflate the cuff, when you start hearing the noise, that's the first number you're going to write down. And then she keep coming down. Eventually you're going to get laminar flow through the vessels. So there's no compression on them at all and that she was diastolic blood pressure. And then. So that's when the sounds go away completely. And that's the second number that you write down. So it's when the noisiest start and when the noise is stopped. So next we are going to talk about how we might manage this. And as we said, we're going to focus predominantly on the nonpharmacological treatments because, uh, they're the better things we have probably now. There are lots of hypotheses around, um, of what might help essentially, there haven't really been any big large studies which we can be really reliably guided by. So while this is an area that has an inverted comments, no evidence, it doesn't necessarily mean that there isn't evidence, it means they haven't really been studies done and each of these things might work for individuals. Say it might be worth working out which ones might suit them and trying them and tried to find the right combination. Now I've written this out as a pneumonic because I know that ian loves pneumonics. How kind of my. It's not very exciting when it's abc, d, e, f, but I don't think that matters to me. And doeS it matter? It's just a way running. So I'm going to tell you what they will stand for first and then we're going to talk through each one in turn. So a is for abdominal binders. B is for bolus of water or bed elevation. C is for caffeine and counter maneuvers. D is for drugs, he is for education, for self management and also for exercise. and f is for fluid. And soaked,
Speaker 1:come back to the topic and talk about abdominal binders. So they're like corsets if you'd like to go around the center of the abdomen, often with velcro and they're beneficial in about 50 percent of people. But their usefulness really comes down to the practicalities of somebody being able to put this on and off themselves. Have you ever seen any way use them? I don't think we use anywhere. We use them post operatively quite often. Yeah. And again, it literally is that when, if people can tolerate them and they're able to get them on and off they went relatively well as part of a, a range of measures.
Speaker 2:Hmm. Um, and coming back to practicalities, a similar thing is compression stockings. Now these need to be full length, grade two and above, which is quite high pressure. And then it's come all the way up to the thighs and they've got very difficult to get on because they're tight and they're long. And so they, they quite often are not beneficial for impart because it's just impossible to use them. Some people will persist with them well. So the amount of blooD in the legs is not all that much as we said, compareD to the abdomen and lower limb. Ted stockings are not useful for this at all. So people quite often think that they're equivalent. If you can't do the volunteer, just use lomax. Actually the amount of blooD in the carbs is quite small, so that's probably going to be helpful at all.
Speaker 1:Second is a bolus of water. This is my favorite drinking water. There is conflicting evidence about lists. It needs to be a fluid bolus. Yeah. So it needs to be sufficient to change the osmolality of the portal blood supply and induce an autonomic response in blood pressure. So you need about a pint of water within five minutes. Um, and the benefit will last around 90 minutes. It's useful if you can predict the timing that the symptoms come on. So if it is first thing in the morning, they could drink that glass of water, sat on the edge of that before they stand up or if it's always after lunch or something.
Speaker 2:So I quite often tell people to go to bed with that point if they drink it before they try and get up, so they've got that period because that tends to be the most vulnerable time is first thing in the morning and the other b is for bed elevation. So tilting the head of the bed and the theory is that lower renal profusion pressure leads to decreased diarrhesis, therefore retaining more fluid in your circulating volume, um, which then maintains prefer pillory pressure for when you stand up.
Speaker 1:I have another theory for that. Let me take all. I think it's all due to resting tone in the autonomic system and that if you're in a more to a vertical
Speaker 2:position, your resting tone in the autonomic system is closer to what you're going to need when you'll operate. There's less of a change that's needed training, isn't it? And I think definitely when people had been unwell and in bed for a long time, I think that is something that comes into play. But I haven't seen these studies describing that. But practically that is what we see and the treatment when people do faint when they sit up, is to keep doing it in a way, is to keep, keep stressing that reflex, so correct. So what they recommend is 10 degrees on the flat, so lifting up the head of the bed by the height of about a brick at nighttime and about 30 degrees in the daytime. So it matters with the bed, like in a bad position, not in a seated position, sitting up in bed during the night. We'll have some benefit, but that's not achieving what you wanted to achieve, which is that sort of trendelenburg position. The whole bed angled seeds for caffeine for which there is no appreciable evidence. But again, it doesn't mean doesn't work. No, I'm counter maneuvers. Something that you can kind of teach people to do themselves. And these are physical maneuvers to increase the blood return to the heart by increasing the peripheral resistance we were talking about earlier. So this is things like I'm standing on your toes, which is a bit of a tricky one to ask people to do if they've got and dizziness on standing, but may work for people who have got delayed postural hypotension and clenching and the abdominal and pelvic muscles as well to try and increase that blood supply back up centrally and the thing you could teach people to do is to cross their legs and squeeze and squeezing their buttocks and thighs and calves while they stand up and that can help some people standing up slowly can help people. It was a small study looking at 24 people, which is for this sort of things, actually got quite high number of people that were observed standing slowly at normal speed and quickly and they had a significant reduction in blood pressure drop when they stood up. Slowly. Ideas for drugs, which we're going to talk about after we've discussed everything else. Then he is for education and self management, so explaining to people why their blood pressure may change when they stand up. It's sometimes helpful and teaching people how then they can live with that through their life and the longer term and understand that they're their own blood pressure responses are not normal and how the need to manage that and see it as a, as a longer term condition they're going to live with and lend to manage. And just going back to what we were saying earlier, actually, if we think about the mechanisms as we age, we lose that. A rapid response to be able to drive a fast heart rate. The neurological symptoms coming down are slightly slowed and then the ability of the muscles in the blood vessels to react swiftly is also slightly slow to actually you. Your hit on each of those sections. So a way to kind of go through this with someone is to, to go through, stop, sit, drink, and think, did just stop what you're doing when you get those symptoms coming on and recognize that they're coming on and that that's your trigger. Um, some to sit down to allow the blood pressure recover to drink some water because it's the most modifiable factor in the immediate term that is available to them and to ask them to think about their triggers so they can recognize patterns, they can create their own kind of self management plan for, for when it happens in the future.
Speaker 1:Sure acronyms that are used in a lot of the patient information leaflets and then the second is exercise and a couple of moments of moderate exercise can improve orthostatic tolerance and symptoms and can also help when people are practicing to stand up slowly to avoid some of their symptoms when they're getting up.
Speaker 2:And so then f is for fluid and salt, so making sure the person maintains good fluid intake is really important and as we talked about, the cell fluid challenge can be really helpful as well. That can obviously get quite complicated and we covered that in hydration episode. If you want to learn a little bit more about that, go back and have a listen there. And there's also a theory that increased salt intake will help you to retain water. And therefore, blood pressure, again, there's limited evidence that that actually work.
Speaker 1:Yeah, it's a shame because, well there's limited evidence. Doesn't mean it doesn't. Look. I've had some really good responses and some of my patients by doing exactly that. I think the fluid intake is the key Bit. I think
Speaker 2:I had a consultant before. He used to tell people to eat. I'm ready. Salted crisps. So onto the drugs, other evidence free zone. Really this is a really difficult area because I think we quite often jumped two drugs with postural hypertension because we want to fix it quickly. We're actually, um, as I said that this whole area is quite difficult, um, evidence wise, but particularly the drugs I'd say compared to some other drugs that we use.
Speaker 1:So the aim of the drugs is not really to treat the postural hypertension as it. It's treating the hypotension bit of it all of the drugs. Put the blood pressure up with the hope that if you're higher up you won't notice the fall so much more. There'll be less of a fall. So it doesn't necessarily always work. And sometimes the problem is that you put the blood pressure up really high when people are lying down, so actually you call supine hypertension, so the hypertensive all night and normotensive during the day, but that may still be symptomatic, so it's very much using them on a patient by patient basis and keep an eye on what that 24 hour blood pressure recording is doing if you're using a particular for using high doses of these medications.
Speaker 2:So there are two main medications and one is called fludrocortisone, which many of you will have come across and it aims to promote fluid retention and therefore blood pressure and you put it in a blister pack. Um, there was a recent nice review of the literature and around this drug and it showed that there were only two studies, so eligible to be included with a total of 19 people, six of which were diabetic men and 13 people with parkinson's. So not exactly a typical cohort or representative of an, an agent population. Um, so essentially there isn't enough evidence of benefit, but we do use it and we do try it and people tend to tolerate it quite well. Um, in terms of the drug itself, I always prefacing giving someone this with. There are lots of different doses we can try. It works for some people. It doesn't for others so that people are prepared for whether it might work or not. It will only work if you have a strategy by increasing fluid intake as well. So have to have the fluid there as well on the way you've got nothing to absorb. So that one works on increasing the blood volume. The second drug midodrine works on the peripheral vascular resistance as she was talking to her, she now has a license which is good because it's always something that we used to use on the continent, but often what didn't have a uk license until relatively recently, which was a real pain because when you wanted to describe it, which you know you're allowed to do, but um, it was never in the banner and it took me forever to find the dose. And it meant the gps can prescribe it, carry on, prescribing it either, so now you can. So it's a got a nice evidence summary that says that it can be used when other measures have failed and it works by causing arterial vasoconstriction, so you do have to be a bit careful of using it with people with heart disease or peripheral arterial disease in particular because you're squeezing those blood vessels when they're already a little bit below. So the dropout rate of taking it was 28 percent within a year. It takes about an hour to work. Um, and you should advise not to lie down for six hours after they've taken it because of that problem. As ian was saying, with the supine or lying down, hypertension, the blood pressure shooting up, the recommendation is that you try it for two weeks and see how they could on. And you have to monitor the blood pressure quite closely. Actually says that you should do a yearly, 24 hour blood pressure and stop getting supine hypertension. There are other drugs, but I think there's probably not enough evidence for us to talk about any of them in particular. You've seen the glorious evidence based. We have these two. There was other stuff coming. Octreotide is being used in specialist units, but all of that is getting quite specialist am and it's not stuff that we'll be using on a day to day basis, but fluid, cortisone and midodrine you will see relatively regularly in common use. And our final, um, reference, uh, it was a nice one to finish on, which is a pun not intended, but finished study of 695 people over the age of 75 randomized to have annual comprehensive geriatric assessment or usual care. Ninety six percent of them are living in their own home over the following three years compared to baseline. There was a seven percent reduction in the prevalence of postural hypotension in the patients who underwent the comprehensive geriatric assessment compare to an increase of eight percent in the standard care group. So yet more evidence that conference of church assessment will be of benefit. And I bet a lot of that came through exercise and medication review and we'll put a link to that in the show notes.
Speaker 1:So if there's any comments you've got on anything to do with postural hypertension, please do let us know. You can drop us a line through the website which is www dot[inaudible] dot hearing aid podcast.org.uk, and follow the link to this episode or via twitter@mdt_podcastoronfacebook.com, forward slash mtt podcast, the mdt podcast. So it's now time for that time for the mdts or which is our mdt item, a guessing game. And if you listened to the last episode, you know we're carrying on with the television based radio thing of catchphrase. If you have any ideas of what you would like us to do. Yeah, do let us know. We'll try anything. Yeah. This one is just a little bit bizarre, but it works. It kind of works too. And there is an empty teaser for you on our twitter feed and some will tell you how to access that in just a moment. I believe it might be my turn to go. I think it is. Okay. So joe, so this is like a picture of a waiting room and maybe a before and an appointment to you, something like that and before appointments, what's going to come and see you. And what happens is the nurse comes out and she calls it the name of the patient and they wander off and you know, they'd have their blood pressure measures and stuff like that. And against the wall is a, is a, a chart and on the side of the chart is a sliding thing that goes up and down a bit like measuring the height but not measuring the hype and there's a number of different levels on it. Um, so the first, the first thing on their personality, well, first level, so sensory perception. The next level up says moisture. The next level up says activity. The next level up. So there's mobility. The next level up says nutrition. And then the top level says friction and shear. Thankfully there's two sides to this. And on the other side it says b. And then the next letter is n o and the next letter is a, then the next letter is a d, and then the next letter is an e. And then the final letter is braden score. Yes. Well done. So, so braden scale, which is a risk predicting tool for developing pressure source. Right. Scale. What? We could've done it with some scales as well.
Speaker 2:I feel like he throwing a red herring there with the. It's on the wall. It's a hm. Hm. I'm not sure how I feel about that people. Alright, my turn. Are you ready? I'm ready. Are you concentrating? Yes. Okay. So in this, that is a podium and there is a person receiving a bronze medal. There was another person who is in a black gown. They're wearing a funny hat. It's square shaped. It's little little tassel thing coming off of it and behind the misery big building, which typically has a younger adults in it. And this particular one is not for then it is a bronze award. This award that is typically for younger people. Yeah. Um, so think about the heart. This is square hats down. Where am I?
Speaker 1:Oh, iS it the university of the third age? University of third age. What's the bronze medal? The thIrd place. Oh yeah. Yeah. Good. Cool.
Speaker 2:So inspired by that. If you wish to take part in our mdts or to you, we will pin it to our twitter page, which is at mtt underscore podcast and if you want to guess, use the hashtag mt. Teaser on facebook or on twitter? Yeah.
Speaker 1:We also have maitland missed. Not asked about that. So if you want to sign up to a mailing list, go to the website and you can sign up to the mailchimp mailing list. I will send you the info graphics and any other little bits and tidbits about mdt that's coming up. And also on the website are the show notes and the curriculum mapping. So if you're someone that's working towards a postgraduate curriculum, the chances are these episodes will be mapped to those. And also on the website is a cpd log where you can write your reflections with sort of assessment of your knowledge and they just really help us guide the content of these episodes. Make sure we're hitting the mark for you and we will send you a that reflection automatically back for your own cpd. Look, yeah. Time for the gallery will have you put this week. So this week I have bought, um, well it's very serendipitous really because I was coming up to do this and I knew that I needed something for the gallery and prepared. No, no, no. I have, I have a poet but I'm going to use that on another time because this was very serendipitous. So I was in the car and I was parking the car and there was a documentary to starting already for cold. We're part of a group of documentary is called enlightenment after dark and this one was called bodies and it, the host is Alan Little and he's going on a series of discussions in the spirit of scottish enlightenment. And in particular he was talking to an artist and the artist that he was talking to you is called chem curry. And he's an artist that I was born northumberland and worse in glasgow. And he paints pictures that are kind of, have a themes related to aging. And older people and some of his collections are in really quite noticeable in institutions, um, particular he was commissioned by the scottish portrait gallery to paint a portrait of three oncologists together and who were doctors from ninewells in dundee. and so he painted these three different oncologists, so through the years and, and it's, it's really, really good. Um, but he, his paintings often have a feeling of sort of mortality and stuff running through them and the descriptions in the, uh, the radio program about them, we were just really, really good as him describing his process of creating these pictures and how they, how they develop them, what he's trying to achieve with the. But the pictureS that you can see. And it was just really, really good, really captivating. hearing him talk about his artistic development. So in the gallery, what we'll do is we'll put a link, some pictures, and then go and have a look, compare, compare and contrast some of the pictures that he's done together. It's really good. And we'll put a link to that episode if you want to listen to it. And that's it for this episode. The mdt, we'll reconvene in two weeks time.
Speaker 3:Dr. Wilkinson has previously received funding from astellas and you see the pharmaceuticals for delivering educational activities. The mdt podcast is a hearing aid, podcasts, big things, media production, additional music by Kevin mCcloud. This podcast has been made possible from a technology enhanced learning grant from health education england, spreading education throughout kent, surrey, and sussex. For more information, visit the hearing aid podcasts.org.uk.