Who receives a diagnosis of orthostatic hypotension and is it underdiagnosed in patients with frailty?
Abstract
Orthostatic Hypotension (OH), defined as a systolic blood pressure (SBP) drop >=20mmHg or diastolic blood pressure (DBP) drop >=10mmHg within three minutes of standing, is associated with falls, cardiovascular risk and cognitive impairment. NICE recommend performing lying and standing blood pressure measurements during falls assessments NG249, 2025. Despite this, OH may being underdiagnosed, a primary care survey showed a symptom driven approach to OH diagnosis that may exclude those with advanced frailty and cognitive impairment McDonagh, 2025.
Method
Our cohort was 9,052,916 patients aged 60 years and over and registered with a CPRD practice between 01/01/2010 to 31/12/2024. An OH diagnosis was identified based on corresponding read/ICD9/ICD10 codes from primary care consultations or hospital admissions or primary care blood pressure measurements showing SBP drop >=20 mmHg or DBP drop >=10mmHg on standing. Sex, age and electronic frailty index (EFI) and co-morbidities (Hypertension, Parkinson’s Disease, Diabetes, Heart failure and Dementia) and social circumstances (housebound, requiring care) were identified through read/ICD9/10 codes.
Results
517,950 patients (males = 246,548(%), mean age=76, primary care=285,779(55%)) with OH were identified. EFI classifications at diagnosis were fit=178,196(34%), mild=201,971(39%), moderate=104,674(20%), severe=32,974(6%). Comorbidities at the time of diagnosis(D) and after diagnosis(AD) were Dementia D=26,936(9%), AD =65961(13%), Parkinson’s D=24,177(5%) AD=7820(2%), Type 2 diabetes D=115,809(22%) AD=21,147(4%), Hypertension D= 321,478(62%) AD=29,521(6%), Heart Failure D= 53,468(10%), AD=39,350(8%). Social circumstances at diagnosis were requiring care D=38,550(7%) and housebound D=98,006(19%).
Conclusion
OH is associated with frailty, with a prevalence of 31% in older adults in long term care McDonagh, 2021. Our findings suggest that OH may be underdiagnosed particularly among patients with increasing frailty, 6% had severe frailty, 9% dementia and 7% were requiring care. Next steps are to assess pharmacological profile and falls events. Understanding the demographics of patients with OH will guide strategies to improve detection and falls prevention.
Comments
OH: primary care vs secondary care diagnosis
It's really interesting to see the difference in how orthostatic hypotension is diagnosed across primary and secondary care, particularly the much higher proportion of secondary-care diagnoses occurring around a fall. I wonder if OH diagnoses are being missed earlier in primary care, rather than this reflecting an increased prevalence of OH in secondary care?
Query about frailty staging
Really interesting work- and of value to improve screening for OH in all settings. Really interested in future subanalysis to see what medications populations were taking
My query is Was frailty graded/staged just using eFI or was this clinically validated using staging tools such as Clinical Frailty Scoring
Frailty staging
The frailty status was graded using electronic frailty index, unfortunately we don't have access to a clinical frailty score that is often completed on hospital admission. We did also look at a subset of codes for requiring care and housebound in addition to the eFI and saw a similar pattern with this patient groups.
Very interesting study. I…
Very interesting study. I look forward to the results of your sub group analysis particularly around pharmacological associations. Perhaps another sub-group analysis of comorbid conditions such as HTN, PD,T2DM in order to further identify groups at risk.