Who receives a diagnosis of orthostatic hypotension and is it underdiagnosed in patients with frailty?

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.