A 75-year-old man residing in a nursing home comes to the office due to episodic lightheadedness over the last 6 months. He feels like he is "graying out" and then has to lie down and close his eyes. The patient has lost consciousness twice over the past 2 months. Tonic-clonic movements have not been observed and there is no associated incontinence. He has not had chest pain, nausea, palpitations, headache, or speech difficulties. The patient's appetite has been good and he eats 3 meals a day. He describes mild lightheadedness occasionally in the morning, but the more severe episodes usually occur between 2:00 and 3:00 PM and around 8:00 PM.
The patient has a history of hypertension, hyperlipidemia, mild cognitive impairment, and type 2 diabetes mellitus. Current medications include hydrochlorothiazide, metformin, rosuvastatin, lisinopril, and low-dose aspirin. There have been no recent changes in his medications.
Blood pressure is 124/82 mm Hg supine and 116/80 mm Hg upright, pulse is 84/min in both positions, and respirations are 14/min. Cardiac, lung, and abdominal examinations are unremarkable. Neurologic examination reveals a decreased sensation to light touch in both distal lower extremities and absent ankle deep tendon reflexes bilaterally.
Fasting laboratory results are as follows:
Which of the following is most likely to provide symptomatic improvement in this patient?

Question

A 75-year-old man residing in a nursing home comes to the office due to episodic lightheadedness over the last 6 months.  He feels like he is "graying out" and then has to lie down and close his eyes.  The patient has lost consciousness twice over the past 2 months.  Tonic-clonic movements have not been observed and there is no associated incontinence.  He has not had chest pain, nausea, palpitations, headache, or speech difficulties.  The patient's appetite has been good and he eats 3 meals a day.  He describes mild lightheadedness occasionally in the morning, but the more severe episodes usually occur between 2:00 and 3:00 PM and around 8:00 PM.
The patient has a history of hypertension, hyperlipidemia, mild cognitive impairment, and type 2 diabetes mellitus.  Current medications include hydrochlorothiazide, metformin, rosuvastatin, lisinopril, and low-dose aspirin.  There have been no recent changes in his medications.
Blood pressure is 124/82 mm Hg supine and 116/80 mm Hg upright, pulse is 84/min in both positions, and respirations are 14/min.  Cardiac, lung, and abdominal examinations are unremarkable.  Neurologic examination reveals a decreased sensation to light touch in both distal lower extremities and absent ankle deep tendon reflexes bilaterally.
Fasting laboratory results are as follows:
 Which of the following is most likely to provide symptomatic improvement in this patient?

Quizplus · Accepted Answer

This patient most likely has postprandial hypotension (PPH), defined as a >20 mm Hg decrease in systolic blood pressure within 2 hours after eating a meal. PPH is relatively common in elderly individuals (up to 35% in some studies); the mechanism is unclear, but it is distinct from typical orthostatic hypotension. Patients may have postprandial dizziness, syncope, falls, or angina. The condition can be worsened by antihypertensive medications and salt and water depletion (eg, due to diuretics). In addition to adjusting potentially offending medications, nonpharmacologic measures to improve PPH include: Smaller and more frequent mealsLow-carbohydrate mealsIncreased salt and water intakeAvoidance of alcoholCustom-fit compression stockingsAvoidance of activities or sudden standing immediately following meals Smaller and more frequent meals Low-carbohydrate meals Increased salt and water intake Avoidance of alcohol Custom-fit compression stockings Avoidance of activities or sudden standing immediately following meals Octreotide may also be effective as it increases splanchnic vascular resistance and reduces pooling of blood in the gut; however, it is reserved for severely symptomatic patients due to high cost and required subcutaneous administration. (Choice A) Decreased ankle reflexes and sensation to light touch in the feet are common with aging. Balance training exercises are helpful in patients with typical orthostatic hypotension and gait disturbances, but they are not as beneficial in PPH. (Choice B) Statins (eg, rosuvastatin) are associated with myopathy but are not known to contribute to lightheadedness or syncope. (Choice C) Low-carbohydrate meals with smaller portion sizes appear to minimize PPH and improve symptoms. High-carbohydrate meals are likely to exacerbate PPH symptoms. (Choice E) Tighter glucose control can reduce volume loss in patients with severe hyperglycemia (by reducing glucosuria and osmotic diuresis), but this is unlikely to have a significant effect in this patient with only mildly elevated glucose levels. Diabetic autonomic neuropathy (due to long-standing uncontrolled diabetes) can contribute to orthostatic symptoms but would not fully explain this patient's postprandial symptoms. Educational objective: Postprandial hypotension is characterized by orthostatic symptoms within 2 hours after eating and is common in the elderly. Decreased portion sizes, increased salt/water intake, low-carbohydrate meals, and avoidance of alcohol can improve symptoms. Octreotide can be considered for severely symptomatic or refractory cases. __________ References: Postprandial hypotension. (http://www.ncbi.nlm.nih.gov/pubmed/20193838)

A 75-Year-Old Man Residing in a Nursing Home Comes to the Office