Orthostatic hypotension, meaning a fall in blood pressure with standing, is an underrecognized cause of faints and falls in the elderly. Risk of traumatic brain injury and hip fracture is substantial and can increase mortality. Parkinsonism and diuretics used for hypertension or heart failure predispose.
Midlife hypertension is a powerful risk factor for ischemic and hemorrhagic stroke and must be treated aggressively with a target of 120/70 or lower.
White-matter ischemic lesions are common MRI findings in older adults and, especially though not exclusively, in those with vascular risk factors. These lesions are thought to represent “small vessel disease,” and correlate with impaired walking and cognition. When severe, the MRI and clinical findings are termed leukoencephalopathy. When seen in younger patients without vascular risk factors, they are termed leukodystrophy, a term which assumes a genetic cause. Recently, several genes correlating with small vessel disease have been identified.
Which leads us back to how low is too low. A new study identified almost 700 patients, mean age of 67 years, with these MRI lesions, and followed them for 4 years. Intensive blood pressure control reduced the rate of progression of the MRI abnormalities.
What to do with the “leukodystrophy” group without hypertension or other vascular risk factors is still a mystery.
See articles by Nasrallah and by Prabhakaran, both in JAMA, August 13, 2019.
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