Some of us get that short bout of head rush and dizziness when we suddenly spring up from our bed or seat due to a sudden dip in our blood pressure. Thankfully, our body automatically resets itself and our blood pressure level gets normalised within a second or two. However, this could emerge as a cause of concern for senior citizens with diabetes.
Loss of balance triggered due to blood pressure variations is a matter of concern among the elderly since they are at a greater risk of injury due to other age-related complications, mainly bone frailty. This downward fluctuation in our blood pressure — when it dips during sudden postural changes — is called postural hypotension and could also be triggered by some external factors such as fatigue and dehydration in addition to physiological factors such as ageing.
Understanding postural hypotension
“Orthostatic or postural hypotension is a common occurrence in people with diabetes. About one-fifth of people with diabetes who are more than 65 years old suffer from postural hypotension,” says Dr Ritesh Gupta, director, diabetes and metabolic diseases, Fortis CDOC Hospital, New Delhi.
Endocrinology experts explained to Happiest Health why orthostatic hypotension is common in diabetics and urged them not to ignore signs and postural hypotension symptoms.
According to Dr Nihal Thomas, professor in endocrinology and head of Unit-1 at the department of endocrinology at the Christian Medical College, Vellore, Tamil Nadu, while postural hypotension is mostly common in people with diabetes who are unable to control their glucose levels, at the same time it may also vary from person to person as to how they may or may not develop such complications. “Sometimes a person may have poorly controlled sugar levels but somehow may not experience postural hypotension while another person in the same place might experience postural hypotension when he gets up or stands,” says Dr Thomas.
According to a research article published in Practical Diabetes, postural hypotension is common in the ageing general population and remains an underdiagnosed clinical problem. In diabetes, the prevalence of postural hypotension is even higher and there are many aetiological (condition causing) factors that need to be addressed. Postural dizziness, light-headedness and fainting may be presenting features and a simple postural challenge with assessment of lying and standing blood pressure confirms this clinical diagnosis.
Postural hypotension and diabetes
Experts reckon diabetics with persistently uncontrolled blood sugars for a long time are susceptible to microvascular conditions including diabetic neuropathy (nerve damage in the body).
“Among diabetics it is the ones who have long-standing diabetes and uncontrolled sugar levels who can experience microvascular changes eventually leading to postural hypotension as a result of diabetic neuropathy or nerve damage,” says Dr Thomas.
He says there are four types of diabetic neuropathies:
- peripheral neuropathy (which affects the feet and legs first and then the hands and arms)
- autonomic neuropathy (related to the autonomic nervous system that takes care of blood pressure, sweating, bladder, digestive system and sex organs)
- proximal neuropathy (affects nerves in the thighs, hips, legs and also the torso)
- mononeuropathy (when damage is caused to a specific nerve in the face, chest, arm, stomach or leg)
The condition of nerve damage in the autonomic nervous system in diabetics is known as autonomic neuropathy, which eventually leads to orthostatic or postural hypotension.
“ANS or autonomic neuropathy is basically the nervous system, which is not in our control because the nerves that control these bodily functions are damaged,” says Prof (Dr) L Sreenivasamurthy, senior consultant physician and diabetologist at Bengaluru-based Life Care Hospital and Research Centre.
Dr Gupta says these are the internal involuntary nerves which control the heart rate and tone of the blood vessels. These nerves normally function automatically. For instance, the nerves in our digestive system, bladder system, cardiovascular system and sexual organs function on their own — unlike the skeletal muscles we can control consciously.
So, diabetics experience postural hypotension when these involuntary nerves get damaged and stop functioning properly.
Understanding postural hypotension
Dr Gupta says that in all individuals there is a tendency for the blood pressure to fall when they stand, but the internal nerves make sure that this fall recovers quickly. However, when you are affected by autonomic neuropathy, the blood pressure is unable to recover and continues to be low on standing position.
However, uncontrolled diabetes is not the sole cause for hypotension. “There are other reasons like old age, heart and kidney diseases, certain neurological conditions, which can also cause postural hypotension. Also, certain medicines used to treat high blood pressure, psychiatric medications and certain newer diabetes medications can also predispose the person to develop postural hypotension,” says Dr Gupta.
Dr Thomas says it is sometimes the diuretics that can cause dehydration resulting in postural hypotension if the fluid intake is inadequate.
Another reason could be inadequate salt consumption because sometimes to control high blood pressure a person can go too low on salt consumption, resulting in low blood pressure.
Extra caution for those with diabetes
The first symptom you should watch out for is dizziness or reeling sensation when you attempt to stand from a lying down or standing position. Dr Gupta says a person may experience light-headedness, blurred vision, headache or palpitations.
The symptoms can be quite severe when it starts affecting your daily life. “The person may find it difficult to follow the daily routine. The most serious problem which can occur is a fall which may cause fracture or head injury,” says Dr Gupta. “Why you need to be extra alert is because the person may have a blackout and may have a severe fall.” These symptoms should prompt a proper medical examination.
Prof (Dr) Sreenivasamurthy says postural hypotension can be diagnosed when the BP is checked from lying down to sitting and standing position within three to five minutes and there is a fall of 20/10mm hg as compared to the reading you had in lying or sitting position.
This means your systolic blood pressure (i.e., the highest pressure in the arteries) drops by 20mm while the diastolic pressure (i.e., the least pressure in the arteries) drops by 10mm hg when compared with the blood pressures at sitting and lying down positions.
Diabetics are prone to high blood pressure, but they can also experience sudden postural hypotension when the flow of blood to the brain is interrupted. This blood flow is interrupted because of the nerve damage resulting from prolonged and uncontrolled sugar levels. If unattended, this condition can lead to numerous health-related complications.
Lifestyle modifications for greener postures
Dr Gupta feels it is important to have awareness and education about postural hypotension to minimise its impact on people undergoing it.
“People experiencing postural hypotension need to be informed and educated that they should avoid getting up suddenly from the bed. Instead, they should slowly sit first, gradually stand up and then start walking. Also, men (with uncontrolled diabetes and specially the elderly) should be advised to avoid urinating in the standing position as that can result in fall,” Dr Gupta. Specially, elderly men with uncontrolled diabetes should be extra cautious while using the washroom.
Once someone has complicated diabetes it is advisable to meet a cardiologist once a year. “Considering the complications related to diabetes and hypotension it is good to keep a tab on your heart’s health as well,” says Dr Thomas.
However, the good news is that if the blood sugars levels come under control, there are fewer chances of living with postural hypotension. “It is important to note that if blood sugars are controlled soon after the diagnosis of diabetes and remain in control for a decade after diagnosis, chances of autonomic neuropathy are greatly minimised,” says Dr Gupta.
