Orthostatic Hypotension Treatment on Rehab Unit
Condition: Orthostatic Hypotension; Falls
MeSH terms: Hypotension, Orthostatic; Hypotension
Study type: Interventional

Summary: 
      For patients recovering from acute illness, the ability to stand, walk, climb stairs, and
      participate in therapy are critical to their recovery and eventual discharge to the least
      restrictive environment. Orthostatic hypotension is a common finding in medically ill adult
      and elderly patients and is a potentially reversible contributor to functional impairment.
      This 4-year project will be a randomized controlled trial of a
      multidisciplinary-multicomponent intervention to determine whether routine identification and
      treatment of OH improves functional outcomes such as: balance, fall rates, therapy
      participation, length of stay, transfer to acute care hospital, and discharge location.
      Routine screening and management of OH may improve outcomes for rehabilitation and long term
      care patients, as well other high-risk patient populations.
    

Detailed description: 
      Objectives Orthostatic hypotension (OH) is a condition that contributes to falls, dizziness,
      syncope, transient ischemic attack, and impaired functional status. OH is defined
      specifically as a 20mmHg drop in systolic, and/or a 10mmHg drop in diastolic BP within 3 min
      of standing. The objectives of this study are to: (1) Examine the effect of OH treatment on
      functional outcomes, and OH prevalence during a subject's inpatient stay, and (2) Evaluate
      whether OH treatment during a subject's inpatient stay affects fall prevalence, and
      functional outcomes by 12 months after discharge.

      Plan This 4-year project will be a randomized controlled trial of a
      multidisciplinary-multicomponent intervention to improve OH in patients admitted to Nursing
      Home (NH) and rehabilitation settings. During the 37-month enrollment period, the
      investigators expect to consent 350 subjects who will be randomized into intervention and
      control groups (175 subjects each). During their stay, subjects in the intervention group
      will receive a standardized treatment for their OH, or to prevent OH, while those in the
      control group will receive usual care. The investigators expect that 85% will remain in the
      study until they are discharged from the NH/rehabilitation unit. Following discharge, the
      investigators will conduct weekly phone calls to monitor incidence of falls for one month.
      Subsequently, at 12-months post-discharge, the investigators will conduct a chart review, and
      the study will terminate. The investigators expect 85% of the subjects discharged from the
      NH/rehabilitation unit that were enrolled in the study will remain in the study at 12-months
      post discharge. The investigators performed a "pilot" study on up to 10 subjects while
      waiting for adequate staffing to conduct the study with blinded data collectors.

      Methods The investigators will evaluate OH blood pressure responses, symptoms during
      standing, and whether there are any specific adverse outcomes related to treatment. In
      addition, the investigators will evaluate whether treatment of OH improves: motor functional
      independence measure (mFIM) scores, therapy participation, length of stay, transfer to the
      acute care hospital, discharge location, and mortality.

      Clinical Relevance OH is a very common finding in many medically ill adult and elderly
      patients, and is associated with falls, syncope, and hip fractures. More aggressive screening
      (possibly the 6th vital sign) and management of this condition may improve outcomes for
      rehabilitation and long term care patients at the investigators' site as well other high-risk
      patient populations.
    

Intervention name(s): Medication review; Nutrition/Salt intake; Education; Exercise; Drug Recommendations
Intervention type(s): Other; Other; Other; Other; Other
Intervention description(s): Current scheduled and as needed medications will be reviewed. Those medications with potentially hypotensive actions will be identified. There will be a joint review by Provider, Pharmacist, and Research staff of those medications and the patient's current clinical status. Plan to continue, decrease, discontinue, or substitute will be made. Examples include substitution of tamsulosin for prazosin in treating benign prostatic hypertrophy, reduction of furosemide dose for patient with stable congestive heart failure, change of sleeping medication from trazodone to lorazepam or zolpidem; change of antidepressant therapy or neuroleptic therapy to one with less hypotensive effects.(Mader 1989); (Poon and Braun 2005);(Mader 2006); (2008).; Current diet orders and meal consumption will be reviewed for sodium and fluid intake. Liberalization of calories, fluid, addition of salt packets to tray, or addition of salty foods/beverages (V8) will be considered as appropriate. Subjects receiving tube feedings will have water flushes replaced with saline flushes. Subjects with a history of congestive heart failure will be liberalized slowly and monitored closely by both the research and treatment team.; The research intervention staff will review symptoms of OH with patient/family and explain pathophysiology using a standardized pt information handout (NINDS 2007), subjects will be encouraged to spend maximal time out of bed, and to ambulate on ward as much as possible.; The patient's PT and/or Provider will review patient function for the ability to perform appropriate exercises and train patients (Ten Harkel, van Lieshout et al. 1994); (Bouvette, McPhee et al. 1996). Research staff will reinforce using these exercises while standing.; The protocol permits the study physician to recommend medications for orthostatic hypotension. The patient's clinical team can implement, ignore, or modify these recommendations and only the clinical team can write orders for them. Fludrocortisone may be given 0.05mg at bedtime up to 0.2mg twice a day (Ten Harkel, Van Lieshout et al. 1992). Subjects with a history of congestive heart failure or peripheral edema will be carefully monitored. Sodium chloride tablets may be given starting at 1gm daily and increased to 2 gms twice daily [Mukai 2002; Grubb 2003]. Subjects with a history of congestive heart failure or peripheral edema will be carefully reviewed and monitored closely by the research staff and the treatment team. Midodrine may be given 2.5-5mg daily to three times daily [Low, 1997]. The dose will be started at 2.5mg every morning and then increased to 5mg every morning, then 5mg every morning and afternoon, then 5mg three times a day.
Other intervention name(s): Chart review; Review orders; Change nutrition/Salt intake orders; Physical therapy; Consultant recommendation
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: hypotension, orthostatic; falls; rehabilitation; blood pressure; aging