JR is an 88-year-old female who reports increasing episodes of dizziness upon standing over the past month. She describes it as a lightheaded sensation that lasts about 10–15 seconds after getting up from bed or a chair. From a medical standpoint, we would likely call this orthostatic hypotension. She denies chest pain, palpitations, or visual disturbances. Last week, she had two falls while getting out of bed, one resulting in a minor elbow bruise. She did not hit her head and did not lose consciousness.
Her past medical history includes hypertension, edema, hyperlipidemia, GERD, delirium, and osteoarthritis. Her current medication list includes the following:
- Hydrochlorothiazide 25 mg daily
- Atorvastatin 40 mg daily
- Quetiapine 100 mg at bedtime
- Metformin 1000 mg twice daily
- Acetaminophen 650 mg as needed for joint pain
- Omeprazole 20 mg BID
In the review of this medication list and reported symptoms, the first thing to look at is blood pressure. More specifically, we could try to check orthostatic blood pressure readings, but from a symptom assessment point of view, this is very likely orthostatic hypotension.
The most easily identifiable issue is the hydrochlorothiazide. Any medication that has the intended purpose of lowering blood pressure will be a likely culprit for causing orthostasis. If we dig a little deeper, I don’t love the dose of quetiapine. Quetiapine is an antipsychotic that has dopamine-blocking activity. Also, recall that quetiapine is well known to have alpha-blocking activity (great board exam question). Medications with alpha blocking (prazosin, doxazosin, etc.) activity are notorious for causing orthostatic hypotension. This effect is dose dependent and can play a role in causing orthostasis in this case scenario.
Delirium is considered to be a short-term condition, and if the patient’s behavioral concerns have subsided, I’d be inclined to begin to reduce the quetiapine for the dual purpose of not having a good long-term indication to continue the medication and its potential to cause orthostatic hypotension. Depending upon the length of use of quetiapine, I would likely recommend trying to reduce the dose from 100 mg daily to at least 75 mg, but maybe even down to 50 mg daily. Cutting down on the hydrochlorothiazide would also be reasonable with follow up monitoring of blood pressure and symptoms of orthostatic hypotension.
As a former psychiatric nurse I would want to know what the quietipine is prescribed for in someone of this age