Clinical Manifestations Of Oh

OH is manifested as a constellation of symptoms that develop on standing and dissipates on lying back down. Lightheadedness is common, but other symptoms are also very common. These include a sense of weakness, especially of the legs, and difficulty thinking clearly. Pain in the neck and trapezii (coat hanger headache) occurs in about 20% of patients. It was evaluated in a prospective study, 90 patients with symptomatic OH, 60 patients with symptoms but without laboratory confirmation of OH, and 5 patients with asymptomatic OH. Although lightheadedness is common about 50% of patients more than the age of 60 have problems of cognitive impairment on standing that clears on sitting or lying down (25). Cognitive problems are typically more obvious to the companion than the patient, although not infrequently the patient will use terms like "I feel goofy," at least in Minnesota. Some patients complain of a retrocollic heaviness or headache on continued standing (26). The patient may feel faint only under certain conditions. Many patients complain of weakness, especially in the legs on standing. Some patients develop ataxia when their BP falls. Aggravating symptoms need to be sought. Apart from continued standing other orthostatic stressors include exercise, environmental warming, or food ingestion. Standing time is most commonly less than 1 minute before the onset of symptoms. Indeed, an increase in standing time by 1-2 minutes results in a dramatic increase in activities of daily living. Although it is well known that patients are often worse on first awakening in the morning, the most common time of day when orthostatic intolerance is worse is not particular. It should be emphasized that, although the patients were highly symptomatic about 75% having frequent symptoms, the majority of patients do not have syncope, suggesting that these patients either have sufficient warning to avert syncope or have sufficient compensatory mechanisms to avoid syncope.

It is important to obtain an estimate of the severity and its effect on the patient's activities encountered in daily living. An orthostatic intolerance grade has been generated that grades patients by the severity of symptoms, standing time, and interference with ability to perform activities of daily living (Table 1) (27). This scale was validated against comprehensive autonomic function tests in 145 patients, 97 (67%) of whom had OH. The 5-item scale demonstrated strong internal consistency (coefficient a = .91). Patients with OH had significantly higher scores on each questionnaire item and the composite autonomic severity score (CASS) subscores than those without OH. The scale items correlated significantly with each of the CASS subscores, maximally with the CASS adrenergic subscore. Based on this evaluation, the following conclusions were made. OH is not the only cause of reduced orthostatic tolerance, and some patients may have OH, but be asymptomatic. Results of this study indicate that this 5-item questionnaire is a reliable and valid measure of the severity of symptoms of OH and that it can supplement laboratory-based measures

Table 1

Symptom Scale for Evaluation of Autonomic Symptoms

1. Frequency of orthostatic symptoms

0. I never or rarely experience orthostatic symptoms when I stand up

1. I sometimes experience orthostatic symptoms when I stand up

2. I often experience orthostatic symptoms when I stand up

3. I usually experience orthostatic symptoms when I stand up

4. I always experience orthostatic symptoms when I stand up

2. Severity of orthostatic symptoms

0. I do not experience orthostatic symptoms when I stand up

1. I experience mild orthostatic symptoms when I stand up

2. I experience moderate orthostatic symptoms when I stand up and sometimes have to sit down for relief

3. I experience severe orthostatic symptoms when I stand up and frequently have to sit back down for relief

4. I experience severe orthostatic symptoms when I stand up and regularly faint if I do not sit back down

3. Conditions under which orthostatic symptoms occur

0. I never or rarely experience orthostatic symptoms under any circumstances

1. I sometimes experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)

2. I often experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)

3. I usually experience orthostatic symptoms under certain conditions, such as prolonged standing, a meal, exertion (e.g., walking), or when exposed to heat (e.g., hot day, hot bath, hot shower)

4. I always experience orthostatic symptoms when I stand up; the specific conditions do not matter

4. Activities of daily living

0. My orthostatic symptoms do not interfere with activities of daily living (e.g., work, chores, dressing, bathing)

1. My orthostatic symptoms mildly interfere with activities of daily living (e.g., work, chores, dressing, bathing)

2. My orthostatic symptoms moderately interfere with activities of daily living (e.g., work, chores, dressing, bathing)

3. My orthostatic symptoms severely interfere with activities of daily living (e.g., work, chores, dressing, bathing)

4. My orthostatic symptoms severely interfere with activities of daily living (e.g., work, chores, dressing, bathing). I am bed or wheelchair bound because of my symptoms.

5. Standing time

0. On most occasions, I can stand as long as necessary without experiencing orthostatic symptoms

1. On most occasions, I can stand more than 15 minutes before experiencing orthostatic symptoms

2. On most occasions, I can stand 5-14 minutes before experiencing orthostatic symptoms

3. On most occasions, I can stand 1-4 minutes before experiencing orthostatic symptoms

4. On most occasions, I can stand less than 1 minute before experiencing orthostatic symptoms

Table 2

Studies for the Patient With Suspected OH

1. Autonomic reflex screen

• Quantitative sudomotor axon reflex test

• Tests of cardiovagal function

• Beat-to-beat BP responses to the Valsalva maneuver

• BP and heart rate response to HUT

2. Thermoregulatory sweat test

3. Plasma catecholamines—supine/standing

4. 24-hour urinary sodium excretion to provide a rapid, more complete clinical assessment. This questionnaire would also be useful as a brief screening device for orthostatic intolerance to aid physicians in identifying patients who may have OH.

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