CORRESPON DENCE
Postural hypotension and diuretic blood pressure. Nitroglycerine can therapy in the elderly cause hypotension and is best given To the editor: The study by Myers and colleagues (Can Med Assoc I 119: 581, 1978) provided useful information on the differential diagnosis of postural hypotension in elderly persons taking diuretics. However, the study did not negate the importance of postural hypotension as a clinical problem in elderly patients. As the authors said, diuretic therapy may not necessarily result in postural hypotension in the elderly, but it may provoke symptoms of this problem in patients with predisposing medical conditions (e.g., diabetic or alcoholic peripheral neuropathy, large varicose veins or debilitation) that alone can cause postural hypotension. Elderly men, particularly those with prostatic disease, take a long time to empty their bladder and may fall while voiding because of postural hypotension (diuretics may enhance the hypotension). Elderly patients take many drugs which, if taken in combination with diuretics, may increase the risk of postural hypotension developing. Treatment with benzodiazepines, such as diazepam and chlordiazepoxide, is known to cause postural changes in Contributions to the Correspondence
section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
with the patient seated. Agents used in the treatment of parkinsonism can cause postural hypotension. To prevent postural changes, especially in patients also taking a diuretic, simplify the medication schedule, keep the number of different drugs to a minimum and keep all doses as low as possible. If the patient needs a drug that tends to cause postural hypotension, be sure the patient understands that he or she must always get up slowly from lying or sitting. The elderly patient who has been in bed for several days is at high risk for postural hypotension once ambulation is permitted because of the pooling of blood in the legs. To avert some of the risk, especially if the patient is taking diuretics, have him or her start walking as soon as possible after an illness requiring bed rest, and perhaps have the patient spend short periods sitting in a chair until the body compensates. Long trips by plane or car carry a similar risk. As Myers and colleagues said, treatment with diuretics in itself rarely causes postural hypotension; however, if diuretics are given to elderly patients with the above-mentioned conditions, the frequency of this disorder should be borne in mind by the clinician. REIN TIDEIKSAAR, RPA-C
Jewish Institute for Geriatric Care New Hyde Park, New York
Dialysis and transplantation To the editor: The results of treatment of patients with end-stage renal disease by hemodialysis alone, pentoneal dialysis alone or an integrated program of dialysis and transplantation were recently analysed by Higgins and colleagues in the Journal (117: 880, 1977). Survival was better in the group treated by the combined approach. We question the advisability of considering these groups as similar except for the mode of therapy, since they represent different populations in terms of age and complicating disease. Most transplant recipients are treated by hemodialysis for several months before transplantation. Therefore the group treated by combined therapy includes only patients who have survived several months after the onset of end-stage renal disease. Higgins and colleagues point out that no patient was excluded from their analysis even if death occurred within a few days after initiation of treatment. Almost all the early deaths, presumably of the most severely ill, must have occurred while the patients were undergoing dialysis since only 2 of the 83 patients receiving a transplant had not undergone dialysis. At the University of Michigan Medical Center we analysed the survival of 152 patients undergoing hemodialysis and of 135 recipients of cadaver allografts who had endstage renal disease between 1973
CMA JOURNAL/JANUARY 6, 1979/VOL. 120 13
Postural hypotension and diuretic blood pressure. Nitroglycerine can therapy in the elderly cause hypotension and is best given To the editor: The study by Myers and colleagues (Can Med Assoc I 119: 581, 1978) provided useful information on the differential diagnosis of postural hypotension in elderly persons taking diuretics. However, the study did not negate the importance of postural hypotension as a clinical problem in elderly patients. As the authors said, diuretic therapy may not necessarily result in postural hypotension in the elderly, but it may provoke symptoms of this problem in patients with predisposing medical conditions (e.g., diabetic or alcoholic peripheral neuropathy, large varicose veins or debilitation) that alone can cause postural hypotension. Elderly men, particularly those with prostatic disease, take a long time to empty their bladder and may fall while voiding because of postural hypotension (diuretics may enhance the hypotension). Elderly patients take many drugs which, if taken in combination with diuretics, may increase the risk of postural hypotension developing. Treatment with benzodiazepines, such as diazepam and chlordiazepoxide, is known to cause postural changes in Contributions to the Correspondence
section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
with the patient seated. Agents used in the treatment of parkinsonism can cause postural hypotension. To prevent postural changes, especially in patients also taking a diuretic, simplify the medication schedule, keep the number of different drugs to a minimum and keep all doses as low as possible. If the patient needs a drug that tends to cause postural hypotension, be sure the patient understands that he or she must always get up slowly from lying or sitting. The elderly patient who has been in bed for several days is at high risk for postural hypotension once ambulation is permitted because of the pooling of blood in the legs. To avert some of the risk, especially if the patient is taking diuretics, have him or her start walking as soon as possible after an illness requiring bed rest, and perhaps have the patient spend short periods sitting in a chair until the body compensates. Long trips by plane or car carry a similar risk. As Myers and colleagues said, treatment with diuretics in itself rarely causes postural hypotension; however, if diuretics are given to elderly patients with the above-mentioned conditions, the frequency of this disorder should be borne in mind by the clinician. REIN TIDEIKSAAR, RPA-C
Jewish Institute for Geriatric Care New Hyde Park, New York
Dialysis and transplantation To the editor: The results of treatment of patients with end-stage renal disease by hemodialysis alone, pentoneal dialysis alone or an integrated program of dialysis and transplantation were recently analysed by Higgins and colleagues in the Journal (117: 880, 1977). Survival was better in the group treated by the combined approach. We question the advisability of considering these groups as similar except for the mode of therapy, since they represent different populations in terms of age and complicating disease. Most transplant recipients are treated by hemodialysis for several months before transplantation. Therefore the group treated by combined therapy includes only patients who have survived several months after the onset of end-stage renal disease. Higgins and colleagues point out that no patient was excluded from their analysis even if death occurred within a few days after initiation of treatment. Almost all the early deaths, presumably of the most severely ill, must have occurred while the patients were undergoing dialysis since only 2 of the 83 patients receiving a transplant had not undergone dialysis. At the University of Michigan Medical Center we analysed the survival of 152 patients undergoing hemodialysis and of 135 recipients of cadaver allografts who had endstage renal disease between 1973
CMA JOURNAL/JANUARY 6, 1979/VOL. 120 13
