Orthostatic Blood Pressure: What a Seated Reading Misses

An orthostatic blood pressure reading catches the drop on standing that a seated reading misses, and in older adults that drop is common: pooled across 13 studies of 5,465 people aged 65 and over, continuous tracking found it in 29.0 percent, occasional cuff readings in only 5.6 percent.

Families usually hear a parent’s blood pressure from a reading taken sitting down. In an older adult who falls, grows confused or seems agitated, the number that matters is often the one taken after standing up.

An orthostatic blood pressure is a reading taken at rest and then again after a person stands, to see how far the pressure falls. In an older parent, the gap between those two numbers can explain a fall, a foggy afternoon or a medication list that has grown too long, and a single reading in a chair never reveals it. The video above, Does She Hurt? Pain in the Elderly, covers chapter 16 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. Its subject is pain in people who cannot report it. The measurements that sit beside that problem are the subject here, and the study detail is in the book companion for chapter 16.

What does a seated blood pressure reading miss?

When researchers pooled 13 studies covering 5,465 people aged 65 and over, a drop in pressure on standing showed up in 29.0 percent when pressure was tracked continuously through the move. Checked with occasional cuff readings instead, the same kind of drop showed up in only 5.6 percent. In geriatric outpatient clinics the continuous figure reached 35.2 percent. The people did not change. The method did, and the usual method catches roughly one drop in five.

The drop matters beyond dizziness. Pooled across cohorts, it carried a 1.40-fold risk of death from any cause, and across 15 long-term studies it was linked to a higher rate of later dementia, a hazard of 1.267. These are associations, and the death link weakened in the best-adjusted studies, but they explain why a standing reading belongs in the record of anyone who is falling or slipping mentally.

Can blood pressure pills cause falls in older adults?

Among 4,961 adults over 70 with high blood pressure, followed for three years, moderate-intensity treatment was tied to a 1.40 hazard of a serious fall injury, and in people who had already been hurt in a fall, high-intensity treatment was tied to 2.31. The other side is just as real. Across 46 randomized trials, blood pressure treatment did not increase falls, and a Cochrane review found that withdrawing these drugs pushed systolic pressure up by 9.75 points. In a careful trial of 569 patients with a mean age of 84.8, one drug was removed under a physician’s supervision, and most patients kept their pressure controlled at twelve weeks.

The lesson is not to stop a pill. It is that the decision needs a standing number and a prescriber, together.

When a parent cannot say it hurts

The book opens with an eighty-four-year-old on a memory-care floor whose nighttime agitation was answered with a sedating antipsychotic. She was lying on a fresh spinal compression fracture visible on a scan read for something else, and her pressure on standing ran 30 points under her seated pressure while she took two blood pressure drugs. Pain, fracture and pressure all went unmeasured at the same time, and each one fed the next.

The reporting gap is national. Across 8.6 million nursing-home admissions, pain made it into the record for 68.9 percent of residents who could describe it and for 32.9 percent of those with severe cognitive impairment. The chart holds what gets said, and people with advanced dementia say less. When a Norwegian trial gave a structured pain treatment to 352 residents with dementia and agitation, agitation dropped by 17 percent, and most of those treated, 69 percent, did well on acetaminophen alone.

What measurement can show, and what it cannot

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service. It measures; it does not treat, and it does not diagnose disease on its own. Results go to your parent’s physician. No test in its library measures pain, and a memory test does not either. What the library can do is put numbers on the conditions that travel with hidden pain and falls.

• Cardiac autonomic reflex tests look at how heart rate and blood pressure respond to position changes and breathing, the reflexes involved when pressure sags on standing.
• Vestibular and balance testing documents steadiness and the inner-ear balance system. That matters because joint pain in two or more sites raised the rate of falls 1.53-fold in adults 70 and older.
• Bioimpedance body composition measures muscle and fat. Sarcopenia, the loss of muscle with age, travels with chronic pain at an odds ratio of 1.52.
• Cognitive assessment sets a baseline for memory and thinking. It does not detect pain. It gives the family and physician a reference point, which matters because persistent pain was linked to 9.2 percent faster memory decline over a decade.
• Laboratory panels describe the metabolic picture. In Americans older than 65, diabetes reaches 29.2 percent and prediabetes 48.8 percent.

Why is orthostatic blood pressure so rarely checked?

Two biological drivers are at work. Blood pressure regulation on standing weakens in many older adults, and the aging body clears drugs slowly, with liver clearance of most medications down 10 to 40 percent, so pressure-lowering and sedating drugs build up. The third driver is the setting. A reading in a chair takes seconds; a standing one takes a second pair of hands and a few extra minutes that a busy floor does not budget. The old body also complains quietly: pain thresholds rise with age, and in one national cohort 12.6 percent of heart attacks arrived without chest pain. Less complaining is not less disease.

The book is candid that the fixes are imperfect too. Repairing a spinal fracture is contested, and taking drugs away on its own did not reliably prevent falls in community trials. Measurement does not settle those questions. It makes sure they get asked. Dizziness and the risk of falling covers the fall side in more depth.

What should you ask if a parent is falling, confused or agitated?

• Has her blood pressure been taken standing as well as sitting, and how was it measured?
• Has anyone checked for pain by watching her move, instead of asking a question she cannot answer?
• Has any recent scan, even one taken for a cough, been looked at for a spinal fracture?
• Has her muscle or grip strength been measured, and is there a memory baseline to compare against later?
• Is any medication treating a symptom that another medication might be causing?

Keep every medication decision with the prescriber; the standing reading is where that conversation begins. Memory and cognitive screening explains what a baseline is for, and physicians can read delirium in elderly patients and the pain workup.

Frequently asked questions

References

• Tran, J., Hillebrand, S. L., Meskers, C. G. M., Iseli, R. K., & Maier, A. B. (2021). Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis. Age and Ageing, 50(5), 1520-1528. https://doi.org/10.1093/ageing/afab090
• Duval, G. T., Raud, E., Gohier, H., Dramé, M., Tabue-Teguo, M., & Annweiler, C. (2023). Orthostatic hypotension and cognitive impairment: Systematic review and meta-analysis of longitudinal studies. Maturitas, 185, 107866. https://doi.org/10.1016/j.maturitas.2023.107866
• Tinetti, M. E., Han, L., Lee, D. S., McAvay, G. J., Peduzzi, P., Gross, C. P., Zhou, B., & Lin, H. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Internal Medicine, 174(4), 588-595. https://doi.org/10.1001/jamainternmed.2013.14764
• Reddin, C., Murphy, R., Hanrahan, C., Loughlin, E., Ferguson, J., Judge, C., Waters, R., Canavan, M., Kenny, R. A., & O’Donnell, M. (2023). Randomised controlled trials of antihypertensive therapy: does exclusion of orthostatic hypotension alter treatment effect? A systematic review and meta-analysis. Age and Ageing, 52(4), afad044. https://doi.org/10.1093/ageing/afad044
• Gnjidic, D., Langford, A. V., Jordan, V., Sawan, M., Sheppard, J. P., Thompson, W., Todd, A., Hopper, I., Hilmer, S. N., & Reeve, E. (2025). Withdrawal of antihypertensive drugs in older people. The Cochrane Database of Systematic Reviews, 3(3), CD012572. https://doi.org/10.1002/14651858.CD012572.pub3
• Dube, C. E., Morrison, R. A., Mack, D. S., Jesdale, B. M., Nunes, A. P., Liu, S.-H., & Lapane, K. L. (2020). Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes. Journal of Pain Research, 13, 2663-2672. https://doi.org/10.2147/JPR.S270689
• Husebo, B. S., Ballard, C., Sandvik, R., Nilsen, O. B., & Aarsland, D. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 343, d4065. https://doi.org/10.1136/bmj.d4065
• Leveille, S. G., Jones, R. N., Kiely, D. K., Hausdorff, J. M., Shmerling, R. H., Guralnik, J. M., Kiel, D. P., Lipsitz, L. A., & Bean, J. F. (2009). Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA, 302(20), 2214-21. https://doi.org/10.1001/jama.2009.1738
• Whitlock, E. L., Diaz-Ramirez, L. G., Glymour, M. M., Boscardin, W. J., Covinsky, K. E., & Smith, A. K. (2017). Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Internal Medicine, 177(8), 1146-1153. https://doi.org/10.1001/jamainternmed.2017.1622
• Chen, J., Wang, X., & Xu, Z. (2023). Sarcopenia and Chronic Pain in the Elderly: A Systematic Review and Meta-Analysis. J Pain Res, 16, 3569-3581. https://doi.org/10.2147/JPR.S435866

Related reading

• Cortisone Shot Blood Sugar: What a Knee Injection Does to Your Numbers
• What Is MME? The Number on Your Chart and What It Misses
• Cardiac Autonomic Reflex Tests

Cognitive screening: what a baseline is for

A cognitive screening baseline is a first score, taken under fixed conditions, that gives every later score something to be compared against. It does not diagnose anything today; it makes a future measurement mean something.

A single screening score is close to uninterpretable. Two scores, taken the same way two years apart, are one of the more informative things in a chart.

What is the purpose of a baseline cognitive test?

Almost everyone who worries about their memory is worried about a change. But without a prior measurement there is nothing to compare against, and both patients and clinicians are unreliable at recalling how someone was performing two years ago.

A structured instrument, administered the same way each time, converts that from an impression into a comparison. That is the entire purpose — not to diagnose anything today, but to make a future measurement mean something.

What does a cognitive test check?

• Short-term recall.
• Attention and concentration.
• Executive function — planning, sequencing, switching between tasks.
• Language, including naming and fluency.
• Visuospatial construction.
• Orientation in time and place.

About ten minutes, pencil and paper, no time pressure. At Measura it is administered by a certified rater; Dr. Padda holds Montreal Cognitive Assessment rater certification.

Why do test conditions change a cognitive score?

Version, order, prompting, language, whether glasses and hearing aids were worn, whether the room was quiet, time of day — all of these shift a score. Two scores obtained under different conditions are not a comparison, they are two unrelated numbers. Fix the conditions, write them down, and do not change them.

Bring your glasses and hearing aids. A screen taken without them measures vision and hearing rather than cognition, and it will underestimate.

Does a low cognitive test score mean dementia?

It does not establish dementia. Scores are lowered by depression, poor sleep, pain, medication — anticholinergic burden in particular — thyroid disease, vitamin B12 deficiency, hearing loss, anxiety about being tested, and simply having a bad day. Several of those are correctable, and excluding them comes before attributing a low score to anything neurodegenerative.

Why it sits next to balance testing

Attention, processing speed and executive function are part of the control loop that keeps a person upright: they determine whether a postural correction happens in time. Screening balance without screening cognition describes half a risk. That is why the two are paired rather than treated as unrelated topics, and why the cognitive screen is administered before positional balance testing rather than after it. Cognitive assessment and fall prevention.

When should you get a baseline cognitive test?

While things still look fine. A baseline established during a normal year is worth more than a first score obtained after someone has already noticed a change.

Frequently asked questions

How do I prepare for a cognitive test?

Bring your glasses and hearing aids. A screen taken without them measures vision and hearing rather than cognition, and it will underestimate you. The test takes about ten minutes, with pencil and paper and no time pressure. The version, order, room and time of day are written down so every later screen can be given exactly the same way.

What are the components of a cognitive test?

A short screen covers short-term recall, attention and concentration, executive function (planning, sequencing and switching between tasks), language including naming and fluency, visuospatial construction, and orientation in time and place. At Measura it is given by a certified rater; Dr. Padda holds Montreal Cognitive Assessment rater certification.

What are the benefits of cognitive testing?

Most of the benefit arrives later. A single score is close to uninterpretable, but two scores taken the same way two years apart are among the more informative things in a chart, because they turn a worry about change into a real comparison. Paired with balance testing, the screen also shows whether attention and processing speed are adding to fall risk.

How is a cognitive test administered?

At Measura a certified rater gives the screen with pencil and paper and no time pressure, and it takes about ten minutes. The version, the order of tasks and the prompting stay the same every time, so a later score can be compared fairly with the first. When balance is also being checked, the cognitive screen comes before positional balance testing, not after it.

Related reading

• Memory and cognitive screening
• Cognitive assessment
• Dizziness and the risk of falling

Dizziness and the risk of falling

Dizziness raises the risk of falling when one of the systems that keep you upright fails: the inner ear, blood pressure control on standing, sensation from the feet, or the brain’s central processing of all three.

Feeling unsteady is not an inevitable part of getting older. It is a failure of specific, measurable systems — and which one is failing determines what helps.

How common this is

In a national survey of US adults aged 40 and older, 35.4% — about 69 million people — had vestibular dysfunction detectable on a simple standing-balance test. The odds increased significantly with age and were 70% higher among people with diabetes. Among those who also reported dizziness, the odds of falling were twelve times higher.

Falls are the leading cause of injury and injury death among adults aged 65 and over. In 2020, 27.6% of that group — 14 million people — reported falling in the previous year, and in 2021 there were 38,742 deaths from unintentional falls, a rate of 78.0 per 100,000.

What causes dizziness and loss of balance?

Standing upright depends on three inputs. The inner ear reports head position and movement. The eyes report where the world is. Sensation from the feet and joints reports where the body is. Any one can fail, and the others compensate until they cannot.

Why is dizziness on standing often misdiagnosed?

Lightheadedness on standing gets called an inner-ear problem, sent for vestibular rehabilitation, and does not improve — because the cause is a blood pressure drop on standing, which is an autonomic problem with a completely different fix, frequently including a medication review.

This is why the balance battery is run alongside autonomic and orthostatic testing rather than on its own.

Cognition belongs in the same assessment

Attention, processing speed and executive function determine whether a postural correction happens in time. Screening balance without screening cognition describes half a risk, which is why the two are paired. Cognitive assessment and fall prevention.

Why test balance before the first fall?

Because the standard screening question is whether someone has fallen in the past year, which depends on recall and on willingness to admit it, and because measurable vestibular dysfunction is common well before anyone falls. A measurement identifies the risk while it is still preventable rather than after it has been demonstrated.

Frequently asked questions

Can dizziness make you fall?

Yes. In a national survey of US adults aged 40 and older, people who had measurable inner-ear balance problems and also reported dizziness were twelve times more likely to fall. Falls are the leading cause of injury and injury death in adults 65 and over, which is why dizziness is worth measuring before the first fall, not after it.

Why am I suddenly dizzy and losing my balance?

Balance depends on the inner ear, the eyes and sensation from the feet and joints, with the brain pulling all three together. When one fails, the others cover for it until they cannot, so unsteadiness can seem to arrive suddenly. Spinning with head movement points to the inner ear, graying vision on standing points to blood pressure, and unsteadiness in the dark points to the feet.

Why does standing up make me dizzy?

Lightheadedness or graying vision when you stand, without spinning, usually means your blood pressure drops on standing. That is an autonomic problem, not an inner-ear one, and it has a different fix, often starting with a review of your medications and hydration. It is commonly mislabeled as an inner-ear problem and sent for vestibular rehabilitation, which does not help it.

Is dizziness a normal part of getting older?

No. Feeling unsteady is not an inevitable part of aging. It is a failure of specific systems that can be measured: the inner ear, blood pressure control, sensation from the feet, and the brain’s processing of all three. The odds of measurable balance problems do rise with age, and are 70% higher in people with diabetes, which is why it pays to measure before a fall.

References

• Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001–2004. Archives of Internal Medicine. 2009;169(10):938–944. doi:10.1001/archinternmed.2009.66
• Kakara R, Bergen G, Burns E, Stevens M. Nonfatal and Fatal Falls Among Adults Aged ≥65 Years — United States, 2020–2021. MMWR Morbidity and Mortality Weekly Report. 2023;72(35):938–943. doi:10.15585/mmwr.mm7235a1

Related reading

• Dizziness, balance and falls
• Vestibular and balance testing
• Cognitive screening: what a baseline is for