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orthostatic hypotension and parkinsons

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My husband has Parkinsons, Orthostatic Hypotension and RLS. What to eat? His BP goes very low after meals. Often times it is 2-3 hrs before his BP is high enough to stand or move about. He is on 25/100 mg sinemet, 2 tabs, 3x a day for parkinsons; 5 mg midodrine for OH, 2 tabs, 3x a day; 600 mg Horizant for RLS once a day at 5 p.m. He will start the Parkinsons BIG therapy program next week. I'm having a problem trying to fix meals that will accomodate all the challenges he has in his health. Please help with suggested foods for breakfast, lunch, dinner, snacks.

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Dear Ladygolfer,

It must be a struggle indeed for you to try to manage your husband's multiple concerns. You do not state your husband’s age or when diagnosed with PD; however, it appears that PD, or Sinemet, or both together, are causing postprandial orthostatic hypotension.


I imagine his physician has already discussed the need to maximize blood volume, but let me emphasize its importance. When blood volume is too low it increases the likelihood of hypotension, thus it will be important for him to drink plenty of fluids; and, unless he has high blood pressure, increase salt intake to help retain fluids and blood volume.


Further, after a meal, the process of digestion causes a great deal of the body’s energy and blood to be diverted away from the periphery, and toward the gastrointestinal tract. This is why the condition occurs after eating. Both PD and levodopa can worsen this. It may help to provide smaller meals, with light, nourishing snacks in between. The process of digestion will be shorter and may help shorten the period of hypotension after meals.


Has his physician considered switching to another OH medication, for example pyridostigmine, to see if it gives better results? For more on pyridostigmine, see:




Finally, has he tried TED stockings? Although designed to prevent blood clots in the legs, they can also improve OH in some individuals.


Regarding restless leg syndrome, Horizant has as possible side effects somnolence/sedation and dizziness, as well as vertigo; so it is possible it could be contributing to the OH effects. Has his physician checked for iron deficiency? It is a fairly frequent cause/contributor to RLS, and a test for ferritin may be warranted. If iron deficiency is present, he might be able to discontinue the Horizant, and you could note whether that improved the OH symptoms.


Regarding meals and snacks, I do not know his preferences/aversions, or his calorie and protein needs, but as a general guide consider for example:


7:00 AM Sinemet plus 8 oz water


Add salt to the following under direction of his physician.


7:30 AM - Breakfast


8 oz water

1 egg

1 slice bacon

1 slice whole-grain toast, butter, jam

orange juice

coffee or tea as desired


10:00 AM - Snack

8 oz water

1 or 2 oz mixed raw almonds, pecans, walnuts

1 cup fresh or frozen fruit (berries, apple, pear, etc.)


11:30 AM Sinemet plus 8 oz water


12:00 noon - Midday meal


8 oz water

½ roast beef sandwich

½ cup green beans or other vegetable

1 small tomato, sliced


cookie or cake


3:00 PM - Snack


8 oz water

remaining ½ roast beef sandwich

½ cup carrot or celery sticks


5:30 PM Sinemet plus 8 oz water


6:00 PM - Evening meal


8 oz water

3 oz salmon

small potato

small tossed salad with tomato slice


8:00 PM - Snack


8 oz water

Yogurt or 1 ounce cheese

2 whole grain crackers


Whether this design will alleviate his OH, I don’t know; but I would certainly try small, frequent meals and snacks for about a month and note if there are any changes. And I would also make it a point to talk with his physicians about the OH medication, and determine whether iron deficiency for RLS has been ruled out.


Let me know if you have further questions, or if this did not address your concerns sufficiently.

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My husband is 80 yrs old.  He was first diagnosed with RLS abt 2005 and started taking requip.  Over time the requip decreased in helping.  He has 2 doctors - both neurologists - one that takes care of the PD & RLS and the other the OH.  His PD neurologist has tried several meds for the RLS and  he has been on the Horizant abt a month now which seems to be working.  He was offically diagnosed (neurologist, speciality in movement disorders)  in Oct 2009.  His family doctor would say to him "I think you have parkinsons"  over and over before sending him to the neurologist, at my insistence.   A yr and 1/2 later he developed the OH.    His OH neurologist is a specialist in autonomics.   My husband has had the tilt test, as well as others.

His fluid intake is about 100 - 120  oz of water/fluids a day.   I have increased his salt intake.   He is presently in the BIG parkinsons therapy program and he goes to a gym when not in therapy.  Mostly, he eats small meals and a snack later.   It still takes 45 min to an hr for his BP to get over 100 systolic.  That is our gage for his getting to do something.   He has developed a "quick step" where he starts and can't stop until he runs into something.  His therapist says this is parkinson's festinating gait.

As to iron deficiency - his last blood work-up in August did not show a deficiency.

Thank you so much for your suggestions as to the food.   He'll eat anything I fix for him.  :-)

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You are doing a fantastic job of looking after your husband's needs. It isn't easy to provide that much fluid daily, increase salt, and offer frequent meals and snacks, along with assisting with his therapy and gym. You are both very proactive, which helps enormously.


I'm delighted to hear that the OH is now reduced from 2-3 hours to 45-60 minutes following meals, that should help somewhat. If this occurs after each snack as well as meals, you may feel it would be better to return to three bigger meals daily and see if the OH still remains at 45-60 minutes. If so, then 3 meals a day would increase his active time.


You were right to insist he see a neurologist in movement disorders; both RLS and OH can be due to Parkinson's and may have been early signs. I mentioned checking ferritin levels because these are not always part of the tests for iron sufficiency. Some folks with PD have a type of deficiency that is masked with the usual tests, but which can be uncovered by ferritin levels.


Iron can be problematic in PD -- abnormal deposits have been seen in the brain upon autopsy. At the same time, RLS can be due to iron deficiency, so I like to know that this has been ruled by including a test for ferritin.


Please continue to let us know how your husband is doing -- with the BIG therapy, as well as with medications and PD. You are both in my thoughts and prayers.

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