The Intersection of Autonomic Dysfunction and Parkinson’s Disease: Insights into Neurogenic and Classical Orthostatic Hypotension

Neurogenic Orthostatic hypotension (nOH) and classical orthostatic hypotension (OH) are prevalent non-motor manifestations of Parkinson’s disease (PD), affecting 5.7–64.9% of patients. They can significantly impact quality of life, increasing the risk of falls, cognitive decline, and functional impairment. The current manuscript aims to review the epidemiology, pathophysiology, diagnostic strategies, and management of nOH and OH in PD. External factors cause classical OH, whereas nOH is caused by impaired autonomic control. nOH in PD results from complex interactions between central and peripheral autonomic dysfunction, alpha-synuclein accumulation, baroreflex failure, and medication effects. Its prevalence increases with disease progression and age. Clinical evaluation remains the cornerstone of diagnosis, supported by specialized testing such as the active standing test, ambulatory blood pressure monitoring, and autonomic function assessments. Management requires a tailored approach, combining non-pharmacologic strategies—like fluid and salt intake optimization, compression garments, and physical counter-maneuvers—with pharmacologic treatments, including midodrine, droxidopa, and fludrocortisone. Emerging therapies and ongoing clinical trials offer promising avenues for future interventions. Early recognition and individualized management of OH are critical in PD care.