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). They can significantly impact quality of life, increasing the risk of falls, cognitive decline, and functional impairment. Despite the high prevalence and clinical impact of neurogenic orthostatic hypotension and OH in PD, no comprehensive consensus integrates recent advances in pathophysiology, diagnostic tools, and personalized treatment. This review synthesizes current evidence to bridge this gap, offering a practical framework for clinicians to improve patient outcomes. Neurogenic orthostatic hypotension 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, such as fluid and salt intake optimization, compression garments, and physical counter-maneuvers, with pharmacological 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.