"Mum, slowly sit up." The daughter has just helped her mother from the hospital bed to sit upright, and the mother frowns: "I can't. The whole ceiling is spinning, and everything has gone black..." Her arms go limp and she almost falls back onto the pillow. After two weeks in bed, the first time out of bed often goes just like this, with dizziness and vision going dark as soon as the person sits up. In families of patients who have just left hospital, this scene is played out almost every day.
Dizziness and vision going dark on standing after long bed rest are mostly caused by orthostatic hypotension. Because blood volume is reduced and the sympathetic nervous system responds more slowly, the brain is briefly short of blood supply on standing. Staged sitting up, compression and fluids can manage it safely, but if it happens again and again, or the person really faints, medical attention is needed at once. In fact, getting out of bed is the first hurdle in going from sitting to standing in the five stages of progressive rehabilitation after hospital, and the first thing to deal with in crossing that hurdle is often the blood pressure.
Dizziness on getting up is mostly orthostatic hypotension
The cause has to be clear before it can be handled properly. The most common explanation for vision going dark on sitting up after bed rest is orthostatic hypotension. When the body changes from lying flat to standing, gravity pulls blood towards the legs. If blood pressure regulation does not keep up in time, blood flow to the brain falls briefly, causing vision to go dark and a light-headed feeling. This is not simply because the body is too weak. It has a clear physiological mechanism, a medical definition, and can be managed.
Orthostatic hypotension has a clear medical definition(Naschitz & Rosner 2007): within 3 minutes of standing up or raising the head of the bed, the systolic blood pressure falls by ≥20 mmHg and/or the diastolic blood pressure falls by ≥10 mmHg. This is not a problem only for people with long-term illness. Even healthy people get it if they stay in bed long enough (Kamiya 2003).
Why long bed rest makes dizziness especially likely: lower blood volume and a slower sympathetic response
Bed rest alone is enough to cause orthostatic hypotension, and it is not simply because of "weakness after illness". A study in which 22 healthy volunteers spent 14 days in head-down bed rest found that 10 of them developed orthostatic hypotension when tested on standing after the bed rest, although they were completely healthy before it (Kamiya 2003). The reason is not weak muscles. Two regulating mechanisms in the body fail at the same time.
In other words, "sleeping two more days and getting up when there is strength" not only does not help, but lowers blood volume further and blunts the sympathetic response more, so the longer the person lies the dizzier they get. Instead of waiting passively, it is better to learn a safe way of getting out of bed, so the body can win back its blood pressure step by step.
Four steps for getting out of bed safely
The core of managing orthostatic hypotension is not "getting the person up as fast as possible". It is "giving the body time to win back its blood pressure". The four steps below are the actual process a therapist uses to take a bedbound patient out of bed for the first time. Each step is meant to let the circulation adapt level by level, and not to stand straight up in one go.
Four stages from lying to standing (with someone nearby and a handrail throughout):
- Raise the head of the bed gradually and sit semi-reclined first—First raise the head of the bed to a semi-reclined position, so the circulation slowly adapts to the raised upper body, and move the arms and legs a little. During this time, watch whether the patient is dizzy or pale, and move to the next step only when everything is fine.
- Sit at the edge of the bed with both feet on the floor for a while—Help the patient to the edge of the bed with both feet firmly on the floor and both hands lightly holding the bed surface, and sit quietly for one to a few minutes. Sitting at the edge of the bed is the step most easily forgotten, but it is the most important buffer time for avoiding dizziness and falls.
- March on the spot and tighten the thighs before standing—Before standing, march on the spot and tighten the thigh and buttock muscles hard, to pump blood from the leg veins back to the heart. This helps to raise blood pressure at once (Wieling 2015).
- Stand only when there is no dizziness, and walk only when steady—After standing, pause first and confirm that there is no dizziness and the face colour is normal. Walk only after holding on steadily. Keep watching how the patient feels throughout, and if vision goes dark, sit back down on the bed at once.
Sitting up slowly in stages, together with marching on the spot and tightening the thigh muscles before standing, greatly reduces the risk of falling because of orthostatic hypotension. This approach is closely linked to whether the person can stand steadily after getting up. To practise standing posture and transfers further, see preparatory exercises in bed and at the bedside.
The scientific evidence on compression stockings, drinking water and raising the head of the bed
Besides the movements for getting out of bed safely, a few basic everyday measures can reduce how often episodes happen. Most of these methods have guideline-level evidence behind them, but each has its own conditions of use and recommended amounts, which are worth clarifying one by one.
- Fluids: keep up 2 to 2.5 litres of fluid a day (Palma & Kaufmann 2020)
- Drink about 500 mL of water quickly before getting up, which takes effect in 5 to 10 minutes and lasts about 30 to 45 minutes (Palma & Kaufmann 2020)
- Sleep with the head of the bed raised 30 to 45 degrees (Palma & Kaufmann 2020)
- Waist-high compression stockings of at least 15 to 20 mmHg, or graded compression garments of 30 to 40 mmHg, with an abdominal binder as an alternative (Palma 2020 / Kim & Farrell 2022)
- Eat smaller meals more often, to avoid a fall in blood pressure after a large meal
- People with heart failure or kidney disease must ask the doctor about the amount of fluid, and should not drink a lot alone
- Compression stockings work only when worn up to the waist with enough pressure. Stockings to the ankle only have a limited effect
- Raising the head of the bed is a way of managing sleeping posture and cannot replace staged sitting up when getting up
- If episodes keep happening, the medicines (such as blood pressure tablets and diuretics) should be reviewed and adjusted by the doctor
- The above are first-line non-drug measures and do not suit everyone, so they should be adjusted to the individual case
What to do at the moment of dizziness
If dizziness and vision going dark are already felt in the middle of getting up, a few movements can raise blood pressure on the spot. These "physical counter-pressure manoeuvres" work by mechanically squeezing the leg venous bed, together with a muscle-receptor reflex that raises vascular resistance, so that blood is pushed back to the heart straight away (Wieling 2015; Palma & Kaufmann 2020). They are safe with no side effects, and anyone can use them.
On-the-spot counter-pressure manoeuvres
- Sit or squat down, with the upper body lower than the height of the heart
- Cross the legs and squeeze the buttocks hard
- Tighten the thigh and abdominal muscles hard, and clench the fists at the same time
- If already standing, hold on to something firm nearby and march on the spot
What to do if the dizziness does not go away
- Sit or lie down at once, and raise both legs higher than the heart
- Loosen any tight collar or clothing, and keep the air moving
- Try getting up again only when the person is fully clear and no longer dizzy
- If it happens every time with the same movement or in the same place, note down the situation and tell the doctor at the follow-up
Situations where a doctor must be seen at once
Most orthostatic hypotension can be got through safely with the measures above, but some warning signs show that the problem may not be simply due to long bed rest. The patient then needs a medical assessment at once, and should not be left to cope at home.
- A real faint or loss of consciousness, or a fall when getting up with a knock to the head
- At the same time chest pain, an abnormal heartbeat, breathlessness, or slurred speech or weakness of the arm and leg on one side
- Vision goes dark often, dizziness every time the person gets out of bed, and no improvement at all after trying the measures above
- Dizziness together with fever, dehydration, vomiting or black stools
- If any of the above occurs, never just put up with it. A healthcare professional must assess first, and then decide on the rehabilitation arrangements
Safety note: A faint or a fall can itself cause a fracture or a head injury, and the danger is certainly no less than the original illness. If dizziness keeps coming back, or the patient has really fainted, see a doctor promptly, so that the doctor can check whether the blood pressure tablets and the water pills (diuretics) the patient is taking need adjusting.
When a physiotherapist is needed
When the family is not sure when it is safe to help the patient up and when to slow down, or when a bedbound patient is dizzy every time getting out of bed and the risk of falling is very high, it is suitable to arrange a therapist to visit and assess. When the registered physiotherapists at Nova Health provide home physiotherapy, they use the real furniture in the home (such as the bedside, handrails and a dining chair) to design the first getting-out-of-bed process for a long-term bedbound patient. First the head of the bed is raised so the older adult sits semi-reclined for a few minutes, with attention to any dizziness. Then the patient moves to sitting at the edge of the bed with both feet on the floor for a short rest, and only then is helped to stand, with the face colour and complaints watched closely throughout. The therapist also guides the family to recognise the signal of orthostatic hypotension, "vision going dark as soon as the person gets up", reminds the older adult to drink a little clear water before getting up and to have a handrail ready, and records repeated episodes so that medicines can be referred for the doctor to review. Teaching the carer the on-the-spot counter-pressure manoeuvres and the safe getting-out-of-bed process ensures that the older adult's daily transfers between two visits are protected too. If the patient often loses balance and falls after getting out of bed, it is advisable to read the page on balance and fall-prevention training after illness as well, and then progress rehabilitation training step by step.
Hong Kong home environment and community resources: Homes in Hong Kong are generally small, the bed of an older adult is usually against a wall, and there are few handrails by the bed. The first time out of bed after long bed rest, vision often goes dark as soon as the person sits up, and it is easy to collapse against the bed frame or a corner of the wall. It is also especially dangerous to get up after a hot shower, in stuffy weather, and to go to the toilet in the middle of the night (when the light is dim and the floor is wet). The public can make use of community resources, such as the Elderly Health Service of the Department of Health (elderly.gov.hk; office telephone 2121 8621). There are 18 Elderly Health Centres across Hong Kong, offering health assessments for older adults and information on fall prevention and home safety. There is also the Personal Emergency Link alarm service (一線通 平安鐘) of the Senior Citizen Home Safety Association (長者安居協會) (schsa.org.hk), which lets an older adult call for help at once after a fall or feeling unwell at home.