Autonomic dysfunction in neurological disorders: a narrative review

Purpose: Autonomic dysfunction is a common but frequently underrecognized feature of many neurological disorders. It may present as orthostatic hypotension (OH), supine hypertension, bladder and gastrointestinal dysfunction, sudomotor abnormalities, or sexual dysfunction, and it contributes substantially to morbidity and reduced quality of life. This review provides a clinically oriented overview of autonomic dysfunction across major neurological disorders, outlines a practical diagnostic framework, and summarizes current management principles for general physicians and neurologists.Current concepts: The spectrum of neurological diseases associated with autonomic involvement is broad, ranging from peripheral neuropathies—such as diabetic autonomic neuropathy, Guillain-Barré syndrome, and hereditary transthyretin amyloidosis—to central neurodegenerative disorders, including Parkinson disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure. Motor neuron disease and autoimmune autonomic ganglionopathy represent additional important categories. Clinical evaluation of autonomic dysfunction relies on careful history taking, bedside orthostatic blood pressure measurement, and standardized autonomic function tests, including the Valsalva maneuver, deep breathing, tilt-table testing, and sudomotor assessment. Distinguishing neurogenic from non-neurogenic causes of OH is critical because it determines both prognosis and management. Management requires a multifaceted approach that includes treatment of the underlying disease, nonpharmacologic interventions, and targeted pharmacotherapy for specific autonomic manifestations. The coexistence of OH and supine hypertension in patients with autonomic failure presents a particularly challenging therapeutic dilemma.Discussion and conclusion: Autonomic dysfunction spans diverse neurological diseases, impairing quality of life and survival. Systematic evaluation enables early detection, while multifaceted management—combining nonpharmacologic measures and pharmacotherapy—improves outcomes. Greater awareness will enhance diagnostic accuracy and care for affected patients.