What is the best approach to manage a 70-year-old female with persistent vertigo (dizziness)?

From the Guidelines

The best approach to manage a 70-year-old female with persistent vertigo is to determine the underlying cause through a thorough evaluation, including a detailed history, physical examination, and possibly vestibular testing, and then provide targeted treatment, such as the Epley maneuver for Benign Paroxysmal Positional Vertigo (BPPV), while also addressing fall prevention and medication review. The evaluation should include a Dix-Hallpike test to diagnose posterior semicircular canal BPPV, and a supine roll test to assess for lateral semicircular canal BPPV, as recommended by the clinical practice guideline for BPPV 1. Key considerations in the management of BPPV include:

• Diagnosing BPPV through bedside testing, such as the Dix-Hallpike maneuver, without relying on radiographic imaging or vestibular testing unless necessary 1
• Treating BPPV with a canalith repositioning procedure, such as the Epley maneuver, which has a high success rate and can be performed with minimal equipment 1
• Avoiding routine use of vestibular suppressant medications, such as antihistamines and benzodiazepines, which can interfere with central compensation and prolong recovery 1
• Implementing fall prevention strategies, including home safety assessment and appropriate assistive devices, to reduce the risk of falls and related injuries 1
• Educating patients about the diagnosis, treatment, and potential recurrence of BPPV, as well as the importance of follow-up and self-management strategies 1. By following this approach, clinicians can provide effective management of persistent vertigo in elderly patients, reducing the risk of falls, improving quality of life, and minimizing healthcare costs.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Recommended dosage: 25 mg to 100 mg daily, in divided doses.

The best approach to manage a 70-year-old female with persistent vertigo is to consider meclizine as a treatment option, given its indication for vertigo associated with diseases affecting the vestibular system in adults 2. The recommended dosage is 25 mg to 100 mg daily, in divided doses. However, it is essential to exercise caution due to potential adverse reactions and drug interactions, such as increased CNS depression when coadministered with other CNS depressants, including alcohol 2.

• Key considerations:
  • Patient's medical history, including hypersensitivity to meclizine or any of the inactive ingredients
  • Potential anticholinergic action, which may affect patients with a history of asthma, glaucoma, or enlargement of the prostate gland
  • CYP2D6 inhibitors, which may interact with meclizine 2
• Monitoring and patient counseling are crucial to ensure safe and effective use of meclizine.

From the Research

Evaluation Approach

To evaluate a 70-year-old female with persistent vertigo, the following steps can be taken:

• Conduct a thorough patient history and physical exam to determine the cause of vertigo
• Consider red flags for serious differential diagnoses, such as stroke or multiple sclerosis
• Use assessment techniques, such as the Dix-Hallpike test, to diagnose benign paroxysmal positional vertigo (BPPV)

Treatment Options

Treatment options for BPPV include:

• The Epley maneuver, a canalith repositioning procedure that has been shown to be effective in resolving vertigo symptoms 3, 4, 5, 6
• Vestibular rehabilitation, which may be equally effective as the Epley maneuver at 1-month follow-up 5
• Medication, such as antihistamines or benzodiazepines, to alleviate symptoms

Epley Maneuver Efficacy

The Epley maneuver has been shown to be a safe and effective treatment for posterior canal BPPV, with a high success rate in resolving vertigo symptoms 3, 4, 6

• A systematic review of 11 randomized controlled trials found that the Epley maneuver was associated with a significant increase in complete resolution of vertigo symptoms compared to a sham maneuver or control 3
• A meta-analysis of 4 randomized controlled trials found that the Epley maneuver was associated with a higher complete resolution of vertigo at 1 week compared to control 4

Considerations

When evaluating and treating a 70-year-old female with persistent vertigo, it is essential to consider the following:

• The patient's age and medical history, as certain conditions may increase the risk of falls or other complications
• The potential for underlying serious conditions, such as stroke or multiple sclerosis, that may require immediate medical attention
• The importance of patient education and follow-up to ensure proper treatment and prevention of future episodes 7