From the Guidelines
Managing dizziness in a 75-year-old male with schizophrenia, neurocognitive disorder, and complex medical history requires a comprehensive approach that prioritizes his morbidity, mortality, and quality of life. To address his dizziness, it is essential to identify and address potential medication-related causes by reviewing his current regimen, particularly antipsychotics like olanzapine, and antidepressants like Effexor, which can cause orthostatic hypotension 1. Consider medication adjustments such as dose reductions or switching to alternatives with fewer vestibular side effects, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. Implement non-pharmacological strategies including:
- Slow position changes (sitting before standing)
- Adequate hydration (6-8 glasses of water daily)
- Compression stockings
- Environmental modifications to prevent falls, such as providing appropriate lighting and clear signage, and ensuring that a clock and a calendar are easily visible to the person at risk 1 A thorough medical evaluation is essential to rule out cardiovascular causes (arrhythmias, carotid stenosis), neurological conditions (Parkinson's, stroke), inner ear disorders (BPPV, Meniere's), and metabolic issues (hypoglycemia, electrolyte imbalances). Physical therapy focusing on vestibular rehabilitation exercises can improve balance. Given his neurocognitive disorder, provide simple written instructions and involve caregivers in management. This multifaceted approach addresses the complex interplay between his psychiatric conditions, age-related changes, and potential medication effects that contribute to dizziness. Additionally, addressing cognitive impairment or disorientation by providing appropriate lighting, clear signage, and facilitating regular visits from family and friends can help prevent delirium and improve his overall quality of life 1. The patient's complaint of dizziness should be managed with the initiation of Zofran 4 mg TID PRN as prescribed, while also considering the potential benefits of adjusting his current medication regimen and implementing non-pharmacological strategies to improve his overall health outcomes.
From the FDA Drug Label
Commonly Observed Adverse Reactions in Short-Term, Placebo-Controlled Trials The most commonly observed adverse reactions associated with the use of oral olanzapine (incidence of 5% or greater) and not observed at an equivalent incidence among placebo-treated patients (olanzapine incidence at least twice that for placebo) were: Dizziness114
Dose Dependency of Adverse Reactions A dose group difference has been observed for fatigue, dizziness, weight gain and prolactin elevation The incidence of dizziness (10 mg/day: 2. 6%; 20 mg/day: 1.6%; 40 mg/day: 6.6%) was observed with significant differences between 20 vs 40 mg.
The patient is complaining of dizziness, and dizziness is a commonly observed adverse reaction associated with the use of oral olanzapine. The incidence of dizziness was observed with significant differences between 20 vs 40 mg of olanzapine. To manage dizziness in this patient, it may be necessary to:
- Monitor the patient's olanzapine dose and adjust as needed to minimize the risk of dizziness.
- Consider alternative treatments or dose reductions if dizziness persists.
- Ensure the patient's safety, especially given their history of falls and confusion. 2
From the Research
Management of Dizziness in a 75-year-old Male with Complex Medical History
The patient's condition is complex, involving schizophrenia, neurocognitive disorder, and a history of falls with resulting rib fractures. The management of dizziness in this context requires careful consideration of the patient's overall health status and current medications.
- Current Medications and Potential Side Effects: The patient is currently on olanzapine and Effexor, which are being managed by the psychiatry team. Olanzapine has been shown to have benefits in managing nausea and vomiting 3, 4, but its impact on dizziness is not directly addressed in these studies.
- Dizziness Management: For the management of dizziness, particularly in the context of vertigo, studies suggest that ondansetron or promethazine could be considered 5. However, the choice between these medications may depend on the specific symptoms (nausea vs. vertigo) and the side effect profile. Promethazine may be more effective for vertigo but has a higher side effect rate.
- Considerations for Ondansetron: Ondansetron is effective for nausea and vomiting but may have a role in managing vertigo as well 5. However, there is a case report suggesting a potential link between ondansetron and acute severe depression in a postoperative setting 6, which warrants caution in patients with a history of psychiatric disorders.
- Role of Olanzapine in Nausea and Vomiting: Olanzapine has been studied in the context of preventing chemotherapy-induced nausea and vomiting, showing promise as an adjunct therapy 3, 7. Its use in this patient for managing psychiatric symptoms may have the added benefit of helping with nausea, but its direct effect on dizziness is not well-documented.
Approach to Managing Dizziness
Given the patient's complex medical and psychiatric history, managing dizziness will require a multifaceted approach:
- Monitor and Adjust Current Medications: Continue to work with the psychiatry team to adjust medications as necessary to minimize side effects that could contribute to dizziness.
- Consider Anti-vertigo Medications: If dizziness is primarily due to vertigo, consider the use of ondansetron or promethazine, weighing the potential benefits against the risk of side effects.
- Non-pharmacological Interventions: Implement fall prevention strategies and consider physical therapy to improve balance and reduce the risk of falls.
- Regular Review: Regularly review the patient's condition and adjust the management plan as necessary to ensure the best possible outcome.