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 safety, minimizes fall risk, and improves 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, which he is currently taking, and mood stabilizers that commonly cause orthostatic hypotension 1. Consider medication adjustments such as dose reductions or switching to alternatives with fewer vestibular side effects. Some key considerations in managing his condition include:
- Implementing non-pharmacological strategies including slow position changes, adequate hydration (at least 6-8 glasses of water daily), compression stockings, and physical therapy focusing on vestibular rehabilitation exercises.
- Monitoring blood pressure in both lying and standing positions to detect orthostatic hypotension.
- Ensuring comprehensive medical evaluation to rule out other causes like inner ear disorders, cerebrovascular disease, or metabolic abnormalities.
- Providing simple written instructions for safety measures and involving caregivers in management, given his neurocognitive disorder.
- Addressing cognitive impairment or disorientation by providing appropriate lighting and clear signage, ensuring that a clock and a calendar are easily visible, talking to the person to reorient them, introducing cognitively stimulating activities, and facilitating regular visits from family and friends 1. Given the complexity of his condition and the need for a multifaceted approach, it is crucial to develop a comprehensive, person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for schizophrenia, as recommended by the American Psychiatric Association 1. This approach will help minimize his risk of falls, improve his quality of life, and address the complex interplay between his psychiatric conditions, aging, and potential medication effects.
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 2, 3, 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 4. 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 4. However, there is a case report suggesting a potential link between ondansetron and acute severe depression in a postoperative setting 5, 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 2, 6. 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.