How to manage dizziness in a 75-year-old male with schizophrenia, neurocognitive disorder, and complex medical history?

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, reduces fall risk, and addresses potential underlying causes. Given his current regimen of olanzapine and Effexor, it is essential to review these medications for potential contributions to dizziness, as antipsychotics and antidepressants can have vestibular side effects 1. Consideration should be given to dose reductions or switching to alternatives with fewer side effects, such as quetiapine or aripiprazole at lower geriatric doses, while closely monitoring his psychiatric symptoms and adjusting the treatment plan as necessary 1. Evaluation for orthostatic hypotension is also crucial, with recommendations for gradual position changes, increased fluid intake, compression stockings, and possibly fludrocortisone if severe 1. Ruling out other medical causes through appropriate testing, including complete blood count, metabolic panel, cardiac evaluation, and vestibular assessment, is vital to ensure no underlying condition is contributing to his dizziness. Implementing fall prevention strategies, including home safety modifications, assistive devices, and physical therapy focusing on balance exercises, is critical to reduce his risk of falls and related injuries 1. Ensuring proper hydration and adequate salt intake, unless contraindicated, is also important, as dehydration can exacerbate dizziness. For symptomatic relief, meclizine could be considered short-term, but with caution due to his significant cognitive impairment, as it may worsen confusion. Involving caregivers in management plans and providing clear, simple instructions is essential, given his neurocognitive disorder. This multifaceted approach addresses both the immediate symptoms and underlying causes while considering his psychiatric conditions and age-related vulnerabilities. Given the complexity of his condition and the need for a tailored approach, involving a multidisciplinary team, including psychiatry, neurology, and geriatrics, is recommended to ensure comprehensive care 1. Additionally, addressing cognitive impairment or disorientation by providing appropriate lighting, clear signage, and facilitating regular visits from family and friends can help in reorienting him and reducing confusion 1. Overall, the management of dizziness in this patient requires a careful balance of addressing potential underlying causes, managing his psychiatric symptoms, and ensuring his safety to improve his quality of life and reduce morbidity and mortality.

From the FDA Drug Label

Dizziness114 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. Dose group differences were also noted for weight gain and prolactin elevation [see Warnings and Precautions (5.5. 15)].

The patient is complaining of dizziness. Given the patient's complex medical history, including schizophrenia and neurocognitive disorder, and the fact that dizziness is a known adverse reaction associated with olanzapine (2), it is possible that the patient's dizziness is related to their medication.

• The patient has been prescribed Zofran 4 mg TID PRN for dizziness, but the primary approach to managing dizziness in this patient should be to review and adjust their current medications, particularly olanzapine, as it may be contributing to their dizziness.
• It is also important to monitor the patient's condition closely and adjust their treatment plan as needed to minimize the risk of adverse reactions and ensure their safety.

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.