How to manage a 70-year-old female's persistent vertigo, worsening at night, on antipsychotics?

Management of Persistent "Off Balance" Sensation in a 70-Year-Old Female on Antipsychotics

Discontinue the antipsychotic medication immediately if clinically feasible, as antipsychotics are a well-established cause of balance disturbances in older adults and should be avoided in this population due to increased mortality risk and anticholinergic burden. 1

Immediate Medication Review

• Antipsychotics are potentially inappropriate medications in older adults and carry strong recommendations against use due to increased mortality, falls, and anticholinergic effects that directly cause balance disturbances 1
• The anticholinergic burden from antipsychotics (particularly clozapine, olanzapine, and quetiapine) significantly contributes to cognitive symptoms and balance problems 1
• If the antipsychotic cannot be discontinued, reduce to the lowest effective dose while remaining within therapeutic range, as dose reduction may improve balance without compromising psychiatric control 1

Diagnostic Approach to the Balance Disturbance

• Perform the Dix-Hallpike maneuver to assess for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo in elderly patients 1, 2
• If Dix-Hallpike is negative, perform the supine roll test to evaluate for lateral semicircular canal BPPV 1, 2
• Differentiate true vertigo (spinning sensation) from other forms of dizziness such as disequilibrium, presyncope, or medication-induced imbalance 1, 2
• The 9-month duration and nighttime worsening suggest this is NOT acute vestibular neuritis, which typically improves over weeks 3, 4

Treatment Algorithm Based on Findings

If BPPV is Confirmed:

• Perform canalith repositioning procedures (Epley or Semont maneuver) as first-line treatment, which achieves 78.6%-93.3% improvement versus only 30.8% with medication 2, 5
• Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV, as they increase fall risk in elderly patients and delay central compensation 1, 2, 5
• Reassess within 1 month to document resolution or persistence 2, 5

If BPPV is Ruled Out:

• Refer for vestibular rehabilitation therapy as the primary intervention for persistent balance disturbances that have failed to resolve, as this promotes central compensation and long-term recovery 5
• Vestibular rehabilitation significantly improves overall gait stability compared to medication alone 5
• Consider betahistine 16-48 mg three times daily ONLY if the patient fits the specific subgroup (over 50 years, hypertensive, symptom onset less than 1 month), though evidence is mixed 5

Critical Medication Warnings

• Avoid benzodiazepines entirely, as they are a significant independent risk factor for falls in older adults and should be discontinued 1, 5
• Do not use vestibular suppressants (meclizine, antihistamines) for chronic balance problems, as they interfere with central compensation, cause drowsiness and cognitive deficits, and significantly increase fall risk 2, 5, 6
• Meclizine is FDA-approved for vertigo but carries warnings about drowsiness and anticholinergic effects, making it particularly problematic in elderly patients already on antipsychotics 6
• Polypharmacy dramatically increases fall risk, and adding vestibular suppressants to an antipsychotic regimen compounds this danger 2, 5

Fall Prevention Counseling

• Provide immediate fall prevention counseling, as 53% of elderly patients with chronic vestibular disorders have fallen at least once in the past year 5
• Address home safety assessment, activity restrictions, and need for supervision given her age and medication profile 5
• The nighttime worsening suggests increased risk during low-light conditions when visual compensation is reduced 3

Common Pitfalls to Avoid

• Do not order routine brain imaging or vestibular testing unless the diagnosis is uncertain or there are additional neurological symptoms unrelated to the balance complaint 1, 2
• Do not prescribe vestibular suppressants as long-term therapy regardless of the underlying cause 5
• Do not continue antipsychotics without reassessing the indication, as the Beers Criteria strongly recommend avoiding these medications in older adults due to mortality risk 1
• Recognize that the 9-month duration makes this a chronic rather than acute problem, requiring rehabilitation-focused rather than medication-focused treatment 5