How to manage dizziness in an elderly patient with stable vitals on multiple medications including Metoprolol, Ramipril, Citalopram, Amlodipine, and Dapagliflozin?

Management of Dizziness in an 86-Year-Old on Polypharmacy

Your primary focus should be identifying and addressing medication-induced orthostatic hypotension from this patient's triple antihypertensive regimen (metoprolol 100mg daily, ramipril 10mg daily, amlodipine 2.5mg daily), while ruling out BPPV through Dix-Hallpike testing before considering any vestibular suppressants.

Immediate Assessment Steps

Orthostatic Vital Signs

• Measure blood pressure and heart rate supine, then at 1 and 3 minutes standing 1
• A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension, which is the most likely culprit given her medication burden 1
• The combination of metoprolol (beta-blocker), ramipril (ACE inhibitor), and amlodipine (calcium channel blocker) creates significant risk for hypotension and bradycardia 2

Characterize the Dizziness Type

• Since she reports no room spinning, this is NOT classic vertigo 1, 3
• No loss of consciousness rules out true syncope 1
• This presentation suggests either presyncope (from hypotension) or disequilibrium 1, 3

Perform Dix-Hallpike Maneuver

• Essential to rule out BPPV despite absence of rotational vertigo, as BPPV can present with non-specific dizziness in elderly patients 2
• If positive, proceed with Epley maneuver rather than medications 2

Medication Review and Adjustment

High-Priority Culprits

Metoprolol 50mg BID (100mg total daily):

• Beta-blockers commonly cause hypotension, bradycardia, and dizziness in elderly patients 2, 4
• Consider reducing to 25mg BID initially 2
• The ACC/AHA guidelines note that hypotension from beta-blockers may produce dizziness and lightheadedness 2
• Monitor for bradycardia, which can cause dizziness even without hypotension 2

Ramipril 10mg daily:

• ACE inhibitors are strongly associated with dizziness in elderly patients 4
• This is the maximum dose; consider reducing to 5mg daily 4
• ACE inhibitors combined with beta-blockers have additive hypotensive effects 2

Amlodipine 2.5mg daily:

• Lowest dose, but still contributes to cumulative hypotensive burden 2
• Consider holding temporarily if orthostatic hypotension confirmed 2

Secondary Considerations

Citalopram 5mg daily:

• SSRIs can contribute to dizziness and increase fall risk in elderly patients 2
• However, at this low dose, less likely to be primary culprit 5

Dapagliflozin 5mg daily:

• SGLT2 inhibitors cause volume depletion and can worsen orthostatic hypotension 1
• Check volume status; if dehydrated, this may be contributing significantly

Serc (Betahistine) 16mg BID:

• Already prescribed, suggesting prior vestibular concerns 2, 5
• Betahistine is NOT routinely recommended for non-vertiginous dizziness 2
• Consider discontinuing if BPPV ruled out and symptoms are presyncope-related 2

Recommended Management Algorithm

Step 1: Confirm Orthostatic Hypotension

• If present, reduce metoprolol to 25mg BID and ramipril to 5mg daily 2, 4
• Reassess in 1 week 2

Step 2: Optimize Volume Status

• If patient appears volume depleted, reduce or hold dapagliflozin temporarily 1
• Ensure adequate hydration 1
• Consider reducing potassium supplementation if blood pressure improves, as hyperkalemia from triple therapy (ramipril + potassium + dapagliflozin) may necessitate higher doses than needed 2

Step 3: If BPPV Confirmed

• Perform Epley maneuver immediately 2
• Continue betahistine only if patient >50 years with hypertension and symptom onset <1 month 2
• Do NOT add vestibular suppressants (benzodiazepines, antihistamines) as they significantly increase fall risk in elderly patients on polypharmacy 2

Step 4: If No Improvement After Medication Adjustment

• Consider cardiac causes: arrhythmia, valvular disease 1, 3
• Evaluate for diabetic neuropathy given metformin use (possible autonomic dysfunction) 1
• Screen for anemia (she's on iron supplementation) 1

Critical Pitfalls to Avoid

Do NOT add vestibular suppressants:

• Benzodiazepines and antihistamines dramatically increase fall risk in elderly patients on multiple medications 2
• These medications cause drowsiness, cognitive deficits, and worsen polypharmacy 2
• Only indicated for severe nausea/vomiting with acute vertigo, not for non-specific dizziness 2

Do NOT continue betahistine indefinitely:

• If symptoms are medication-induced hypotension rather than vestibular disease, betahistine provides no benefit 2, 5

Do NOT adjust all medications simultaneously:

• Change one or two medications at a time to identify the culprit 2
• Abrupt beta-blocker withdrawal can cause clinical deterioration 2

Follow-Up

• Reassess within 1 week after medication adjustments 2
• Document resolution or persistence of symptoms within 1 month 2
• If dizziness persists despite medication optimization, refer to cardiology for Holter monitoring and echocardiography 1, 3