What workup is recommended for an elderly patient with asthma and hypertension presenting with dizziness, blurred vision, headaches, and imbalance?

Workup for Elderly Hypertensive Patient with Dizziness, Blurred Vision, Headaches, and Imbalance

This patient requires immediate blood pressure assessment with orthostatic measurements, comprehensive ophthalmologic evaluation including gonioscopy and fundoscopy, 12-lead ECG, and basic laboratory testing to exclude hypertensive emergency, medication-related adverse effects, and vision-threatening angle-closure disease. 1

Immediate Cardiovascular Assessment

Blood pressure evaluation is the first priority, as these symptoms—dizziness, blurred vision, headaches—are classic manifestations of both hypertensive complications and medication adverse effects in elderly patients 1:

• Measure blood pressure in both supine and standing positions (after 1 and 3 minutes upright) to detect orthostatic hypotension, which commonly causes dizziness and imbalance in elderly hypertensive patients on antihypertensive medications 1
• Obtain 12-lead ECG to detect atrial fibrillation, left ventricular hypertrophy, or ischemic changes that could explain symptoms 1
• Check pulse rate and rhythm for bradycardia or arrhythmias, particularly if the patient is on beta-blockers for asthma or hypertension 1

Critical Medication Review

Review all current medications immediately, as polypharmacy in elderly patients with multiple conditions frequently causes these exact symptoms 1:

• Beta-blockers (commonly used for both hypertension and asthma) cause dizziness, blurred vision, and bradycardia in elderly patients 1, 2
• Alpha-adrenergic blockers cause postural hypotension and dizziness, especially when combined with other antihypertensives 1
• Inhaled bronchodilators (ipratropium bromide, salbutamol) can precipitate angle-closure attacks in susceptible patients 1

Urgent Ophthalmologic Evaluation

Same-day ophthalmology referral is mandatory because intermittent blurred vision and headaches in an elderly hyperopic patient raises immediate concern for primary angle-closure disease, which causes permanent blindness in 18% of untreated cases 1, 3:

Essential Ophthalmologic Components

• Gonioscopy to assess anterior chamber angle and detect iridotrabecular contact, as standard examination between episodes may appear normal 1, 3
• Intraocular pressure measurement in both eyes 1
• Fundoscopy to detect papilledema (indicating elevated intracranial pressure), retinal hemorrhages, or hypertensive retinopathy 1
• Slit-lamp biomicroscopy to assess anterior chamber depth and detect corneal edema or iris abnormalities 1
• Pupil examination for mid-dilation, asymmetry, or poor reactivity suggesting intermittent angle closure 1

The combination of headaches, blurred vision, and use of anticholinergic asthma medications (ipratropium) creates high suspicion for intermittent angle closure, which presents with episodic symptoms that resolve spontaneously but can progress to acute crisis 1, 3.

Laboratory Investigations

Obtain the following blood tests to assess for hypertensive complications, secondary causes, and medication effects 1:

• Serum sodium, potassium (hypokalemia from diuretics causes dizziness and weakness) 1
• Serum creatinine and estimated GFR (renal impairment affects medication clearance and blood pressure control) 1
• Fasting glucose and hemoglobin A1c (diabetes is a vasculopathic risk factor) 1
• Dipstick urinalysis for proteinuria or hematuria indicating hypertensive kidney damage 1

Neurological Considerations

If symptoms persist despite normal blood pressure control and ophthalmologic evaluation, consider additional workup 1:

• Carotid ultrasound to assess for atherosclerotic plaques or stenosis causing cerebral hypoperfusion 1
• Brain MRI with and without contrast if symptoms suggest TIA, stroke, or other structural pathology, particularly if focal neurological signs develop 1

Critical Clinical Pitfalls to Avoid

Do not assume symptoms are "just the hypertension" without measuring actual blood pressure, as elderly patients on antihypertensives frequently experience hypotension-related symptoms rather than hypertension-related symptoms 1, 4:

• Dizziness in hypertensive patients is typically caused by hypotension after antihypertensive medication, not by elevated pressure itself 4, 5
• Orthostatic hypotension occurs in 27.4% of elderly patients on beta-blockers and causes the exact symptom constellation described 2, 1

Never delay ophthalmologic evaluation in elderly patients with blurred vision and headaches, as acute angle-closure crisis requires time-sensitive intervention to prevent permanent blindness 1, 3.

Do not overlook medication interactions between asthma and hypertension treatments, as anticholinergic bronchodilators can precipitate angle closure, and beta-blockers can cause bronchospasm, dizziness, and blurred vision 1, 2.

Diagnostic Algorithm Summary

1. Immediate orthostatic blood pressure measurement and medication review 1
2. Same-day ophthalmology consultation with gonioscopy and fundoscopy 1, 3
3. 12-lead ECG and basic metabolic panel 1
4. If initial workup negative, proceed to carotid ultrasound and consider neuroimaging 1

The most common causes in this clinical scenario are medication-related orthostatic hypotension and intermittent angle-closure disease, both of which require immediate identification to prevent serious morbidity 1, 3.