What is the diagnosis and treatment for an elderly patient experiencing episodic dizziness (lightheadedness)?

From the Guidelines

I recommend a comprehensive evaluation for this elderly patient with episodic dizziness, focusing on both vestibular and cardiovascular causes, as supported by the most recent guidelines 1. The initial assessment should include:

• Orthostatic vital signs
• Detailed neurological examination
• Cardiovascular assessment including EKG Laboratory tests should include:
• CBC
• Comprehensive metabolic panel
• Thyroid function
• Vitamin B12 levels For medication management, I would first review and potentially modify any medications that could contribute to dizziness, such as antihypertensives, sedatives, or anticholinergics. If benign paroxysmal positional vertigo (BPPV) is suspected based on positional triggers and brief episodes, the Epley maneuver should be performed as the first line of treatment, given its high success rate and low risk of adverse effects 1. For vestibular neuritis or labyrinthitis, a short course of vestibular suppressants like meclizine 25mg three times daily for 3-5 days may help acute symptoms. If orthostatic hypotension is identified, interventions should include gradual position changes, increased fluid and salt intake, compression stockings, and possibly midodrine 2.5-10mg three times daily if non-pharmacological measures are insufficient. Referrals to ENT, neurology, or cardiology may be necessary depending on findings. Patient education should emphasize fall prevention strategies, including home safety modifications, proper footwear, and the use of assistive devices if needed. Follow-up should be scheduled within 2-4 weeks to assess response to interventions and adjust the treatment plan accordingly, taking into consideration the patient's quality of life and potential risks of treatment, as highlighted in recent studies 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The patient's dizziness may be related to vertigo, and meclizine (PO) can be considered for treatment, but the drug label does not explicitly mention episodic dizziness.

• The indication is for vertigo associated with vestibular system diseases in adults, which may include elderly patients.
• However, the label does not provide direct information on the treatment of episodic dizziness in the elderly. 2

From the Research

SOAP Note for Elderly Patient with Episodic Dizziness

Subjective

• The patient presents with episodic dizziness, which is a common symptom among the elderly population 3, 4, 5.
• The patient's history and physical examination are crucial in determining the cause of dizziness 4, 6.
• The patient may experience dizziness triggered by head motion, which could be due to benign paroxysmal positional vertigo (BPPV) 4, 6.
• The patient may also experience vertigo with unilateral hearing loss, suggesting Meniere disease 4.

Objective

• A thorough physical examination, including orthostatic blood pressure measurement, full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver, is necessary to determine the cause of dizziness 4, 6.
• Laboratory testing and imaging are not required and are usually not helpful in diagnosing the cause of dizziness 4.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of dizziness 4.

Assessment

• The most common cause of dizziness in the elderly is presyncope, followed by peripheral vestibular disease and neurological disease 3.
• Adverse effects of drugs are a common contributory cause of dizziness in the elderly 3.
• Cardiovascular disease is a common underlying cause of dizziness in the elderly 3.
• Hemodynamic orthostatic dizziness/vertigo is a condition that can be diagnosed using specific criteria, including orthostatic hypotension, postural tachycardia syndrome, or syncope documented on standing or during head-up tilt test 7.

Plan

• Treatment of dizziness in the elderly depends on the underlying cause and may include canalith repositioning procedure (e.g., Epley maneuver) for BPPV, salt restriction and diuretics for Meniere disease, and vestibular suppressant medications and vestibular rehabilitation for vestibular neuritis 4, 5, 6.
• Primary care physicians should anticipate that many elderly dizzy patients can have more than one cause of dizziness and should use a systematic and planned approach to effectively treat dizziness in the elderly 3.