What medications can cause dizziness in an elderly person?

Medications That Cause Dizziness in Elderly Patients

Multiple medication classes commonly cause dizziness in elderly patients, with cardiovascular drugs, central nervous system agents, and anticholinergic medications being the primary culprits. 1

High-Risk Medication Categories

Cardiovascular Medications

• Antihypertensives cause orthostatic hypotension and dizziness through excessive blood pressure lowering, particularly problematic in elderly patients due to age-related reductions in baroreceptor response 1, 2
• Calcium channel blockers (e.g., amlodipine) cause dose-related dizziness in 1.1-3.4% of patients, with significant blood pressure drops occurring as early as 15 minutes after administration 3, 4
• Diuretics induce hypovolemia that enhances vasodilatory effects and worsens orthostatic hypotension, especially when combined with other antihypertensives 1, 4
• Beta-blockers, ACE inhibitors, and nitrates all produce more pronounced hypotensive effects in elderly patients due to delayed drug elimination and increased bioavailability 2, 5

Central Nervous System Agents

• Benzodiazepines (e.g., diazepam) cause dizziness, vertigo, ataxia, and drowsiness as commonly reported adverse effects, with increased fall risk in elderly patients 6, 1
• Opioids impair judgment and psychomotor function, contributing to dizziness and falls 1
• Muscle relaxants including baclofen, tizanidine, and clonazepam cause sedation, cognitive effects, and orthostasis 1
• Cannabinoids (nabilone, dronabinol) have high incidence of dizziness/drowsiness, with elderly patients particularly prone to postural hypotension 1
• Tramadol causes drowsiness through mixed opioid and norepinephrine/serotonin reuptake mechanisms 1

Anticholinergic Medications

• Anticholinergic drugs show significant association with vertigo, dizziness, and balance problems (OR: 1.73) when measured by Drug Burden Index 7
• High-risk anticholinergics include diphenhydramine, cyclobenzaprine, oxybutynin, prochlorperazine, promethazine, tricyclic antidepressants, and paroxetine 1, 8
• H2-receptor antagonists (e.g., cimetidine) contribute to anticholinergic burden 1

Antiparkinsonian Medications

• Carbidopa/levodopa (Sinemet) causes orthostatic hypotension requiring blood pressure monitoring, especially after dose adjustments 9
• Dopamine agonists and antagonists precipitate syncope through autonomic effects 1

Antidepressants and Antipsychotics

• Tricyclic antidepressants induce orthostatic hypotension through anticholinergic and autonomic effects 1, 5
• SNRIs should be avoided in persons with history of falls or fractures 1
• Antipsychotic agents cause hypotension as unwanted adverse effect, with greater responses in elderly 1, 5

Critical Risk Factors in Elderly Patients

Age-Related Physiological Changes

• Reduced baroreceptor response and heart rate response to orthostatic stress 1
• Decreased ability to preserve sodium and water, reduced thirst 1
• Delayed drug elimination and increased bioavailability due to pharmacokinetic changes 2, 5
• Loss of peripheral autonomic tone that exacerbates drug effects 1

Polypharmacy Concerns

• Risk increases dramatically with multiple medications, particularly when combining CNS-active drugs with cardiovascular agents 1, 9
• Drug-drug interactions amplify dizziness risk, especially with five or more medications 1
• Alcohol consumption further contributes to medication-induced dizziness 1

Clinical Management Approach

Immediate Assessment Steps

• Review all current medications when evaluating dizziness in elderly patients, as drugs are a major reversible cause 2, 5
• Test orthostatic vital signs at bedside to identify medication-induced orthostatic hypotension 1
• Evaluate for anticholinergic burden using Drug Burden Index calculation as routine risk assessment 7

Medication Adjustment Strategy

• Discontinue antihypertensive drugs whenever possible when orthostatic hypotension is present 2
• Reduce dosages of essential medications rather than continuing standard doses 2, 5
• Avoid combining medications from multiple high-risk categories (e.g., diuretics with calcium channel blockers) 4
• Monitor blood pressure closely after any dose adjustments, particularly with antiparkinsonian drugs 9

High-Priority Medications to Avoid

According to the 2019 AGS Beers Criteria, strongly avoid these medications in elderly patients: benzodiazepines, anticholinergics (diphenhydramine, hydroxyzine, cyclobenzaprine), H2-receptor antagonists, sedative-hypnotics, and meperidine 1