What are the recommendations for treating dizziness and vertigo symptoms in palliative and hospice patients?

Treatment of Dizziness and Vertigo in Palliative and Hospice Patients

In palliative and hospice patients with dizziness and vertigo, avoid routine use of vestibular suppressants (meclizine, antihistamines, benzodiazepines) as they provide no definitive benefit and may worsen outcomes by interfering with central compensation, increasing fall risk, and causing sedation that impairs quality of life. 1

Primary Treatment Approach

Avoid Vestibular Suppressants as Routine Treatment

• Vestibular suppressants including antihistamines (meclizine, diphenhydramine) and benzodiazepines (diazepam, clonazepam) are not recommended for treating vertigo in any population, including palliative patients. 1
• These medications show no evidence of effectiveness as definitive treatment and may mask symptoms without addressing underlying causes. 1
• Long-term use interferes with the brain's natural compensation mechanisms for vestibular disorders, potentially prolonging symptoms and delaying recovery. 2, 3
• In elderly patients (common in hospice settings), vestibular suppressants significantly increase fall risk, which can be catastrophic in frail populations. 2, 3

Short-Term Symptomatic Management Only

• Vestibular suppressants may be used only for short-term management of severe vegetative symptoms (nausea, vomiting) in severely symptomatic patients who refuse other options. 1
• Promethazine (phenothiazine with antihistamine properties) or ondansetron (5-HT3 antagonist) can address motion sickness symptoms accompanying vertigo. 1
• Levomepromazine or chlorpromazine may be alternatives for refractory nausea in the palliative setting. 1

Identify and Treat Underlying Causes

Medication-Related Causes

• Review and discontinue medications that may cause or worsen vertigo, including chemotherapeutic agents (capecitabine, topotecan, ifosfamide), immunotherapies, opioids, NSAIDs, anticonvulsants, and antidepressants. 1
• Medication withdrawal is specifically recommended for delirium and confusion related to anticancer treatments. 1
• Any drug that persistently worsens vertigo symptoms should be discontinued. 2

Metabolic and Systemic Causes

• Evaluate and correct hyponatremia from SIADH (common with small cell lung cancer, platinum-based chemotherapy, vinca alkaloids, opioids). 1
• Discontinue implicated medications, implement fluid restriction, and ensure adequate oral salt intake for confirmed SIADH. 1
• In patients with short prognosis, strict fluid restriction may not be appropriate if inconsistent with goals of care. 1

Paraneoplastic Syndromes

• Consider paraneoplastic neurologic syndromes (e.g., Anti-Hu syndrome) in cancer patients with progressive vertigo and coordination disorders. 4
• Treatment focuses on managing the underlying malignancy. 4

Non-Pharmacological Interventions

Vestibular Rehabilitation

• Vestibular rehabilitation therapy promotes central compensation and long-term recovery, and is strongly advised for most patients with vestibular disorders. 2, 3
• Physical rehabilitation is rarely contraindicated and should be considered even in palliative populations when consistent with goals of care. 3, 5

Supportive Measures

• Ensure adequate hydration and regular sleep patterns. 2
• Address visual problems (cataracts, squints), proprioceptive deficits (neuropathy), and mobility limitations that impede vestibular compensation. 5
• Provide simple counseling about the condition and realistic expectations. 5

Special Considerations for Palliative Sedation

When Vertigo is a Refractory Symptom

• If vertigo becomes refractory and death is imminent, palliative sedation with midazolam (first-line), levomepromazine, chlorpromazine, phenobarbital, or propofol may be appropriate. 1
• Titrate sedation to the least level necessary to provide adequate relief of suffering. 1
• For imminently dying patients, monitor only comfort parameters; gradual respiratory deterioration is expected and should not prompt sedation reduction. 1

Hydration Decisions

• Decisions about hydration are independent of vertigo treatment and palliative sedation decisions. 1
• No evidence supports that hydration prevents delirium in hospice patients with advanced cancer. 1

Common Pitfalls to Avoid

• Do not continue vestibular suppressants long-term, as this delays recovery by interfering with central compensation. 2, 3
• Do not prescribe meclizine as primary treatment for BPPV or other vestibular disorders in any patient population. 1
• Recognize that anticholinergic effects of meclizine (dry mouth, blurred vision, urinary retention) are particularly problematic in elderly palliative patients. 6
• Avoid combining vestibular suppressants with other CNS depressants (including opioids commonly used in palliative care) due to increased sedation and fall risk. 6

Reassessment

• Reassess patients within 1 month to confirm symptom resolution or identify treatment failures requiring alternative approaches. 1, 2
• Persistent symptoms warrant evaluation for underlying peripheral vestibular or CNS disorders that may require different management. 1