What is a safe initial treatment for an elderly woman presenting with vertigo in a primary care setting?

Safe Initial Treatment for Vertigo in an Elderly Woman in Primary Care

The safest and most effective initial treatment for an elderly woman with vertigo in primary care is the canalith repositioning procedure (Epley maneuver) if benign paroxysmal positional vertigo (BPPV) is diagnosed, while avoiding vestibular suppressant medications like meclizine or benzodiazepines. 1

Diagnostic Approach First

Before treating, perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV, which accounts for 85-95% of vertigo cases in this population. 2 This bedside test involves bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for characteristic torsional upbeating nystagmus. 2 If the Dix-Hallpike is negative but BPPV is still suspected, perform the supine roll test to assess for lateral canal BPPV (10-15% of cases). 2

First-Line Treatment: Canalith Repositioning Procedure

For posterior canal BPPV, perform the Epley maneuver immediately upon diagnosis with success rates of 80-90% after 1-3 treatments and 90-98% with repeat maneuvers if needed. 1, 2 The procedure involves:

• Patient sitting upright with head turned 45° toward affected ear
• Rapidly laying back to supine head-hanging 20° position for 20-30 seconds
• Turning head 90° toward unaffected side
• Rolling patient onto side while maintaining head position
• Returning to upright position 2

Critically important: No postprocedural restrictions are needed. The patient can resume normal activities immediately, as restrictions provide no benefit and may cause unnecessary complications. 1, 2

What NOT to Do: Avoid Vestibular Suppressants

Do not routinely prescribe meclizine, antihistamines, or benzodiazepines for BPPV treatment. 1, 2 Despite meclizine being FDA-approved for vertigo 3, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against these medications because:

• No evidence they work as definitive treatment for BPPV 1
• They cause significant adverse effects including drowsiness and cognitive deficits 1
• They are an independent risk factor for falls in elderly patients 1
• They interfere with central compensation mechanisms 2
• The risk of polypharmacy further exposes elderly patients to additional harm 1

The only acceptable use is short-term management (not ongoing treatment) of severe nausea/vomiting in severely symptomatic patients who refuse other treatment or need prophylaxis immediately before/after the repositioning procedure. 1, 2

Special Considerations for Elderly Patients

Fall Risk Assessment is Critical

Elderly patients with BPPV have a 12-fold increased fall risk. 2 Counsel immediately regarding:

• Home safety assessment
• Activity restrictions until symptoms resolve
• Need for supervision 1, 2

Nine percent of elderly patients in geriatric clinics have unrecognized BPPV, and three-quarters have fallen within the previous 3 months. 2

Physical Limitations May Require Modified Approach

Assess for contraindications before performing repositioning maneuvers, including: 1, 2

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis or ankylosing spondylitis
• Morbid obesity
• Down syndrome
• Paget's disease
• Spinal cord injuries

For patients with these limitations, consider Brandt-Daroff exercises (home-based habituation exercises) or referral to specialized vestibular physical therapy. 2

Adjunctive Treatment: Vestibular Rehabilitation

Add vestibular rehabilitation exercises after successful repositioning to reduce recurrence rates by approximately 50%. 2 This is particularly beneficial for elderly patients, as the effect against recurrence may be more pronounced in this population. 1

Vestibular rehabilitation includes habituation exercises, gaze stabilization, balance retraining, and fall prevention training. 1 These exercises are safe with no serious adverse events reported in clinical trials. 1, 4 Home-based therapy appears equally effective as clinician-supervised therapy. 1, 4

Follow-Up Protocol

Reassess within 1 month to confirm symptom resolution. 1, 2 If symptoms persist:

1. Repeat the diagnostic test to confirm persistent BPPV 2
2. Perform additional repositioning maneuvers (success rates reach 90-98%) 2
3. Check for canal conversion (occurs in ~6% of cases) 1, 2
4. Evaluate for multiple canal involvement or bilateral BPPV 2
5. Rule out coexisting vestibular pathology or CNS disorders if atypical features present 2

Common Pitfalls to Avoid

• Do not order imaging or vestibular testing unless there are atypical neurological signs (abnormal cranial nerves, severe headache, visual disturbances). 2
• Do not prescribe vestibular suppressants as primary treatment despite their FDA approval—they increase fall risk in elderly patients. 1
• Do not impose postprocedural restrictions after repositioning maneuvers—they provide no benefit. 1, 2
• Do not delay treatment while waiting for specialty referral—primary care providers can safely perform these maneuvers. 1