Is Zyrtec (cetirizine) a suitable first-line treatment for an elderly male with occasional intermittent dizziness, normal laboratory results, and a normal electrocardiogram (EKG)?

Cetirizine (Zyrtec) is NOT Appropriate for Treating Dizziness in Elderly Patients

Do not use cetirizine (Zyrtec) to treat dizziness in elderly patients—antihistamines are specifically identified as medications that can precipitate syncope and dizziness in this population. 1

Why Antihistamines Are Contraindicated

• Antihistamines are listed among medications that precipitate syncope and dizziness in elderly patients, alongside diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotic agents, tricyclic antidepressants, dopamine agonists/antagonists, and narcotics. 1

• The effects of these drugs are exacerbated in the elderly due to loss of peripheral autonomic tone that occurs with aging, making them particularly problematic in this population. 1

• While cetirizine has a low rate of CNS penetration and minimal sedation compared to traditional antihistamines 2, it remains on the list of medications to avoid in elderly patients with dizziness/syncope symptoms. 1

Proper Diagnostic Approach for This Patient

Characterize the Type of Dizziness

• Dizziness in elderly patients falls into four categories: vertigo (spinning sensation), disequilibrium (imbalance), near-syncope (lightheadedness/presyncope), or nonspecific. 3

• The clinical presentation in elderly patients is often variable and atypical, with marked overlap between falls, orthostatic hypotension, and dizzy spells. 1

• Brief episodes lasting seconds suggest either benign paroxysmal positional vertigo (BPPV) or orthostatic hypotension as the most likely etiologies. 1

Essential Physical Examination Components

• Perform Dix-Hallpike testing to identify BPPV, which is the most common inner ear problem causing vertigo and can be reliably diagnosed with this simple bedside test. 1

• Measure blood pressure in both supine and standing positions to detect orthostatic hypotension, which causes syncope in 6% to 33% of elderly patients and is frequently confused with other conditions. 1

• Conduct a screening neurological examination to rule out focal deficits, though neurological causes rarely present as isolated dizziness without other symptoms. 1

Common Etiologies in Elderly Males

• Peripheral vestibular dysfunction is found in 71% of elderly men with dizziness and is the principal cause in 56%, with benign positional vertigo present in 34%. 4

• Orthostatic hypotension is common in older patients due to age-related reductions in baroreceptor response, heart rate response to orthostatic stress, and autonomic dysfunction. 1

• Multifactorial causes are present in 49% of elderly patients with dizziness, requiring evaluation of multiple systems. 4

• Carotid sinus hypersensitivity accounts for 30% of unexplained syncope in the elderly and is under-recognized. 1

Appropriate Treatment Based on Etiology

If BPPV is Diagnosed

• Canalith repositioning procedures (CRP) such as the Epley maneuver are the definitive treatment and should be performed rather than prescribing medications. 1

• Vestibular rehabilitation may be offered as an adjunct or alternative therapy. 1

• Avoid antivertigo medications for BPPV, as the Dix-Hallpike test can reliably identify this condition, making medications unnecessary. 1

If Orthostatic Hypotension is Identified

• Review and discontinue or reduce offending medications including diuretics, antihypertensives, and other agents that can cause orthostatic changes. 1

• Implement non-pharmacologic measures: increase fluid and salt intake (if not contraindicated), use compression stockings, educate on positional changes, and elevate the head of the bed. 1

If Acute Vestibular Syndrome

• Antivertigo agents may be used for a maximum of 3 days for acute, severe symptoms only, followed by etiology-specific treatment. 5

• Prolonged use of vestibular suppressants should be avoided as they delay central compensation. 5

Critical Safety Considerations

• Counsel patients about fall risk, as 30% of falls in the elderly may be due to syncope, and BPPV specifically increases fall risk. 1

• Assess home safety, consider activity restrictions, and evaluate need for supervision until symptoms resolve, particularly in frail elderly patients. 1

• Recurrence of BPPV occurs in 10-18% at 1 year and may be as high as 36% long-term, so counsel patients to return if symptoms recur. 1

Common Pitfalls to Avoid

• Do not prescribe medications empirically without characterizing the type of dizziness and identifying the underlying cause. 1, 3

• Do not add antihistamines to an elderly patient's medication regimen for dizziness, as they are part of the problem, not the solution. 1

• Do not overlook orthostatic vital signs—always measure blood pressure both supine and standing in elderly patients with dizziness. 1

• Do not assume a single cause—49% of elderly patients have multiple contributing diagnoses requiring comprehensive evaluation. 4