Management of Severe Dizziness and Vomiting in an Elderly Patient
This elderly patient requires immediate assessment for volume depletion and exclusion of central causes, followed by targeted physical examination to distinguish benign peripheral vestibular disorders from stroke. 1, 2
Immediate Assessment for Volume Depletion
Check for at least four of these seven signs to identify moderate-to-severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, or sunken eyes. 1 The presence of vomiting with severe dizziness in an elderly patient triggers sick day medication guidance intervention. 1
- Assess postural vital signs: A postural pulse change from lying to standing of ≥30 beats per minute or severe postural dizziness preventing standing indicates volume depletion. 1
- New lightheadedness or dizziness with sitting or standing is a recognized trigger for volume depletion management. 1
- If four or more signs are present, initiate isotonic fluid replacement orally, nasogastrically, subcutaneously, or intravenously. 1
Critical Medication Review
Temporarily stop these medications immediately if the patient is taking them: 1
- SGLT2 inhibitors (empagliflozin, canagliflozin)
- Loop diuretics (furosemide)
- Thiazide diuretics (hydrochlorothiazide, indapamide)
- Potassium-sparing diuretics (spironolactone, amiloride)
- ACE inhibitors/ARBs (perindopril, candesartan)
- NSAIDs
Exclude Central Causes First
Perform a focused neurological examination looking for these red flags: 2, 3
- Reduced level of consciousness or new confusion (requires 911/emergency care) 1
- Focal neurological deficits
- Inability to stand or walk
- New severe headache
- Downbeating or central pattern nystagmus
- Sudden hearing loss
If any red flag is present, obtain MRI brain without contrast immediately—do not rely on CT, which misses most posterior circulation strokes (<1% diagnostic yield). 2, 3
Diagnostic Physical Examination
After excluding red flags and volume depletion, perform the Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo in elderly patients (42% of cases) and is present in 9% of elderly patients who have fallen. 2, 3
Positive Dix-Hallpike findings: 2, 3
- 5-20 second latency before symptoms begin
- Torsional, upbeating nystagmus toward the affected ear
- Vertigo and nystagmus that increase then resolve within 60 seconds
If the patient has persistent symptoms 3 weeks after any recent fall, CT head is mandatory to exclude delayed subdural hematoma, even with negative initial FAST exam. 2
Treatment Based on Diagnosis
For confirmed BPPV, perform the Epley maneuver immediately (80% success rate after 1-3 treatments, 90-98% with repeat maneuvers). 2, 3, 4
- Administer prochlorperazine 5-10 mg orally or IV prophylactically before the maneuver if severe nausea is present. 2
- Avoid vestibular suppressants (meclizine, benzodiazepines, antihistamines) as they delay central compensation and significantly increase fall risk in elderly patients. 2, 5
For volume depletion without BPPV: 1
- Continue isotonic fluid replacement
- Monitor for symptom resolution
- Contact healthcare provider if unable to keep fluids down or if symptoms persist beyond 72 hours 1
Critical Pitfalls to Avoid
- Never assume absence of headache excludes intracranial pathology—elderly patients may not report headache with subdural hematoma. 2
- Never rely on negative FAST alone in elderly patients with persistent post-fall symptoms. 2
- Do not use CT instead of MRI when stroke is suspected—CT has only 20-40% sensitivity for posterior circulation infarcts. 3
- Avoid prolonged use of meclizine or other vestibular suppressants, which increase fall risk 12-fold in elderly patients. 2, 5
Mandatory Follow-Up
Reassess within 1 month to document resolution or identify persistent symptoms requiring further evaluation. 2, 3 If symptoms persist after initial BPPV treatment, repeat Dix-Hallpike and consider vestibular rehabilitation therapy, which significantly improves gait stability in elderly patients. 2, 3