What is the best approach to manage dizziness in an older adult with potential comorbidities and medication side effects?

Management of Dizziness in Older Adults

Begin with an immediate comprehensive medication review, as drug side effects are the most common contributory cause of dizziness in older adults (20% of cases), and discontinue or reduce any potentially causative medications—particularly antipsychotics, benzodiazepines, antihypertensives, and vestibular suppressants. 1, 2

Immediate Medication Assessment and Deprescribing

• Discontinue antipsychotic medications immediately if clinically feasible, as they are strongly contraindicated in older adults due to increased mortality risk, anticholinergic burden causing balance disturbances, and cognitive impairment 1
• Stop all benzodiazepines, as they are a significant independent risk factor for falls and should be avoided entirely in older adults with dizziness 1, 3
• Discontinue vestibular suppressants (meclizine, antihistamines) if currently prescribed, as they interfere with central compensation, cause drowsiness and cognitive deficits, and significantly increase fall risk in elderly patients 1, 3
• Review all antihypertensive medications and consider dose reduction if orthostatic hypotension is present, as thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers can cause dizziness and orthostatic hypotension 4
• Maintain an updated medication list including nonprescription drugs to evaluate for drug-drug interactions and inappropriate prescribing 4

Characterize the Dizziness Subtype Through Focused History

• Determine if the patient experiences true vertigo (spinning sensation), presyncope (lightheadedness), disequilibrium (imbalance), or nonspecific dizziness, as this guides the differential diagnosis 4, 5, 6
• Presyncope is the most frequent dizziness subtype in older adults (71.5% of cases) and suggests cardiovascular causes 2
• Ask about timing: seconds suggests orthostatic hypotension; minutes to hours suggests Ménière disease or vestibular migraine; brief recurrent episodes suggest vestibular paroxysmia 4, 7
• Identify triggers: positional changes suggest BPPV or orthostatic hypotension; spontaneous attacks suggest Ménière disease, vestibular migraine, or TIA 6, 7

Perform Orthostatic Vital Signs and Targeted Physical Examination

• Measure blood pressure and heart rate supine and after standing for 30 seconds to 3 minutes to detect initial, classical, or delayed orthostatic hypotension, which causes dizziness in older adults taking vasoactive drugs 4
• Classical orthostatic hypotension (drop ≥20/10 mmHg within 3 minutes) is common in older adults on antihypertensives and diuretics 4
• Perform the Dix-Hallpike maneuver to assess for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo in elderly patients 1, 6
• If Dix-Hallpike is negative, perform the supine roll test to evaluate for lateral semicircular canal BPPV 1
• Conduct a full cardiac and neurologic examination, including assessment for nystagmus 4, 6

Identify and Address Underlying Comorbidities

• Cardiovascular disease is the most frequent underlying cause of dizziness in older adults (40% of cases), followed by peripheral vestibular disease (22.3%) and neurological disease (19%) 2
• Screen for cognitive impairment using a standardized instrument (e.g., MMSE), as diabetes and other conditions cause cognitive decline that manifests as difficulty with self-care and may contribute to dizziness 4
• Evaluate for depression, vitamin B12 deficiency, and hypothyroidism as reversible causes of cognitive impairment that can exacerbate dizziness 4
• Anticipate that 66% of elderly dizzy patients have more than one contributing cause, requiring a systematic approach to identify all factors 2

Treatment Based on Etiology

For BPPV (if Dix-Hallpike positive):

• Perform canalith repositioning procedures (Epley or Semont maneuver) as first-line treatment, which achieves 78.6%-93.3% improvement versus only 30.8% with medication 1, 3
• The Epley maneuver shows 80% vertigo resolution at 24 hours versus 13% with sham treatment 3
• Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines), as they increase fall risk and delay central compensation 1, 3

For Orthostatic Hypotension:

• Reduce or discontinue causative medications (antihypertensives, diuretics, vasoactive drugs) 4
• Advise nonpharmacologic measures: increase fluid and salt intake, compression stockings, slow positional changes 4

For Persistent Dizziness After Initial Treatment:

• Refer for vestibular rehabilitation therapy as the primary intervention, which promotes central compensation and long-term recovery 1, 3
• Vestibular rehabilitation significantly improves overall gait stability compared to medication alone 3
• Consider betahistine (16-48 mg three times daily) only in specific subgroups: patients >50 years old with hypertension and symptom onset <1 month 3

Fall Prevention and Safety Counseling

• Provide immediate fall prevention counseling, as 53% of elderly patients with chronic vestibular disorders have fallen at least once in the past year 1, 3
• Address home safety assessment, activity restrictions, and need for supervision given the patient's age and medication profile 1
• Document a basic falls evaluation including assessment of injuries and examination of potentially reversible causes (medications, environmental factors) 4

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants as long-term therapy regardless of the underlying cause, as they interfere with central compensation and increase fall risk 1, 3
• Do not order routine brain imaging or vestibular testing unless the diagnosis is uncertain or there are additional neurological symptoms 1
• Do not continue antipsychotics without reassessing the indication, as Beers Criteria strongly recommend avoiding these medications in older adults 1
• Avoid polypharmacy, as the risk of falls increases in patients taking multiple medications 3
• Recognize that amnesia and cognitive impairment are common in older adults, which diminishes the accuracy of recall of the clinical event and requires collateral history 4

Follow-Up Protocol

• Reassess patients within 1 month after initiating treatment to document resolution or persistence of symptoms 3
• Consider syncope as a cause of nonaccidental falls in older adults, as approximately 30% of older adults who present with falls may have had syncope 4
• For recurrent or unexplained dizziness despite treatment, consider referral to geriatric care for multidisciplinary assessment of frailty, multiple morbidities, and other factors predisposing to poor outcomes 4