What is the appropriate workup for an elderly female patient with dizziness who is taking hypertension medications, including diuretics (e.g. hydrochlorothiazide), beta-blockers (e.g. metoprolol), or ACE inhibitors (e.g. lisinopril)?

Workup for Elderly Female with Dizziness on Hypertension Medications

Immediately measure lying and standing blood pressures to assess for orthostatic hypotension—defined as a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing—as this is the most common medication-related cause of dizziness in elderly patients on antihypertensives. 1

Initial Orthostatic Vital Signs Assessment

• Measure blood pressure after the patient has been lying supine for 5 minutes, then at 1 and 3 minutes after standing 1
• Orthostatic hypotension occurs in approximately 7% of men over 70 years old and carries a 64% increase in age-adjusted mortality, plus increased risk of falls and fractures 1
• Do not rely solely on seated blood pressure measurements, as this misses orthostatic hypotension 1

Medication Review and Risk Stratification

Review the patient's current antihypertensive regimen for drugs most likely to cause orthostatic hypotension and dizziness:

• Beta-blockers (metoprolol) have a strong correlation with orthostatic hypotension and baroreflex dysfunction 1
• ACE inhibitors (lisinopril) increase the risk of hypotension, dizziness, fatigue, and falls, especially when started at high doses in patients ≥75 years 1
• Diuretics (hydrochlorothiazide) may aggravate orthostatic hypotension through volume depletion 1
• Alpha-blockers can cause postural hypotension and dizziness, especially when combined with diuretics or vasodilators 1
• Cardiovascular and central nervous system agents are highly associated with dizziness in older adults 2

Blood Pressure Target Verification

• Verify if the patient's blood pressure is being overtreated, with a target systolic BP <150 mmHg for most patients ≥60 years to reduce mortality, stroke, and cardiac events 1
• Aggressive BP targets (<140 mmHg) show only small additional benefits with inconsistent results 1
• Do not continue aggressive BP lowering in elderly patients experiencing dizziness without reassessing targets 1

Critical Red Flags Requiring Immediate Evaluation

Assess for the following symptoms that suggest serious underlying pathology:

• Postural unsteadiness, visual disturbances, or syncope suggest orthostatic hypotension 1
• New neurological symptoms, chest pain, or severe headache require evaluation for end-organ damage 1
• Cognitive impairment may indicate chronic hypoperfusion from overly aggressive BP control 1
• Falls or near-falls indicate increased fracture risk requiring urgent intervention 1

Laboratory and Diagnostic Workup

• Check serum electrolytes (potassium, sodium) to assess for diuretic-induced hypokalemia or hyponatremia 1
• Monitor renal function if adjusting ACE inhibitors or ARBs 1
• Consider 24-hour ambulatory blood pressure monitoring if white coat hypertension is suspected 3
• Document the patient's symptoms in their own words, as charts documenting this are more likely to reach a clinical diagnosis 4

Assessment for Non-Medication Causes

While dizziness in hypertensive patients is often attributed to elevated blood pressure or medications, research shows:

• Dizziness occurs in 20% of hypertensive patients and is unrelated to elevated blood pressure 5
• Dizziness is rather due to associated neurological, peripheral vestibular, and other diseases 5
• Ambulatory pressure monitoring shows that vertigo often occurs during hypotension after intake of hypotensive drugs 5
• After statistical correction for awareness of hypertension, the presence of dizziness is not significantly associated with hypertension itself or antihypertensive treatment 6

Immediate Management Algorithm

If orthostatic hypotension is confirmed:

• Review and adjust the antihypertensive regimen, particularly beta-blockers, alpha-blockers, and high-dose ACE inhibitors 1
• Consider dose reduction or medication discontinuation if BP is below target 1
• Monitor renal function if adjusting ACE inhibitors or ARBs 1

If orthostatic hypotension is absent:

• Evaluate for peripheral vestibular disorders (benign paroxysmal positional vertigo, Meniere's disease) 5
• Assess for neurological causes including stroke, transient ischemic attack, or chronic cerebrovascular insufficiency 5
• Screen for depression and anxiety, as these are associated with higher prevalence of dizziness symptoms 6
• Review all medications for polypharmacy effects, as potentially inappropriate medications in patients ≥75 years increase the risk of adverse drug reactions including falls and dizziness 1

Common Pitfalls to Avoid

• Do not assume dizziness is unrelated to medications without checking orthostatic vitals 1
• Do not attribute dizziness solely to elevated blood pressure, as this is rarely the actual cause 5
• Recognize that older patients may have "brittle hypertension" requiring slow titration 1
• Do not withhold appropriate workup based on the assumption that dizziness is a normal consequence of hypertension or its treatment 6