What evaluation and management are recommended for an adult with fatigue and dizziness?

Evaluation and Management of Tiredness with Dizziness

Begin by categorizing the dizziness through focused history-taking to determine if it represents vertigo (spinning sensation), presyncope (near-fainting), disequilibrium (imbalance), or lightheadedness, as this classification drives the entire diagnostic and therapeutic approach. 1, 2

Initial Clinical Assessment

Critical History Elements

• Timing and triggers: Determine if dizziness occurs with positional changes, during walking, or at rest, as this narrows the differential significantly 1, 3

• Associated symptoms: Ask specifically about:

  • Hearing loss or tinnitus (suggests Meniere disease or vestibular pathology) 2
  • Neck/shoulder pain (common in elderly with chronic dizziness) 3
  • Sleep disturbance and mood symptoms (depression/anxiety can cause vague lightheadedness) 2, 3
  • Cardiac symptoms suggesting presyncope 2

• Medication review: Scrutinize all medications, as many drugs cause fatigue and dizziness, particularly:

  • Beta blockers (cause fatigue and bradycardia-related dizziness) 4
  • Psychotropic medications (cause somnolence and fatigue) 5
  • Bile acid sequestrants (reduce folate, causing fatigue) 6
  • Antihypertensives (cause orthostatic hypotension) 2

Targeted Physical Examination

• Orthostatic vital signs: Measure blood pressure and heart rate supine and after 1-3 minutes standing to detect orthostatic hypotension 1, 2
• Cardiovascular examination: Assess for arrhythmias, murmurs, and signs of heart failure 1
• Neurologic examination: Complete assessment including cranial nerves, cerebellar function, and gait 1
• Nystagmus assessment: Observe for spontaneous nystagmus with and without visual fixation 1
• Dix-Hallpike maneuver: Perform in patients with triggered/positional dizziness to diagnose benign paroxysmal positional vertigo 1, 2
• HINTS examination (head-impulse, nystagmus, test of skew): Use when central etiology is suspected 1

Laboratory and Imaging Workup

Laboratory testing is usually not required but should be targeted based on clinical suspicion: 1

• Complete blood count: Rule out anemia as a cause of fatigue and dizziness 6
• Comprehensive metabolic panel: Assess electrolytes, renal function, and glucose 6
• Thyroid function (TSH): Hypothyroidism commonly presents with fatigue and can be associated with hyperlipidemia 6, 4
• Vitamin B12 and folate levels: Low folate causes fatigue; always check B12 concurrently 6
• Iron studies and vitamin D: Consider if anemia or deficiency suspected 6

Imaging is rarely needed initially but consider brain MRI if central causes are suspected (white matter lesions are common in elderly with chronic dizziness) 3, 1

Management Algorithm by Etiology

For Peripheral Vestibular Causes (Vertigo)

• Benign paroxysmal positional vertigo: Perform Epley maneuver (canalith repositioning procedure) as first-line treatment 1, 2
• Vestibular neuritis: Consider corticosteroids in acute phase 2
• Meniere disease: Intratympanic dexamethasone or gentamicin for refractory cases 2
• Vestibular rehabilitation: Helpful for many peripheral and central etiologies 1, 2

For Medication-Induced Fatigue and Dizziness

Beta blocker-related symptoms:

• Reduce dose to lowest effective level rather than discontinuing abruptly 4
• Monitor for bradycardia (heart rate <60 bpm) which strengthens case for dose reduction 4
• Never abruptly discontinue as this causes rebound sympathetic activation and clinical deterioration 4
• If dose reduction needed, increase diuretics if fluid retention develops 4

Psychotropic medication-related fatigue:

• Adjust medications one at a time with 4-8 week monitoring periods 5
• Consider switching to less sedating alternatives 5
• If adjustments fail, consider adding modafinil 50-100mg daily for persistent fatigue 5

For Nutritional Deficiencies

Folate deficiency management:

• Initiate folic acid 1-5 mg orally daily for at least 90 days 6
• Critical pitfall: Always supplement vitamin B12 concurrently to prevent masking B12 deficiency and irreversible neurological damage 6

For Orthostatic Hypotension (Presyncope)

• Treat with alpha agonists, mineralocorticoids, or lifestyle modifications (increased fluid/salt intake, compression stockings) 2
• Review and adjust medications causing orthostatic changes 2

For Psychiatric Causes (Lightheadedness)

• Treat underlying depression, anxiety, or hyperventilation syndrome 2
• Consider cognitive behavioral therapy for persistent symptoms 5

Critical Pitfalls to Avoid

• Do not supplement folic acid alone: Always give concurrent vitamin B12 to prevent masking deficiency and neurological complications 6
• Do not abruptly stop beta blockers: This causes rebound tachycardia and potential heart failure exacerbation 4
• Do not assume single etiology: Elderly patients often have multifactorial causes including cervical spondylosis, poor vision, white matter disease, and medication effects 3
• Do not over-rely on pharmacologic suppression: Medications for dizziness often impair central nervous system compensation mechanisms 1
• Do not ignore body asymmetry: Left-right imbalance in visual acuity, scoliosis, and neck pain contribute to chronic dizziness in elderly 3

When Diagnosis Remains Unclear

Approximately 20% of dizziness cases remain undiagnosed after initial evaluation 2. In these cases:

• Reassess medication regimen thoroughly 5, 6
• Consider trial of vestibular rehabilitation 1
• Evaluate for sleep disorders, which exacerbate both fatigue and dizziness 3, 5
• Screen for depression and anxiety, which commonly present as vague lightheadedness 2