What is the medical treatment for vertigo in a 90-year-old patient?

From the Guidelines

For a 90-year-old patient with vertigo, medication treatment is not recommended as the first line of treatment, and instead, canalith repositioning procedures or vestibular rehabilitation therapy should be considered. According to the clinical practice guideline for benign paroxysmal positional vertigo (BPPV) 1, clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. This recommendation is based on the lack of evidence supporting the effectiveness of these medications in treating BPPV, as well as the potential harm they can cause, particularly in the elderly 1.

Some key points to consider in the management of vertigo in a 90-year-old patient include:

• Investigating the underlying cause of vertigo, which could be BPPV, vestibular neuritis, medication side effects, or cardiovascular issues
• Considering non-pharmacological approaches like vestibular rehabilitation therapy and fall prevention strategies, which are particularly important in this age group
• Regular medication reviews to minimize polypharmacy risks in this elderly patient
• Counseling patients and their families regarding the risk of falls associated with BPPV and the importance of follow-up after diagnosis 1

It's essential to prioritize the patient's safety and well-being, and to consider the potential risks and benefits of any treatment approach. In this case, a canalith repositioning procedure or vestibular rehabilitation therapy may be a more effective and safer option for managing vertigo in a 90-year-old patient.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1). May cause drowsiness: Use caution when driving a car or operating dangerous machinery (5. 1). Potential anticholinergic action: this drug should be prescribed with care to patients with a history of asthma, glaucoma, or enlargement of the prostate gland (5. 2).

For a 90-year-old patient with vertigo, meclizine can be considered as a treatment option. The recommended dosage is 25 mg to 100 mg daily, in divided doses. However, it is essential to exercise caution due to potential side effects, such as:

• Drowsiness
• Anticholinergic action, which may be problematic in patients with certain medical conditions, like asthma, glaucoma, or prostate enlargement. Given the patient's age, it is crucial to start with a low dose and monitor for adverse reactions. Additionally, consider the patient's medical history and current medications to minimize potential interactions, as meclizine can interact with CNS depressants and CYP2D6 inhibitors 2.

From the Research

Medical Treatment for Vertigo in 90-year-old Patients

• The Epley manoeuvre is a safe and effective treatment for benign paroxysmal positional vertigo (BPPV) in adults, including those aged 90 years 3, 4, 5, 6.
• Studies have shown that the Epley manoeuvre is more effective than sham manoeuvres, no treatment, or other active treatments in resolving vertigo symptoms and converting a positive Dix-Hallpike test to a negative test 3, 4, 5, 6.
• The Epley manoeuvre has been compared to other particle repositioning manoeuvres, such as the Semont and Gans manoeuvres, and has been found to be equally effective 3.
• Adverse effects of the Epley manoeuvre are infrequent and typically mild, with no serious adverse effects reported 3, 4, 6.
• The Epley manoeuvre is recommended for use in the emergency department for the treatment of BPPV, with a number-needed-to-treat of 3 6.
• Vestibular rehabilitation is also a treatment option for BPPV, but the Epley manoeuvre has been found to be more effective at 1-week follow-up, with inconsistent evidence at 1-month follow-up 7.

Key Findings

• Complete resolution of vertigo symptoms occurred significantly more often in the Epley treatment group compared to sham manoeuvres or control (odds ratio 4.42,95% confidence interval 2.62 to 7.44) 3.
• Conversion of a positive Dix-Hallpike test to a negative test significantly favoured the Epley treatment group compared to sham manoeuvres or control (odds ratio 9.62,95% confidence interval 6.0 to 15.42) 3.
• The Epley manoeuvre is a safe and effective treatment for posterior canal BPPV, with a high recurrence rate of 36% 3.