What is the treatment for vertigo in an 81-year-old female?

From the Guidelines

For an 81-year-old female with vertigo, I strongly recommend starting with non-pharmacological approaches, including careful positional changes and vestibular rehabilitation exercises, as the initial management strategy, as suggested by the clinical practice guideline for benign paroxysmal positional vertigo (BPPV) 1. The patient should be assessed for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as recommended by the guideline 1. If the vertigo is due to BPPV, which is common in elderly patients, the Epley maneuver performed by a healthcare provider can be highly effective, with a high success rate of around 80% with only 1-3 treatments, as stated in the guideline 1. The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV, as an option based on controlled observational studies and a balance of benefit and harm 1. However, vestibular suppressant medications, such as antihistamines and benzodiazepines, should not be routinely used for treatment of BPPV, other than for the short-term management of autonomic symptoms, such as nausea or vomiting, in a severely symptomatic patient, due to the potential for significant harm, including drowsiness, cognitive deficits, and increased risk of falls, as highlighted in the guideline 1. Underlying causes should be investigated, including medication side effects, cardiovascular issues, or neurological conditions, and blood pressure should be monitored as orthostatic hypotension can cause dizziness in the elderly. Environmental modifications like removing trip hazards, installing grab bars, and using a cane or walker can prevent falls during vertigo episodes. The treatment approach should be tailored to the specific cause of vertigo, with careful consideration of age-related physiological changes and potential medication interactions in this elderly patient. Key considerations in managing vertigo in an elderly patient include:

• Careful assessment and diagnosis to determine the underlying cause of vertigo
• Non-pharmacological approaches as the initial management strategy
• Vestibular rehabilitation exercises and the Epley maneuver for BPPV
• Avoidance of vestibular suppressant medications due to potential harm
• Investigation of underlying causes and monitoring of blood pressure
• Environmental modifications to prevent falls.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).

For an 81-year-old female with vertigo, meclizine can be considered as a treatment option.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• It is essential to use caution when driving a car or operating dangerous machinery due to the potential for drowsiness.
• Patients with a history of asthma, glaucoma, or enlargement of the prostate gland should be prescribed meclizine with care due to its potential anticholinergic action.

From the Research

Treatment Options for Vertigo in an 81-Year-Old Female

• The most effective treatment method for Benign Paroxysmal Positional Vertigo (BPPV) is the canalith repositioning (CRP) maneuver 3.
• Addition of betahistine or dimenhydrinate pharmacotherapy to repositioning maneuver did not show superiority to treatment with repositioning maneuvers alone 3.
• Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptation and substitution, and is indicated for any stable but poorly compensated vestibular lesion, regardless of the patient's age 4, 5.

Use of Betahistine and Dimenhydrinate

• Betahistine was found to be more effective in improving residual dizziness symptoms compared to dimenhydrinate or placebo 6.
• Patients receiving betahistine were 3.18 times more likely to have no residual dizziness than the placebo group 6.
• Increasing age was associated with a decreased likelihood of improving residual dizziness 6.

Vestibular Rehabilitation

• Vestibular rehabilitation therapy (VRT) facilitates vestibular recovery mechanisms, including vestibular adaptation, substitution by the other eye-movement systems, and habituation 4.
• The key exercises for VRT include head-eye movements with various body postures and activities, and maintaining balance with a reduced support base 4.
• VRT is a recommended treatment option for patients with BPPV, unilateral vestibular loss or hypofunction, and bilateral vestibular loss/hypofunction 5.