Dizziness in Elderly Patients: Diagnosis and Treatment

Introduction to Dizziness in the Elderly

The American College of Cardiology and the American Heart Association recommend that antihistamines, including cetirizine, should not be used to treat dizziness in elderly patients, as they can precipitate syncope and dizziness in this population 1, 2
The American College of Cardiology notes that antihistamines are listed among medications that precipitate syncope and dizziness in elderly patients, alongside diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotic agents, tricyclic antidepressants, dopamine agonists/antagonists, and narcotics 1, 2
The effects of these drugs are exacerbated in the elderly due to loss of peripheral autonomic tone that occurs with aging, making them particularly problematic in this population 1, 2

The clinical presentation in elderly patients is often variable and atypical, with marked overlap between falls, orthostatic hypotension, and dizzy spells, according to the American College of Cardiology 1, 2
Brief episodes lasting seconds suggest either benign paroxysmal positional vertigo (BPPV) or orthostatic hypotension as the most likely etiologies, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 3
The American Academy of Otolaryngology-Head and Neck Surgery recommends performing Dix-Hallpike testing to identify BPPV, which is the most common inner ear problem causing vertigo and can be reliably diagnosed with this simple bedside test 3
Measuring blood pressure in both supine and standing positions is essential to detect orthostatic hypotension, which causes syncope in 6% to 33% of elderly patients and is frequently confused with other conditions, according to the American College of Cardiology and the American Heart Association 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends canalith repositioning procedures (CRP) such as the Epley maneuver as the definitive treatment for BPPV, rather than prescribing medications 3
Vestibular rehabilitation may be offered as an adjunct or alternative therapy for BPPV, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 3
The American College of Cardiology and the American Heart Association recommend reviewing and discontinuing or reducing offending medications, including diuretics, antihypertensives, and other agents that can cause orthostatic changes, in patients with orthostatic hypotension 1, 2
Implementing non-pharmacologic measures, such as increasing fluid and salt intake, using compression stockings, educating on positional changes, and elevating the head of the bed, is recommended for patients with orthostatic hypotension, according to the American College of Cardiology and the American Heart Association 1, 2

The American College of Cardiology and the American Heart Association recommend counseling patients about fall risk, as 30% of falls in the elderly may be due to syncope, and BPPV specifically increases fall risk 1, 2, 3
Assessing home safety, considering activity restrictions, and evaluating the need for supervision until symptoms resolve, particularly in frail elderly patients, is essential, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 3
The American Academy of Otolaryngology-Head and Neck Surgery notes that recurrence of BPPV occurs in 10-18% at 1 year and may be as high as 36% long-term, so counseling patients to return if symptoms recur is crucial 3