Too dizzy to walk: Managing dizziness in the elderly

July 4, 2019

Contributed by:

Dr. Vivian Ewa (Click for bio)

Case

Ms Abawi is an 85-year-old woman with long standing history of dizziness. She presents with worsening dizziness post fall three months ago. Brain imaging post fall showed small vessel ischemic changes with no acute abnormalities. Her past medical history is significant for GERD, hypertension, osteoarthritis, osteoporosis, Type 2 diabetes mellitus and depression. Her current medications include:

  • Amlodipine 10mg orally daily
  • Olmesartan 40mg orally daily
  • Hydrochlorothiazide 25mg orally daily
  • Pantoloc 40mg daily
  • Citalopram 20mg orally daily
  • Alendronate 70mg orally weekly
  • Metformin 1000mg orally twice daily
  • repaglinide 1mg orally three times daily
  • Tylenol extra strength as required
  • Betahistine 16mg orally twice daily.

Ms Abawi is concerned about ongoing dizziness, poor balance and decreasing mobility so is seeking treatment from you.

Background

Dizziness and imbalance are frequent complaints in older adults.1, 2 Untreated, symptoms lead to decreasing balance, loss of confidence and anxiety, difficulty with concentration and memory, inactivity, loss of independence, an increased risk for falls and falls related injuries.1-4 The increased risk for falls makes this a public health concern. Falls were the leading cause of injury in Canada in 2010 accounting for 63% of injuries in seniors.5 Aetiology of dizziness in the older adult is usually multifactorial, including cardiovascular, sensory, neurologic, and psychological and medication-related causes.1, 2 Peripheral vestibular dysfunction is the most frequent cause of dizziness in the elderly1, 6, 7 of which Benign Positional Vertigo (BPPV) is the most frequent diagnosis followed by Meniere’s disease and vestibular neuritis.6, 7

Management of dizziness in the elderly

The cause of dizziness in the elderly is multifactorial and hence a multiprong approach to evaluation and management should be adopted while customizing treatment to individuals.1 Clinical assessment includes detailed history of dizziness, associated symptoms, past medical history, medication review and physical examination. Physical examination should include postural blood pressures, neurological, sensory and cardiovascular examination. The Dix- Hallpike maneuver can be employed to diagnose BPPV.8, 9 Laboratory tests to exclude anemia, electrolyte or metabolic abnormities should be completed. Further investigations such as brain imaging,12 ECG and a Holter monitor will depend on history and clinical exam findings. An audiology assessment – though not routinely recommended – may be required in cases where hearing loss or changes are reported.

Management of dizziness includes medical and rehabilitative strategies in addition to the use of prosthetic devices.1 Medical management of dizziness includes addressing identified causes of dizziness such as postural hypotension, hypoglycemia and anemia. There are no medications to treat age-related vestibular dysfunction.1 Medications such as antihistamines, benzodiazepines and anticholinergics have been used to treat symptoms, however these medications show variable efficacy with significant side effects such as sedation, postural hypotension and falls and hence should generally be avoided in the elderly.10 These medications should also be avoided in BPPV as they blunt central compensation and increase risk of falls.11,12 Betahistine has been shown to improve symptoms associated with Meniere’s disease, it should, however, not be used in other causes of dizziness.11,13 Side effects include GI distress and headaches.

For patients with peripheral vestibular dysfunction, vestibular rehabilitation (an exercise-based program) assists the central nervous system to adapt to changes or loss in inputs to the vestibular system in addition to habituation and substitution exercises.14 Vestibular rehabilitation has been shown to improve symptoms of dizziness caused by vestibular dysfunction, anxiety, head injury, cerebellar dysfunction and Parkinson’s disease.15 Physiotherapists trained in vestibular rehabilitation work with patients to develop personalized, exercise-based management plans that include home exercise programs.1,16

In some cases, no specific diagnosis can be made to explain symptoms; this was seen in 20 to 30% of older people with dizziness.6,7 Age-related deterioration impacting vestibular, visual and sensorimotor function as well as reduction in lower extremity strength accounts for most of these cases.17,18 Focus on exercise therapy and falls risk prevention strategies are mainstay of treatment.1,11

Back to case

Further history of Ms Abawi reveals dizziness symptoms for over 10 years, and her symptoms are continuous with episodic worsening. Betahistine has been used on and off over the last few years with no improvement in symptoms. There was no history of tinnitus or hearing loss. Lying and standing blood pressures were 120/85 and 110/80 respectively. Other aspects of the physical exam were unremarkable. Pertinent findings on laboratory testing were a low serum sodium of 130 and Hba1c of 6.8%. The Dix- Hallpike maneuver showed possible BPPV on the left and slight improvement in symptoms post therapy. Ms Abawi was taught vestibular exercises in addition to gait and balance exercises to continue at home. Betahistine was discontinued as her symptoms did not suggest Meniere’s disease.11,13 Blood pressure medications were reviewed and hydrochlorothiazide discontinued due to hyponatremia and blood pressure targets lower than expected given frailty and falls risk.19 Given her Hba1c levels, Repaglinide was reduced to 0.5mg TID and eventually discontinued.20 Citalopram was reduced to 10mg daily due to concerns with prolonged QTc interval.

Three months post initial assessment, the Dix- Hallpike maneuver was negative. Ms Abawi still complained of dizziness but reported feeling better regarding her balance and mobility. No further falls or near falls were reported. She also reported improvement in anxiety symptoms and is sleeping well at night. Repeat blood work showed a Hba1c of 7 % and normal sodium levels. Her blood pressures were stable at 120- 130 systolic with no postural drops.

She was advised to continue with in-home exercises and a referral was made to an adult day program to facilitate increased social and physical activity.

References

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    2. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med. 2000;132(5):337-44.
    3. Harun A, Li C, Bridges JF, Agrawal Y. Understanding the Experience of Age-Related Vestibular Loss in Older Individuals: A Qualitative Study. Patient. 2016;9(4):303-9.
    4. O'Loughlin JL, Boivin JF, Robitaille Y, Suissa S. Falls among the elderly: distinguishing indoor and outdoor risk factors in Canada. J Epidemiol Community Health. 1994;48(5):488-9.
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    20. Graydon S, Meneilly M, Knip A, Miller D, D S, Daniel T, et al. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Diabetes in older people. Canadian Journal of Diabetes. 2018;42(supplement 1):S283-S95.

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