Managing Dizziness and Falls in Elderly Patients with Hypertension

Hypertension. Mild cardiac edema..?

Dear Deputy Director: My mother, in her seventies, frequently experiences dizziness and has fallen (she has hypertension and mild cardiac enlargement, which are managed with medication, but she still often feels dizzy and falls).
What are the common conditions associated with this? How should it be managed and prevented? Thank you.

Cai Xiansheng, 40~49 year old female. Ask Date: 2006/09/13

Dr. Cai Yaozhou reply Internal Medicine

When you see a doctor for "dizziness," it refers to a sensation of lightheadedness, dullness in the head, and visual disturbances, but not to the extent of feeling like the world is spinning.
This is often caused by internal medical conditions.
On the other hand, "vertigo" is when the patient feels a spinning sensation, as if the surrounding environment is moving, often accompanied by nausea and vomiting, which is typically due to vestibular disorders of the inner ear.

The human balance is primarily maintained by three systems: the visual system, the proprioceptive system, and the vestibular system of the inner ear.
For example, when we turn our head to the right, the horizontal semicircular canal in the right ear generates excitatory potentials, while the left side experiences a relative decrease in potential, resulting in a vestibulo-ocular reflex response.
This is further integrated with visual information and changes in neck proprioception.
Since birth, the interaction of these three systems has been continuously integrated and stored in the brainstem's data center, allowing individuals to gradually adjust to various balance movements.
When these three systems are "out of sync," it can lead to dizziness and vertigo.
For instance, elderly individuals are more prone to dizziness due to declining vision and neurodegeneration (including vestibular nerve degeneration), which leads to poor vestibulo-ocular reflexes.
Degenerative bone spurs in the cervical spine can also impair cerebral blood circulation, and when combined with conditions like hypertension and diabetes, patients may experience persistent lightheadedness.
Clinically, if vertigo is accompanied by nausea and vomiting, it is often indicative of peripheral vestibular system disorders.
However, if the patient only experiences dizziness and visual disturbances without nausea or vomiting, it is more likely due to systemic internal medical conditions.
Additionally, patients with anxiety and stress-related disorders often complain of persistent lightheadedness.

Reply Date: 2006/09/13

More Info

Managing dizziness and falls in elderly patients, particularly those with hypertension, is a multifaceted challenge that requires a comprehensive understanding of the underlying causes and appropriate interventions. In the case of your mother, who is in her seventies and experiences frequent dizziness and falls despite being on medication for hypertension and having a mild heart condition, several factors could contribute to her symptoms.

Common Causes of Dizziness and Falls in Elderly Patients
1. Orthostatic Hypotension: This condition occurs when a person experiences a significant drop in blood pressure upon standing up, leading to dizziness and an increased risk of falls. It is particularly common in older adults and can be exacerbated by medications used to treat hypertension.

2. Medication Side Effects: Many antihypertensive medications can cause dizziness as a side effect. Diuretics, for example, can lead to dehydration and electrolyte imbalances, which may contribute to dizziness. It is essential to review her medication regimen with her healthcare provider to determine if adjustments are necessary.

3. Vestibular Disorders: Conditions affecting the inner ear, such as benign paroxysmal positional vertigo (BPPV), can cause episodes of dizziness. These conditions are common in older adults and can lead to falls if not properly diagnosed and treated.

4. Cognitive Impairment: Dementia or other cognitive disorders can lead to confusion and balance issues, increasing the risk of falls. Assessing cognitive function may be necessary if there are concerns in this area.

5. Visual Impairments: Poor vision can significantly affect balance and spatial awareness, leading to an increased risk of falls. Regular eye examinations are crucial for older adults.

6. Dehydration and Nutritional Deficiencies: Inadequate fluid intake or poor nutrition can lead to weakness and dizziness. Ensuring that your mother is well-hydrated and receives a balanced diet is essential.

Management and Prevention Strategies
1. Regular Monitoring of Blood Pressure: It is crucial to monitor her blood pressure regularly, especially when changing positions (e.g., from sitting to standing). If orthostatic hypotension is suspected, her healthcare provider may recommend specific strategies to manage it, such as increasing fluid intake or adjusting medications.

2. Medication Review: A thorough review of her medications by her healthcare provider can help identify any that may contribute to dizziness. Adjustments or alternative medications may be necessary.

3. Physical Therapy: Engaging in physical therapy can help improve balance and strength, reducing the risk of falls. A physical therapist can design a tailored exercise program focusing on balance training and strength building.

4. Home Safety Modifications: Assessing her living environment for fall hazards is essential. This may include removing tripping hazards, ensuring adequate lighting, and installing grab bars in bathrooms.

5. Vestibular Rehabilitation: If a vestibular disorder is diagnosed, vestibular rehabilitation therapy can help manage symptoms and improve balance.

6. Regular Eye Exams: Ensuring that her vision is regularly checked and corrected as needed can help reduce the risk of falls.

7. Education and Awareness: Educating your mother about the importance of moving slowly when changing positions and being aware of her surroundings can empower her to take precautions against falls.

Conclusion
Dizziness and falls in elderly patients with hypertension can stem from various causes, including medication side effects, orthostatic hypotension, vestibular disorders, and cognitive impairments. A comprehensive approach that includes regular monitoring, medication review, physical therapy, home safety modifications, and education can significantly reduce the risk of falls and improve your mother's quality of life. It is essential to work closely with her healthcare provider to develop a tailored management plan that addresses her specific needs and concerns.

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