Case of the Month

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Bonnie Nelson Wells, PA-C

Bonnie Wells worked as a federal service PA for almost 30 years, most recently at the VA Hospital in Albuquerque, New Mexico. She has indicated no relationships to disclose relating to the content of this article.

CASE

The patient is an 88-year-old white male who presented with a complaint of new-onset dizziness so severe that it caused him to limit his activity. He was spending more and more time in his independent living apartment out of concern that the dizziness would recur and he would fall and injure himself.

HISTORY The patient had a pacemaker implanted 6 months ago for an irregular heart rhythm, and his follow-up examinations were normal. He also was seeing an oncologist for metastatic prostate cancer. Periodic CT and bone scans showed no new pathology other than stable lytic bony metastatic sites throughout his skeleton. Laboratory test results were also normal.

He reported his dizziness problem to all of his physicians. The basal rate of his pacemaker was increased, but this did not significantly change his symptoms. After a tilt test and standing and lying down BP measurements, he was advised that he had orthostatic hypotension and that he should not get up or move about too quickly.

The patient’s medications included amiodarone, ranitidine, warfarin, and nilutamide. The warfarin was added to his regimen after the pacemaker was placed. He had been taking the remaining medications for several years without experiencing any difficulties.

The patient said he experienced episodes of dizziness throughout the day and described two distinct types of episodes. He experienced light-headedness when he got up or moved too quickly. The symptoms subsided quickly once he sat for a minute or two. At other times, he felt as though he was going to pass out, and he would try to get to a chair or his bed to avoid falling. During these episodes, he had to stay immobile for approximately 30 or more minutes. These episodes occurred daily and always in the morning approximately 60 minutes after breakfast.

WHAT IS YOUR DIAGNOSIS?

Benign positional vertigo
Medication side effect
Postprandial hypotension

DISCUSSION

The patient’s history was consistent with postprandial hypotension. His profound dizziness occurred 60 minutes after eating his breakfast, and postprandial hypotension is a decline in arterial BP that occurs after a meal, most commonly after breakfast or lunch. In some elderly persons, BP declines an average of 11 mm Hg within 75 minutes after eating a meal. Up to one third of elderly persons have a postprandial BP decline of more than 20 mm Hg. This decline can be even greater when medications that reduce BP are taken before a meal.

Postprandial hypotension may be related to impaired baroreflex compensation for splanchnic blood pooling during digestion. The condition has two manifestations. One is a physiologic, age-related phenomenon that rarely causes symptoms unless exacerbated by other hypotensive stress, such as antihypertensive therapy. The other is a more severe pathologic syndrome related to autonomic insufficiency in which more profound hypotension is accompanied by syncope.

Medication side effects should be a consistent concern in the elderly. They are more likely to be taking multiple prescription medications, and the addition of OTC medications can further complicate the situation. The elderly are also more susceptible to and less tolerant of drug-drug interactions, adverse drug reactions, and detrimental drug-disease interactions. In this instance, the patient had been taking the same medications for several years without adverse incidents. The warfarin, added most recently, had been well tolerated. Laboratory test results had been stable.

COMMENT All providers caring for elderly patients should be aware of the hypotensive effects of food intake and should consider postprandial hypotension in the evaluation of syncope, falls, dizziness, and other cerebral ischemic symptoms. A general evaluation for hypoxemia, hypoglycemia, volume depletion, and cardiac abnormalities should be performed. BP measurements can detect vasomotor instability such as orthostatic hypotension and postprandial hypotension.

The patient in this case did not want to take additional medication. He was advised to start drinking a small amount of coffee with breakfast and to gradually increase his coffee consumption to a half a cup daily over a 2-week period. By the end of the 2 weeks, his profound morning episodes of dizziness had resolved.

The patient was also advised to supplement his breakfast and dinner with small, frequent meals during the day. He was advised not to take his morning medications before breakfast, as this could also cause dizziness.

Erich Fogg, PA-C, MMSc, department editor