Although there is little evidence for the effectiveness of antivertiginous drugs (AVDs) for dizziness of vestibular origin and no evidence for the effectiveness of AVDs for non-vestibular dizziness,1 prescribing drugs for dizzy patients in general practice is still common practice. Recent publication of the updated Beers Criteria for potentially inappropriate medication use2 stimulated us to investigate the prescription of AVDs by GPs in older patients with non-vestibular dizziness and to analyse the relationship between prescribing AVDs and patient’s age, sex, and presented dizziness symptom(s).
The data used in this study are derived from the Second Dutch National Survey of General Practice (DNSGP-2).3,4 For this survey, 195 GPs in 104 practices recorded data about all patient contacts for 12 consecutive months. We extracted patient characteristics, consultation characteristics (symptom[s] presented/new or existing episode), and prescribed drugs. For the identification of our target population (patients aged ≥65 years who visited their GP because of dizziness) we developed an extensive search strategy, based on Dutch synonyms for dizziness.4 We manually reviewed the full-text medical records of identified patients and included all patients aged ≥65 years with a new episode of dizziness. In order to select only patients with non-vestibular dizziness, we excluded dizzy patients with GP diagnosis vertiginous syndrome, labyrinthitis, Ménière’s disease, vestibulitis, and benign paroxysmal positional vertigo. For group comparisons we used the χ2 test, logistic regression analysis, and multilevel analysis (to adjust for the categorical variable ‘general practice’).
Of 50 601 patients aged ≥65 years, we identified 1640 older patients with a new episode of non-vestibular dizziness (mean age 75.4 years ± 7.1; 64.3% female). Of these, 151 (9.2%) received a prescription for AVDs from their GP during the first consultation in this episode. GPs most frequently prescribed betahistine (54%), followed by cinnarizine (44%), and other AVDs (2%). Prescription of AVDs by GPs for patients with a new episode of non-vestibular dizziness was independently associated with the presented symptoms ‘spinning sensation’ and ‘loss of equilibrium’, whereas not prescribing AVDs was independently associated with the presented symptom ‘near faint’ (Table 1).
Table 1.
Determinants of prescribing antivertiginous drugs by GPs for older patients with a new episode of non-vestibular dizziness
| N (%) | ||||
|---|---|---|---|---|
| Variable | Prescription of AVD: yes (n = 151) | Prescription of AVD: no (n = 1489) | Univariate P-value | Multileve analysis OR (95% CI) |
| Age, years | ||||
| 65-74 | 82 (54.3) | 710 (47.7) | 0.121 | |
| 75-84 | 56 (37.1) | 593 (39.8) | 0.512 | |
| ≥85 | 13(8.6) | 186 (12.5) | 0.164 | |
| Female | 110 (72.8) | 945 (63.5) | 0.022 | |
| Presented dizziness symptom | ||||
| Dizziness | 95 (62.9) | 968 (65.0) | 0.607 | |
| Spinning sensation | 52 (34.4) | 178 (12.0) | <0.001 | 3.6 (2.4 to 5.4) |
| Near faint | 2 (1.3) | 183 (12.3) | <0.001 | 0.1 (0.04 to 0.5) |
| Feeling unwell | 3 (2.0) | 115 (7.7) | 0.009 | |
| Lightheadedness | 3 (2.0) | 75 (5.0) | 0.093 | |
| Loss of equilibrium | 10 (6.6) | 35 (2.4) | 0.002 | 3.7 (1.7 to 8.0) |
| Unsteadiness | 5 (3.3) | 39 (2.6) | 0.616 | |
| Tendency to fall | 4 (2.6) | 37 (2.5) | 0.902 | |
| Instability | 1 (0.7) | 32 (2.1) | 0.215 | |
| Giddy | 0 (0.0) | 32 (2.1) | 0.069 | |
| Everything turning black | 0 (0.0) | 30 (2.0) | 0.078 | |
AVD = antivertiginous drug. OR = odds ratio.
Despite the absent evidence for the effectiveness of AVDs for non-vestibular dizziness, GPs prescribed AVDs during the first consultation in 9.2% of older patients with non-vestibular dizziness. Although this is not exceptionally high (Bregnhøj reported prescribing of ineffective medication in 6% of all GP prescriptions5), AVDs may cause serious side effects, like dystonia and parkinsonism.6,7 Next to this, prescribing ineffective drugs may distract from the preferred approach of non-vestibular dizziness in older patients: a systematic exploration of possible contributory causes of dizziness that are amenable to treatment.8 Reasons for irrational prescribing of AVDs may be the perceived medical need of the patient, patients’ expectations, or doctor’s (incorrect) perceptions of patients’ expectations.9 However, the results of our regression analysis also suggest another explanation: immediate drug prescribing as a clinical reflex (‘looks vestibular’).
Despite the absent evidence, GPs prescribe AVDs for older patients with non-vestibular dizziness. This should be discouraged, as AVDs may have side effects and prescribing ineffective drugs may distract from another, more preferred, approach of dizziness in older patients.
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