One never knows the dangers that lurk in the medicine cabinet...
One month ago I was referred a patient who had dizziness symptoms. He initially was having spinning symptoms and he also had significant allergies with nasal congestion. he was taking Benadryl and a nasal steroid spray. His primary care doctor suspected benign paroxysmal positional vertigo, correctly, and treated him with the Epley maneuver (described in a previous post). Now he was complaining of lightheadedness. I suspected the Benadryl. Benadryl may seem innocuous since it is an over-the-counter medication that has been around for decades but a single dose has the equivalent mental impairment of two alcoholic drinks and it is the chief ingredient in most OTC sleep medications. This patient was taking it four times daily. I told him to stop it and to try Allegra for his allergies since it didn't have these side effects.
He came in to see me a couple of days ago completely cleared of his symptoms of dizziness and very satisfied. When he and I were talking he reminded me of a very interesting patient I treated a few months ago.
An elderly gentleman in his mid eighties was referred for imbalance. I introduced myself and was confronted by an ancient looking man who was in a wheelchair and fairly confused. His examination didn't identify any focal abnormalities in the ear, nose or throat. He did have a tremulous voice and hand tremors. I suspected a neurolgical source of his imbalance as well as age related causes. In my experience no one is really happy treating these patients and they tend to get bounced from doctor to doctor. This patient had already seen the neurologist who hadn't been able to contribute much.
I tried to do a balance test in the office with him but he couldn't even stand up. I ordered a special balance study we do in the office called VideoNystagmography (VNG). In this test we look at eye motion tracking lights in the dark, and we place the patient in various positions seeing if it stimulates dizziness, and finally we place first warm and then cold water in the ears which will stimulate some vertigo which we can measure and compare to see if the ear is having a normal reaction.
In our pre-testing instructions patients are advised to stop medications that my impact balance. A review of this gentleman's medication list was daunting and he was on several medications that could affect the testing. Sometimes when the patients are advised to stop these meds for 48 hours we have poor compliance because they don't like the side effects of being off medication. I had a concern that would be the case in this situation. Either way we scheduled him for the test.
A few days later I heard my audiologist shout down the hallway, "Dan come here and take a look!"
What I saw was hard to believe. This patient who looked days from death just a few days earlier was smiling, bright eyed and walking into the exam for his testing. Needless to say his test was nearly normal and the only treatment he needed was to be taken off the meds that were messing both his mind and his balance.
I saw him again a few weeks later in follow up and asked him how he was doing. He told me he was great and that he had thrown our every medication in his medicine cabinet except for the ones he absolutely needed for maintaining his health. Ironically, many of the meds that had caused him his troubles had been progressively added because he kept on having various side effects from each of them. The problem started with the first anti-anxiety medication but from there he kept getting medications added on one after another until all the side effects resulted in a person who had lost balance, self confidence, and independence.
The Hippocratic Oath says "Do no harm" and in trying to follow that I rarely give patients over the age of 75 medications that impact wakefulness, mood, or balance. Unfortunately, the pharmaceutical industry doesn't agree with me and markets very aggressively to patients now. I suggest that we be wary of over prescribing and we should all make sure we don't pressure our providers into giving us or our loved ones medications that aren't truly necessary.
