Based on PubMed | Is dizziness a recognized symptom in Alzheimer’s disease, and what are the common causes and recommended management strategies?

Dizziness can occur in people with Alzheimer’s disease, but it is usually not a core symptom of the disease itself; instead, it more often reflects treatable issues such as blood pressure changes, medication side effects, inner-ear problems, or other medical conditions. In advanced Alzheimer’s, balance and physical function can decline, which may increase fall risk and a sensation of unsteadiness, but true spinning vertigo or lightheadedness typically has other causes that should be assessed and managed. ^[1]

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Is dizziness a recognized symptom in Alzheimer’s?

• Not a hallmark symptom: The typical early and mid-stage symptoms of Alzheimer’s center on memory, language, and thinking changes rather than dizziness. ^{[2] [3] [4]}
• Late-stage physical changes: As Alzheimer’s progresses, physical functions including balance and swallowing can be affected, which may contribute to falls and perceived unsteadiness; however, that is different from primary dizziness and should prompt evaluation for contributing causes. ^[1]
• Treatment-related dizziness: Some Alzheimer’s therapies particularly anti-amyloid monoclonal antibodies (e.g., lecanemab, donanemab) carry a risk of brain swelling or microbleeds (amyloid-related imaging abnormalities, ARIA) that, though rare, can cause dizziness among other neurologic symptoms; any new dizziness in someone receiving these drugs warrants urgent medical review. ^{[5] [6]}

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Common causes of dizziness in Alzheimer’s or dementia

• Orthostatic hypotension (blood pressure drop on standing): Very common in dementia and linked to confusion, lightheadedness, slow falls, and drowsiness; it often improves with targeted treatment. ^{[7] [8] [9]}
• Medication side effects and polypharmacy: Cardiovascular and central nervous system drugs (e.g., antihypertensives, sedatives), benzodiazepines, and medicines with anticholinergic effects can cause dizziness and worsen cognition; reviewing and reducing anticholinergic/sedative burden is beneficial. ^{[10] [11] [12] [13]}
• Autonomic dysfunction (especially Lewy body dementia): Sudden drops in blood pressure upon standing, dizziness, and falls are common due to autonomic nervous system involvement. ^[14]
• Inner-ear and vestibular disorders: Benign paroxysmal positional vertigo (BPPV), Ménière’s disease, and vestibular migraine are frequent causes of true vertigo in older adults. ^[15]
• Dehydration, anemia, hypoglycemia, or cardiac rhythm problems: Reduced blood flow or metabolic issues can produce lightheadedness, near-fainting, or balance problems and should be screened. ^{[16] [17]}
• Advanced Alzheimer’s-related balance decline: Late-stage disease can impair balance and coordination, raising fall risk and subjective unsteadiness; this still should not preclude evaluation for reversible causes. ^[1]
• ARIA with anti-amyloid therapy: Headache, confusion, dizziness, and focal neurologic signs may signal ARIA and require immediate assessment. ^{[5] [6]}

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Evaluation: practical steps

• Symptom characterization: Clarify whether the sensation is spinning (vertigo), lightheadedness, imbalance, or near-fainting, along with onset, triggers (standing up, turning in bed), duration, and associated symptoms (vision changes, headache, palpitations). ^[18]
• Vitals and orthostatic measurements: Check blood pressure and heart rate after 5 minutes lying down and again at 1 and 3 minutes standing to identify orthostatic hypotension. ^{[7] [8]}
• Medication review: Systematically assess all prescription and over-the-counter medicines for agents that can lower blood pressure, impair vestibular function, or sedate, and reduce anticholinergic/sedative load when feasible. ^{[10] [11] [12]}
• Screen for inner-ear disorders: Positional tests (e.g., Dix–Hallpike) when BPPV is suspected; consider audiovestibular testing if hearing loss or episodic vertigo is present. ^[19]
• Look for systemic contributors: Hydration status, complete blood count for anemia, glucose for hypoglycemia, and rhythm monitoring if palpitations or syncope occur. ^{[16] [15] [17]}
• Red flags: New severe headache, chest pain, breathing difficulty, neurologic deficits (weakness, numbness), fainting, double vision, irregular heartbeat, or difficulty walking warrant urgent evaluation. ^[20]
• Therapy-specific monitoring: In those receiving anti-amyloid monoclonals, promptly evaluate new dizziness with brain imaging to assess for ARIA. ^{[5] [6]}

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Management strategies

Orthostatic hypotension

• Non‑pharmacologic first: Increase fluids and salt intake when appropriate, rise slowly, elevate the head of bed, use compression stockings, and avoid large high‑carb meals; these measures reduce symptoms and prevent orthostasis in dementia units. ^[7]
• Treat reversible factors: Adjust or discontinue offending antihypertensives, diuretics, or psychoactive drugs that contribute to BP drops. ^{[10] [11]}
• Medications when needed: Under clinician guidance, agents such as midodrine or fludrocortisone may be considered if non‑pharmacologic measures are insufficient. Evidence suggests meaningful improvement in symptoms with targeted OH treatment in dementia populations. ^{[8] [9]}

Vestibular causes

• BPPV: Canalith repositioning maneuvers (e.g., Epley) are highly effective; teach caregivers how to minimize rapid head movements during acute episodes. ^[15]
• Vestibular rehabilitation: Balance and gaze stabilization exercises can improve chronic vestibular dysfunction and reduce fall risk. ^[21]

Medication-related dizziness

• Deprescribing: Reduce benzodiazepines and anticholinergic medications where possible; consider safer alternatives for sleep, anxiety, bladder, and allergy symptoms to lessen dizziness and cognitive side effects. ^{[12] [13]}
• Cholinesterase inhibitors and memantine: While generally beneficial for cognition, monitor for occasional dizziness as a side effect and adjust if symptoms are persistent and clinically significant. ^[22]

Safety and fall prevention

• Home modifications: Remove tripping hazards, improve lighting, add grab bars, and consider assistive devices (cane/walker) to reduce injury risk during episodes. ^[21]
• Activity strategies: Avoid sudden changes in position, sit at the bedside before standing, and pace activities during symptomatic periods. ^[23]

Monitoring and follow‑up

• Track episodes: Keep a simple diary of timing, triggers, and accompanying symptoms to guide targeted interventions. ^[18]
• Regular reviews: Ongoing blood pressure monitoring (including orthostatic checks) and medication reconciliation are important in Alzheimer’s to detect harmful drops and side effects over time. ^{[24] [25]}

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When to seek urgent care

Seek immediate medical attention for dizziness accompanied by severe headache, chest pain, shortness of breath, weakness, numbness, fainting, double vision, irregular heartbeat, or difficulty walking, or after a head injury. ^[20]

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Summary table: common causes and actions

Cause	Typical clues	First-line actions
Orthostatic hypotension	Lightheaded on standing, slow falls, fluctuating alertness	Hydration, slow position changes, compression stockings, review antihypertensives; consider meds if persistent
Medication side effects	Recent med changes; sedatives, anticholinergics, multiple drugs	Deprescribe or substitute safer options; monitor for improvement
Vestibular disorders (BPPV, Ménière’s)	Brief spinning with position changes, auditory symptoms	Canalith maneuvers; vestibular rehab; ENT evaluation if needed
Autonomic dysfunction (Lewy body dementia)	BP drops, dizziness, falls	Manage orthostatic hypotension; tailor meds; safety planning
Systemic issues (dehydration, anemia, hypoglycemia, arrhythmia)	General malaise, pallor, palpitations	Labs, hydration, treat underlying cause, cardiac evaluation if indicated
ARIA from anti‑amyloid therapy	New neuro symptoms (headache, confusion, dizziness)	Urgent imaging and specialist review; adjust or pause therapy

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Key takeaways

• Dizziness in Alzheimer’s is usually due to treatable factors, especially orthostatic hypotension, medications, or vestibular disorders. A structured evaluation can identify reversible causes and reduce falls. ^{[7] [8] [10] [15]}
• Balance decline in late-stage Alzheimer’s increases fall risk but should not delay work‑up for other contributors. Addressing environment, mobility aids, and rehabilitation improves safety. ^{[1] [21]}
• Monitor carefully if on anti‑amyloid therapies, as new dizziness can indicate ARIA and needs prompt assessment. ^{[5] [6]}