From the Guidelines
The initial approach to managing unspecified dizziness in elderly patients should focus on a thorough clinical evaluation and assessment of modifiable risk factors, rather than immediate imaging, as the diagnostic yield of CT and MRI is low in the absence of vertigo, ataxia, or other neurologic deficits 1. When evaluating elderly patients with unspecified dizziness, it is essential to consider the high prevalence of this symptom in this population and the potential for underlying life-threatening conditions. However, as noted in the study by 1, the probability of detecting an abnormality on CT or MRI in patients with isolated dizziness is very low.
- A comprehensive assessment should include a detailed history focusing on the characteristics of dizziness, triggers, duration, and associated symptoms.
- A thorough physical examination should be performed, including vital signs, orthostatic blood pressure measurements, cardiovascular assessment, neurological examination, and vestibular testing.
- Laboratory tests, such as complete blood count, electrolytes, glucose, renal function, and thyroid function, should be conducted to identify potential underlying causes.
- Medication review is crucial, as many drugs commonly prescribed to elderly patients can cause dizziness, and addressing medication side effects can be an essential part of management.
- Initial management typically involves addressing modifiable risk factors, such as dehydration, medication side effects, and postural hypotension, and implementing fall prevention strategies, including home safety assessment, appropriate assistive devices, and physical therapy for balance training.
- Vestibular rehabilitation exercises can be beneficial for many causes of dizziness and should be considered early in the management plan, as they can improve symptoms and quality of life 1.
From the Research
Initial Approach to Managing Unspecified Dizziness in Elderly Patients
The initial approach to managing unspecified dizziness in elderly patients involves a thorough history and physical examination to identify the type of dizziness and point to a specific differential diagnosis 2. This approach is crucial as dizziness can be associated with a variety of underlying causes, each with specific treatment options.
Key Factors in Diagnosis
- A directed evaluation can be based on key factors such as a standardized history, physical examination, and basic laboratory evaluation 3.
- The most common disorder is some form of peripheral vestibular disorder, which can be predicted by a positive Nylen-Barany test with either vertigo, vomiting, or both 3.
- Potentially serious causes of dizziness can be identified by factors such as older age, lack of vertigo, or neurologic deficit, which can identify 86% of "serious" dizziness with 42% specificity 3.
Diagnostic Tests
- Certain tests such as Valsalva, carotid stimulation, Romberg and Quix tests, mental status examination, complete blood count, serum electrolytes, and BUN are of low yield and may be done in a directed manner based on a brief history 3.
- Routine testing of glucose in all patients and monitoring rhythm in patients age 45 and older is recommended 3.
Treatment Options
- Medications and vestibular rehabilitation may serve as treatment options for dizziness, but data on their efficacy in older patients is lacking 4.
- Successful amelioration of non-specific dizziness, light-headedness, or disequilibrium in the elderly requires careful assessment of the patient's entire medical condition, with appropriate treatment, and consideration of drug history and therapeutic drug withdrawal 5.