How do I manage a senior with chronic dizziness?

Management of Chronic Dizziness in Seniors

The most effective approach to managing chronic dizziness in seniors is to identify the specific vestibular syndrome type, implement targeted interventions based on the underlying cause, and address modifiable risk factors that contribute to falls and functional decline. 1, 2

Initial Assessment and Classification

First, determine which type of vestibular syndrome the patient has:

• Triggered episodic vestibular syndrome (e.g., BPPV): Dizziness triggered by specific head positions, lasting <1 minute
• Spontaneous episodic vestibular syndrome (e.g., Menière's disease, vestibular migraine): Episodes not triggered by position, lasting minutes to hours
• Acute vestibular syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting
• Chronic vestibular syndrome: Persistent dizziness lasting weeks to months 1

Key diagnostic elements:

• Timing (acute vs. episodic vs. chronic)
• Triggers (positional vs. spontaneous)
• Associated symptoms (hearing loss, headache, neurological symptoms)
• Orthostatic vital signs (rule out postural hypotension)
• Medication review (identify drugs causing dizziness)

Management Algorithm Based on Cause

1. Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause in seniors
• Treatment: Canalith repositioning procedures (Epley maneuver) 2
• Avoid unnecessary imaging for typical BPPV with positive Dix-Hallpike test

2. Vestibular Migraine

• Diagnostic criteria: ≥5 episodes lasting 5 minutes to 72 hours, history of migraine, ≥1 migraine symptoms during dizzy episodes 1
• Treatment: Migraine-specific medications and prophylactic therapy 2

3. Orthostatic Hypotension

• Treatment: Hydration, adequate salt intake, compression stockings, gradual position changes 2
• Review medications that may contribute (alpha-blockers, antihypertensives)

4. Medication-Induced Dizziness

• Treatment: Medication review and deprescribing when possible 3
• Common culprits: sedatives, antihypertensives, muscle relaxants
• Monitor for orthostatic effects with tizanidine, baclofen, and cannabinoids 1

5. Menière's Disease

• Treatment: Low-salt diet, diuretics, and intratympanic medications for refractory cases 2

6. Multifactorial Dizziness

• Common in seniors - often no single cause identified 4
• Treatment: Tailored multifaceted approach addressing all contributing factors

Therapeutic Interventions

Vestibular Rehabilitation Therapy

• First-line treatment for many causes of chronic dizziness 2, 5
• Individualized exercises to promote central compensation
• Particularly effective for uncompensated vestibular neuritis and central vestibulopathy

Pharmacologic Management

• Acute symptomatic relief: Meclizine for vertigo associated with vestibular disorders 6
• Caution: Limit use of vestibular suppressants as they may interfere with central compensation 2, 5
• Avoid long-term use of benzodiazepines and anticholinergics in elderly

Fall Prevention Strategies

• Assess fall risk (history of falls, fear of falling, balance impairment)
• Home safety evaluation
• Balance and strength training
• Appropriate assistive devices

Special Considerations for Seniors

Risk Assessment

• Seniors with dizziness have 12-fold increased risk for falls 1
• One in three community-dwelling adults >65 years falls each year 1
• Dizziness and vertigo account for 13% of falls in seniors 1

Comorbidity Management

• Address visual impairments (cataracts, macular degeneration)
• Manage proprioceptive deficits (neuropathy, arthritis)
• Treat cardiovascular conditions that may contribute to dizziness

Red Flags Requiring Urgent Evaluation

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness
• Altered mental status 2

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks of initiating treatment
• Use validated assessment tools to track progress:
  • Dizziness Handicap Inventory
  • Activities-Specific Balance Confidence Scale
  • Timed Up & Go test 2
• Adjust treatment plan based on response

By systematically identifying the underlying cause(s) of dizziness and implementing targeted interventions, most seniors with chronic dizziness can experience significant improvement in symptoms and quality of life.