What is the approach to evaluating and managing dizziness in the elderly?

Evaluation and Management of Dizziness in the Elderly

The evaluation of dizziness in elderly patients should focus on timing, triggers, and associated symptoms rather than symptom quality, using a structured approach with specific diagnostic maneuvers like the Dix-Hallpike test for vertigo and targeted treatment based on the identified cause. 1

Initial Assessment Framework

Classification by Timing and Presentation

• Acute vestibular syndrome: Sudden onset, severe vertigo lasting days
• Triggered episodic vestibular syndrome: Brief episodes with specific triggers
• Spontaneous episodic vestibular syndrome: Recurrent episodes without clear triggers
• Chronic vestibular syndrome: Persistent symptoms lasting months 1

Key Elements of History

1. Timing characteristics: Onset, duration, frequency
2. Specific triggers: Position changes, standing, medications
3. Associated symptoms: Hearing loss, tinnitus, neurological deficits
4. Medication review: Focus on polypharmacy, recent changes
5. Fall history: Up to 30% of falls in elderly may be due to syncope 2

Physical Examination

• Orthostatic vital signs: Measure BP/HR supine and standing (essential in elderly)
• Dix-Hallpike maneuver: Gold standard for diagnosing posterior canal BPPV
• HINTS examination: Head Impulse, Nystagmus, Test of Skew (more sensitive than early MRI for stroke detection) 1
• Cardiovascular assessment: Evaluate for arrhythmias, carotid disease
• Neurological examination: Assess for focal deficits, gait, and balance

Common Causes and Specific Management

BPPV (Benign Paroxysmal Positional Vertigo)

• Presentation: Brief vertigo with position changes
• Diagnosis: Positive Dix-Hallpike test
• Treatment: Canalith Repositioning Procedure (Epley maneuver) with 80% success rate 1
• Follow-up: Reassess within 1 month; educate about 15% annual recurrence rate

Vestibular Neuritis/Labyrinthitis

• Presentation: Sudden severe vertigo lasting days
• Diagnosis: Unidirectional horizontal nystagmus, normal HINTS exam
• Treatment: Early corticosteroid therapy
• Caution: Must rule out stroke with HINTS exam

Orthostatic Hypotension

• Presentation: Lightheadedness upon standing
• Diagnosis: BP drop ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing
• Treatment:
  • Medication adjustment (reduce/eliminate culprit medications)
  • Hydration, compression stockings
  • Gradual position changes

Medication-Induced Dizziness

• High-risk medications: Diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotics, tricyclic antidepressants, antihistamines 2
• Management: Medication review and adjustment is critical in elderly patients

Menière's Disease

• Presentation: Episodes with hearing loss, tinnitus, aural fullness
• Diagnosis: Characteristic audiometric findings
• Treatment: Low-salt diet and diuretics 1

Vestibular Migraine

• Presentation: Variable duration, history of migraine, photophobia
• Treatment: Migraine prophylaxis and trigger avoidance 1

Central Causes (Stroke/TIA)

• Red flags: Sudden onset with neurological deficits, abnormal HINTS exam
• Diagnosis: MRI brain (without contrast) - more sensitive than CT for posterior circulation strokes
• Management: Urgent neurological referral

Special Considerations in the Elderly

Multifactorial Nature

• Dizziness in elderly is often multifactorial rather than having a single cause 3
• Consider dizziness as both a symptom of specific diseases and as a geriatric syndrome

Age-Related Changes Contributing to Dizziness

• Reduced thirst perception
• Decreased ability to preserve sodium and water
• Diminished baroreceptor response
• Reduced heart rate response to orthostatic stress
• Progressive autonomic dysfunction 2

Assessment Challenges

• Up to 40-60% of elderly patients lack witness accounts of episodes 2
• Up to one-third of events may present as falls rather than typical dizziness 2
• Cognitive impairment may affect symptom reporting (present in 5% of 65-year-olds and 20% of 80-year-olds) 2

Diagnostic Testing

When to Order Imaging

• Acute vestibular syndrome with abnormal HINTS examination
• Neurological deficits
• High vascular risk patients with acute vestibular syndrome
• Chronic undiagnosed dizziness not responding to treatment 1

Preferred Imaging Modality

• MRI brain (without contrast): Higher sensitivity for stroke detection, especially in posterior circulation
• CT scan: Consider when MRI contraindicated or unavailable; useful for detecting large intracranial masses or hemorrhage 1

Other Testing

• Audiogram: For evaluating hearing loss associated with Menière's disease
• ECG/Holter monitoring: For suspected arrhythmias
• Carotid sinus massage: In elderly with suspected carotid sinus hypersensitivity 2

Treatment Approach

Vestibular Rehabilitation

• Effective for persistent dizziness after BPPV resolution
• Can be self-administered or clinician-directed
• Accelerates central compensation for vestibular imbalance 1

Medication Management

• Meclizine: May be used short-term for vertigo associated with vestibular system diseases
• Caution: Not recommended for routine BPPV treatment; use with caution due to anticholinergic effects in elderly 1
• Medication review: Critical to identify and modify medications contributing to dizziness

Monitoring Progress

• Use validated assessment tools:
  • Activities-Specific Balance Confidence Scale
  • Dizziness Handicap Inventory
  • Dynamic Gait Index
  • Timed Up & Go test 1

Pitfalls to Avoid

• Focusing on quality of dizziness rather than timing and triggers
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
• Routinely prescribing vestibular suppressants for BPPV
• Missing central causes of vertigo by not performing the HINTS examination
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1