What is the appropriate workup and management for a 78-year-old female patient presenting with dizziness?

Diagnostic Workup and Management for Dizziness in a 78-Year-Old Female

The diagnostic approach for a 78-year-old female with dizziness should focus on timing, triggers, and associated symptoms, with specific attention to ruling out central causes through targeted physical examination maneuvers like the HINTS test, and should include evaluation for orthostatic hypotension, which is common in this age group. 1

Initial Assessment

Classification of Dizziness

First, determine the specific type of dizziness the patient is experiencing:

• Vertigo: Sensation of spinning or rotation
• Presyncope: Feeling of impending faintness
• Disequilibrium: Unsteadiness when walking
• Lightheadedness: Vague sensation of disconnection 1, 2

Key History Elements

• Timing: Onset, duration, and frequency
• Triggers: Position changes, specific movements, medications
• Associated symptoms: Hearing loss, tinnitus, headache, neurological deficits
• Medication review: Focus on those that can cause dizziness
• Vascular risk factors: Hypertension, diabetes, smoking, hyperlipidemia 1, 3

Physical Examination

Essential Components

1. Vital signs: Including orthostatic blood pressure (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing indicates orthostatic hypotension) 1

2. Neurological examination:

   • Cranial nerves
   • Motor strength
   • Sensory testing
   • Coordination
   • Gait assessment

3. Vestibular assessment:

   • Nystagmus evaluation: Direction, triggers
   • Dix-Hallpike maneuver: For suspected BPPV
   • HINTS examination: (Head-Impulse, Nystagmus, Test of Skew) for acute vestibular syndrome 1, 3

4. Cardiovascular examination:

   • Heart rate and rhythm
   • Carotid bruits
   • Signs of heart failure 4

Diagnostic Testing

Indicated Tests Based on Clinical Presentation

1. Laboratory testing:

   • Complete blood count
   • Electrolytes
   • Glucose
   • Thyroid function tests
   • Vitamin B12 level (especially in elderly)

2. Imaging:

   • MRI brain (without contrast): Indicated for:

     • 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

   • CT scan: Not routinely indicated but should be performed when vertigo is accompanied by:

     • Severe headache
     • Age >60 years (applicable to this patient)
     • Vomiting
     • Focal neurological deficits 1

3. Specialized testing (when indicated):

   • Video head impulse testing (vHIT)
   • Audiometry (if hearing loss present)
   • Vestibular evoked myogenic potentials 1

Management Approach

Treatment Based on Diagnosis

1. Benign Paroxysmal Positional Vertigo (BPPV):

   • Canalith Repositioning Procedure (Epley maneuver): 80% success rate 1

2. Vestibular neuritis/labyrinthitis:

   • Early corticosteroid therapy
   • Vestibular rehabilitation 1

3. Orthostatic hypotension:

   • Medication adjustment
   • Hydration
   • Compression stockings
   • Gradual position changes 1

4. Ménière's disease:

   • Low-salt diet
   • Diuretics
   • Intratympanic dexamethasone or gentamicin in refractory cases 1

5. Central causes (stroke, TIA):

   • Urgent neurological referral
   • Management of vascular risk factors 1, 3

Vestibular Rehabilitation

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

Special Considerations for Elderly Patients

• Higher risk of polypharmacy contributing to dizziness
• Increased prevalence of multifactorial dizziness
• Greater risk of falls and associated complications
• Higher likelihood of central causes requiring urgent attention
• Consider using validated assessment tools:
  • Activities-Specific Balance Confidence Scale
  • Dizziness Handicap Inventory
  • Dynamic Gait Index
  • Timed Up & Go test 1

Common 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 by not performing the HINTS examination
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo
• Attributing dizziness to "old age" without thorough evaluation 1

In this 78-year-old female, particular attention should be paid to medication review, orthostatic hypotension assessment, and evaluation for central causes of dizziness given her age puts her at higher risk for cerebrovascular events.