What is the best approach for managing dizziness in the elderly?

Management of Dizziness in the Elderly

The best approach for managing dizziness in the elderly is to identify the specific underlying cause, with BPPV being the most common treatable cause, followed by vestibular rehabilitation for general disequilibrium, and targeted medication management for specific conditions. 1

Diagnostic Approach

• Determine the specific type of dizziness by assessing timing and triggers (episodic vs. constant, positional vs. spontaneous) to guide appropriate treatment 1
• Ensure patients are describing true vertigo (sense of rotation or spinning) versus vague dizziness, which may indicate different underlying causes 2
• Perform targeted physical examination including:
  • Dix-Hallpike maneuver for BPPV 1
  • Orthostatic blood pressure measurement 1
  • Assessment for nystagmus 1
  • HINTS examination (Head Impulse, Nystagmus, Test of Skew) for suspected central causes 1
• Assess for fall risk, as dizziness significantly increases fall risk in older adults 2

Common Causes and Specific Management

Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause of vertigo in older adults (characterized by brief episodes when changing head position) 1
• Treatment: Canalith Repositioning Procedures (CRP) such as the Epley maneuver with 80-90% success rates 1, 2
• Counsel patients about recurrence risk (30-50% within 5 years) and importance of follow-up 2
• Vestibular rehabilitation exercises if symptoms persist 1

Vestibular Disorders

• For conditions like vestibular neuritis, labyrinthitis, and Menière's disease 1
• For Menière's disease: low-salt diet and diuretics as first-line therapy; intratympanic steroid or gentamicin injections for refractory cases 1
• Use vestibular suppressants (like meclizine) with caution and short-term only, as they may delay central compensation 1, 3
  • Meclizine dosage: 25 mg to 100 mg daily in divided doses 3
  • Monitor for side effects including drowsiness, dry mouth, and blurred vision 3

Orthostatic Hypotension

• Implement lifestyle modifications: gradual position changes, adequate hydration, compression stockings 1
• Adjust medications that may contribute to orthostatic hypotension 1

Multifactorial Dizziness

• Dizziness in older adults is often multifactorial, requiring comprehensive assessment 1, 4
• Review and potentially modify medications that may contribute to dizziness 5
• Address sensory deficits such as visual impairment, peripheral neuropathy, and proprioceptive loss 1

Vestibular Rehabilitation and Fall Prevention

• Initiate vestibular rehabilitation early to avoid psychosocial complications like fear of falling 4
• Implement proprioceptive training with exercises on varying surfaces to improve balance 1
• Develop fall prevention strategies:
  • Home modifications to reduce fall hazards 1
  • Proper footwear 1
  • Activity pacing 1
  • Assessment of home safety and need for supervision until dizziness resolves 2

Special Considerations for Elderly Patients

• Assess for cognitive impairment which may affect symptom reporting and treatment adherence 1
• Screen for falls risk with questions such as:
  • "Have you had a fall in the past year? How many times? Were you injured?" 2
  • "Do you feel unsteady when standing or walking?" 2
  • "Do you worry about falling?" 2
• Consider using standardized tools like Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale for detailed falls risk assessment 2
• The "Dizziness Handicap Inventory Scale" can help establish the extent of the dizziness problem 4

When to Consider Imaging

• Obtain neuroimaging (MRI preferred) when:
  • Neurological symptoms accompany dizziness 1
  • Symptoms suggest central vertigo rather than peripheral causes 1
  • Symptoms persist despite appropriate treatment 1
• Avoid unnecessary diagnostic testing, as it increases healthcare costs without improving outcomes 2

Medication Management

• Use vestibular suppressants like meclizine cautiously and short-term only 1, 3
• Be aware of potential drug interactions:
  • Coadministration with other CNS depressants, including alcohol, may increase CNS depression 3
  • CYP2D6 inhibitors may interact with meclizine 3
• Review all medications as polypharmacy is a common contributor to dizziness in the elderly 5, 6