What are the common causes of vertigo in a 62-year-old female?

Common Causes of Vertigo in a 62-Year-Old Female

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in this age group, accounting for approximately 42% of cases in primary care settings, followed by vestibular neuritis (41%) and Ménière's disease (10%). 1

Primary Peripheral Causes (Most Common)

Benign Paroxysmal Positional Vertigo (BPPV)

• Brief episodes of vertigo lasting seconds to less than one minute, triggered by specific head position changes 1
• Not associated with hearing loss, tinnitus, or aural fullness 1
• Diagnosed with Dix-Hallpike maneuver showing characteristic torsional nystagmus 1
• Most common peripheral cause in this age demographic 1

Vestibular Neuritis

• Acute prolonged vertigo lasting 12-36 hours with severe nausea and vomiting 1
• No associated hearing loss, tinnitus, or aural fullness 1
• Viral infection of the vestibular system with decreasing disequilibrium over 4-5 days 1

Ménière's Disease

• Episodic vertigo attacks lasting 20 minutes to 12 hours 1
• Associated with fluctuating low-to-mid frequency hearing loss, tinnitus, and aural fullness in the affected ear 1
• Important note: Elderly patients with long-standing Ménière's may present with vague dizziness rather than frank vertigo 1

Vestibular Migraine

• Attacks lasting hours (can range from minutes to >24 hours) 1
• History of migraine with photophobia, phonophobia, or visual aura during at least 50% of dizzy episodes 1
• Hearing loss less likely than in Ménière's disease 1
• Lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 1

Critical Central Causes (Must Not Miss)

Posterior Circulation Stroke/Ischemia

• Vertigo lasting minutes with nausea, vomiting, and severe imbalance 1
• May include visual blurring, drop attacks, dysphagia, dysphonia, or other neurologic symptoms 1
• Usually no associated hearing loss or tinnitus 1
• In patients presenting with acute vestibular syndrome, posterior circulation infarct prevalence approaches 25% and may be as high as 75% in high vascular risk cohorts 1
• Critically, 75-80% of patients with stroke-related acute vestibular syndrome have no focal neurologic deficits 1

Vertebrobasilar Insufficiency

• Transient episodes related to vascular insufficiency 1
• More common in this age group with vascular risk factors 2

Less Common but Important Causes

Labyrinthitis

• Sudden severe vertigo with profound hearing loss lasting >24 hours 1
• Not episodic or fluctuating 1

Vestibular Schwannoma

• Chronic imbalance more prominent than episodic vertigo 1
• Asymmetric hearing loss and tinnitus that does not fluctuate 1

Autoimmune Disorders (e.g., Multiple Sclerosis)

• Progressive fluctuating bilateral hearing loss that is steroid-responsive 1
• May present with vision, skin, and joint problems 1
• Accounts for approximately 4% of acute vestibular syndrome cases 1

Age-Specific Considerations

In adults aged >65 years, one in three falls annually, with dizziness/vertigo deemed the primary etiology in 13% of falls 1. This creates significant morbidity risk, with fall-related costs exceeding $20 billion annually in the United States 1.

In one study, 9% of patients referred to a geriatric clinic had undiagnosed BPPV, and three-fourths of those with BPPV had fallen within the preceding 3 months 1.

Clinical Pitfalls to Avoid

• Do not dismiss isolated vertigo without focal neurologic findings as benign—11% of such patients presenting with acute persistent vertigo have acute infarct on imaging 1
• Elderly patients may describe "vague dizziness" rather than true spinning vertigo, even with significant inner ear pathology 1
• Timing and triggers are more diagnostically useful than the patient's descriptive terms for dizziness 1
• In emergency department settings, less than 1% of patients with vertigo and normal neurologic examination have contributory CNS pathology on CT, but this increases substantially with vascular risk factors 1