What questions and clinical examinations should be performed to determine the cause of vertigo in an elderly patient?

Evaluating Vertigo in the Elderly: Essential Questions and Clinical Examinations

Critical First Step: Define True Vertigo vs. Vague Dizziness

The most important initial task is to determine whether the patient is experiencing true vertigo (a sensation of spinning or rotational movement) versus vague dizziness, lightheadedness, or presyncope, as elderly patients often struggle to articulate their symptoms clearly and may present with atypical "vestibular disturbance" rather than frank spinning sensations. 1

Key Distinguishing Questions:

• "Do you feel like you or the room is spinning or rotating?" - A confident description of spinning is specific for inner ear dysfunction 1
• "Does it feel like you might faint or pass out?" - This suggests presyncope, NOT vertigo 1
• "Do you feel unsteady or off-balance without spinning?" - This represents dizziness rather than true vertigo 1

Essential History Questions

Timing and Duration (Most Critical for Differential Diagnosis)

Ask about the precise duration of vertigo episodes, as this single feature distinguishes most causes: 1

• Seconds only: BPPV (positional vertigo lasting <1 minute) 1
• Minutes: Possible stroke/TIA or vestibular migraine 1
• Hours: Ménière's disease or vestibular migraine 1
• Days (>24 hours continuous): Vestibular neuritis (12-36 hours of severe vertigo) or labyrinthitis 1

Triggering Factors

• "Does changing your head position trigger the spinning?" - BPPV is provoked by specific head movements; spontaneous onset suggests other causes 1
• "What were you doing when it started?" - Distinguish spontaneous versus provoked episodes 1

Associated Otologic Symptoms

Ask specifically about hearing changes, tinnitus, and ear fullness before, during, or after vertigo attacks: 1

• Fluctuating hearing loss + tinnitus + aural fullness: Ménière's disease 1
• Sudden profound hearing loss with vertigo: Labyrinthitis 1
• No hearing symptoms: BPPV, vestibular neuritis, or stroke 1
• Chronic progressive asymmetric hearing loss: Vestibular schwannoma 1

Neurologic Red Flags (Critical for Stroke Detection)

Inquire about symptoms suggesting posterior circulation stroke, which occurs in approximately 25% of acute vestibular syndrome cases and may reach 75% in high vascular risk elderly patients: 2

• "Do you have difficulty swallowing or speaking?" - Dysphagia/dysphonia suggests brainstem involvement 1
• "Have you had visual problems, double vision, or blurring?" - Visual disturbances suggest central causes 1
• "Have you had any weakness, numbness, or clumsiness?" - Sensory/motor deficits indicate stroke 1
• "Have you experienced sudden drop attacks or falls without warning?" - Can occur with stroke 1
• "Did you lose consciousness or have no memory of the event?" - Loss of consciousness is NEVER a symptom of peripheral vertigo 1

Critical caveat: Focal neurologic symptoms may be absent in one-third to two-thirds of stroke patients presenting with vertigo, so their absence does NOT rule out stroke. 2

Migraine History

• "Do you have a history of migraine headaches?" - Vestibular migraine is very common (34% of BPPV patients have migraine history) 1
• "Do you experience light sensitivity, sound sensitivity, or visual changes with the vertigo?" - Photophobia and phonophobia suggest vestibular migraine 1

Medical Comorbidities and Medications

Obtain detailed history of vascular risk factors and medications, as elderly patients with vertigo have significantly higher rates of: 1

• Diabetes (14% vs 5% in controls) 1
• Hypertension (52% vs 22% in controls) 1
• Prior stroke (10% vs 1% in controls) 1
• Current medications: blood pressure medications, diuretics, vestibular suppressants 1

Otologic History

• Prior ear surgery, chronic ear infections, ear pain, or previous hearing loss 1
• History of head trauma - Associated with BPPV 1

Falls Risk Assessment (Mandatory in Elderly)

Elderly patients with vertigo have a 12-fold increased risk of falls, and one-third of community-dwelling adults >65 years fall annually. 1, 2

Ask the CDC-recommended screening questions: 1

• "Have you fallen in the past year? How many times? Were you injured?"
• "Do you feel unsteady when standing or walking?"
• "Do you worry about falling?"

Essential Physical Examination

Dix-Hallpike Maneuver (For Posterior Canal BPPV)

Perform this positioning test to diagnose the most common cause of vertigo in elderly patients: 1, 3

• Position patient sitting upright, turn head 45° to one side
• Rapidly lay patient back with head hanging 20° below horizontal
• Observe for rotatory upbeating nystagmus with torsional component
• Positive test: Nystagmus appears after brief latency, fatigues with repetition 3
• Note: BPPV fatigue typically disappears within 30 minutes 3

Head Roll Test (For Lateral Canal BPPV)

Perform this test when Dix-Hallpike is negative but positional vertigo is suspected: 3

• Patient supine, rapidly turn head 90° to each side
• Observe for horizontal nystagmus

HINTS Examination (Critical for Stroke Detection)

This three-component examination has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% for early MRI: 2

1. Head Impulse Test: Rapid head thrust to each side while patient fixates on examiner's nose; abnormal corrective saccade indicates peripheral lesion
2. Nystagmus assessment: Direction-changing nystagmus suggests central cause
3. Test of Skew: Alternate cover test; vertical misalignment suggests central lesion

Nystagmus Patterns Suggesting Central (Stroke) Causes

The following nystagmus patterns indicate central pathology and require immediate neuroimaging: 1, 2

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component) 1
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) 1
• Gaze-holding, direction-switching nystagmus (beats right with right gaze, left with left gaze) 1
• Baseline nystagmus without provocative maneuvers 1

Neurologic Examination

Perform focused posterior circulation assessment: 1

• Cranial nerves: Assess for dysarthria, dysphagia, facial numbness, Horner's syndrome 1
• Cerebellar testing: Finger-to-nose, heel-to-shin for dysmetria 1
• Gait assessment: Observe for ataxia and fall risk 1
• Sensory and motor examination: Detect focal deficits 1

Otoscopic Examination

• Assess for chronic ear disease, effusion, or infection 1

Cardiovascular Examination

Given that cardiovascular disorders represent 20.4% of vertigo causes in the elderly, assess: 4

• Orthostatic vital signs
• Cardiac auscultation for arrhythmias
• Carotid bruits

Common Pitfalls to Avoid

Never rely solely on CT imaging for suspected stroke, as it frequently misses posterior circulation strokes. 2

Never assume absence of focal neurologic deficits rules out stroke, as up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs. 2

Recognize that elderly patients may not describe classic "spinning" even with true peripheral vertigo, instead reporting vague dizziness or vestibular disturbance. 1

Be cautious when performing positional maneuvers in elderly patients - use slow, gentle movements to avoid vascular or orthopedic complications. 5

Do not overlook multiple concurrent etiologies, as elderly patients often have several contributing factors (audio-vestibular 28.4%, cardiovascular 20.4%, neurological 15.1%, psychiatric 9.1%). 4