What is the appropriate evaluation and management for a 67-year-old patient presenting with falls and dizziness?

Evaluation and Management of a 67-Year-Old Male with Falls and Dizziness

Begin with a focused assessment to rule out benign paroxysmal positional vertigo (BPPV) using the Dix-Hallpike test, perform orthostatic vital signs, conduct a thorough neurologic examination, and implement a multifaceted fall prevention program that includes medication review, home safety evaluation, and physical therapy referral. 1

Immediate Clinical Assessment

History Taking

• Obtain detailed circumstances of the fall including location, whether loss of consciousness occurred (noting that amnesia is common with syncope and may be reported simply as a fall), time spent on the ground, and any preceding symptoms such as palpitations, chest pain, or shortness of breath 1, 2
• Specifically ask about positional triggers for dizziness, as BPPV is the most common cause of vertigo in older adults and frequently presents as vague unsteadiness rather than classic vertigo in this age group 3
• Review all current medications with special attention to vasodilators, diuretics, antipsychotics, and sedative/hypnotics that increase fall risk 1, 2
• Assess for risk factors including difficulty with gait/balance, visual or neurological impairments, and alcohol use 1

Physical Examination

• Perform the Dix-Hallpike maneuver to identify BPPV, as this simple bedside test can reliably diagnose the condition and make expensive radiologic testing unnecessary 4, 3
• Measure orthostatic blood pressure (supine and after 1-3 minutes of standing); a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic is diagnostic for orthostatic hypotension 2
• Complete head-to-toe examination to rule out occult injuries, focusing on neurological assessment for neuropathies and proximal muscle strength 1
• Perform cardiovascular examination focusing on heart rate, rhythm, murmurs, and signs of heart failure 2
• Conduct the "get up and go test" to assess safety prior to discharge—patients unable to rise from bed, turn, and steadily ambulate require reassessment 1

Diagnostic Testing

• Obtain a 12-lead ECG to identify arrhythmias, conduction abnormalities, or structural heart disease 1, 2
• Consider complete blood count and standard electrolyte panel when clinically appropriate 1
• Order DEXA scan and check vitamin D, calcium, and parathyroid hormone levels to evaluate osteoporosis risk, as this reduces fracture risk with future falls 1
• Consider ambulatory ECG monitoring (Holter or event recorder) if arrhythmic syncope is suspected 2
• Imaging should only be obtained if trauma is suspected based on examination findings 1

Important caveat: Routine laboratory testing and radiography have low yield in unselected patients with dizziness and should be guided by clinical evaluation 5. The history and physical examination lead to a diagnosis in approximately 75% of patients 5.

Treatment and Intervention

BPPV Management (if diagnosed)

• Perform canalith repositioning procedure (Epley maneuver) immediately, as BPPV responds well to treatment and this is highly effective 4, 6
• Refer for vestibular rehabilitation if symptoms persist 6
• Avoid prescribing meclizine, as medications are unnecessary when BPPV is properly diagnosed and treated with repositioning maneuvers 4

Fall Prevention Program Components

The evidence strongly supports multifaceted interventions over single interventions 4, 1. Implement the following:

1. Physical Therapy and Exercise

• Refer to physical therapy for gait or balance problems 1
• Recommend balance training 3 or more days per week and strength training twice weekly 1
• Target interventions to improve balance, transfers, and gait, as these are particularly effective 4, 1

2. Medication Review

• Perform comprehensive medication assessment and consider referral to primary physician for medication review if polypharmacy concerns exist 1
• Pay particular attention to medications causing postural hypotension, as addressing this is particularly effective in fall prevention 4

3. Home Safety Assessment

• Arrange occupational therapy home safety evaluation with direct intervention, advice, and education 4, 1
• Recommend removing loose rugs or clutter, avoiding slippery surfaces, ensuring adequate lighting, and wearing properly fitting shoes with non-skid soles 1

4. Vitamin D Supplementation

• Prescribe vitamin D 800 IU daily for fall prevention 1

5. Cardiovascular Management

• For orthostatic hypotension, consider alpha agonists, mineralocorticoids, or lifestyle modifications 6
• Teach patient to recognize symptoms of orthostatic hypotension and slow down movements during transfers 1

Disposition and Follow-Up

• Consider admission if patient safety cannot be ensured based on the "get up and go test" 1
• Arrange expedited outpatient follow-up including home safety evaluation 1
• Refer to bone health clinic for osteoporosis treatment 1
• Implement structured interdisciplinary approach combining medical assessment, home safety evaluation, and targeted interventions 4, 1

Patient Education

• Counsel about BPPV recurrence risk (10-18% at 1 year, up to 36% long-term) and the importance of early return if symptoms recur 4
• Educate about increased fall risk, particularly important in elderly patients who may be more susceptible to serious injury 4
• Discuss atypical symptoms (hearing loss, gait disturbance, non-positional vertigo, persistent nausea/vomiting) that warrant further evaluation, as these may indicate underlying vestibular or CNS disorders 4
• Provide instruction on safe transfer techniques and scheduled voiding to prevent falls when rushing to the bathroom 1

Critical pitfall: Many older adults with BPPV experience dizziness as vague unsteadiness rather than vertigo, and some experience no dizziness symptoms at all due to "vestibular agnosia" 3. Therefore, all older adults with balance problems should have positional testing regardless of whether they report vertigo 3.