What should a 65-year-old female do about experiencing dizziness for a week?

Evaluation and Management of One Week of Dizziness in a 65-Year-Old Female

This patient requires urgent clinical evaluation to distinguish between benign peripheral causes (most likely) and potentially dangerous central causes of dizziness, with the diagnostic approach and treatment determined by the specific pattern and timing of symptoms rather than empiric medication trials. 1, 2

Immediate Diagnostic Priorities

Classify the Dizziness Pattern

The first critical step is determining whether this represents true vertigo (spinning sensation), presyncope (near-fainting), disequilibrium (imbalance), or vague lightheadedness, as this fundamentally changes the diagnostic approach. 3, 4 However, more important than the quality of symptoms is identifying the timing and triggers, as patients describe these more consistently than symptom quality. 4

Key questions to ask:

• Is the dizziness episodic or constant? 4
• Is it triggered by head movements or position changes? 2
• Are there associated hearing symptoms (fullness, tinnitus, hearing loss)? 2
• Duration of each episode (seconds, minutes, hours)? 2

Rule Out Central Causes First

At age 65, stroke accounts for 3-7% of all vertigo presentations and must be excluded. 5 Central causes require urgent treatment and carry significant mortality risk. 1

Perform the HINTS examination (head-impulse, nystagmus, test of skew) to distinguish peripheral from central etiologies—this is more sensitive than early MRI for posterior circulation stroke. 4 Look for:

• Atypical nystagmus patterns (direction-changing, purely vertical, or gaze-evoked) 4
• Negative head impulse test (abnormal—suggests central cause) 4
• Skew deviation present (suggests central cause) 4
• Associated neurologic symptoms: gait disturbance, dysarthria, diplopia, or focal weakness 1

If any central features are present, neuroimaging is mandatory. 1

Most Likely Diagnoses and Treatment Approach

Benign Paroxysmal Positional Vertigo (BPPV) - Most Common

If dizziness is episodic, lasts seconds to minutes, and is triggered by head movements or position changes, BPPV is the leading diagnosis. 2, 4 BPPV accounts for 36.7% of chronic vestibular disorders in elderly patients. 1

Diagnostic test: Perform the Dix-Hallpike maneuver. 2, 3

Treatment if BPPV confirmed:

• Perform canalith repositioning procedures (Epley maneuver) immediately—this is first-line treatment with 78.6-93.3% improvement rates versus only 30.8% with medication. 1, 2
• The Epley maneuver shows 80% vertigo resolution at 24 hours compared to 13% with sham treatment. 1
• Do NOT prescribe vestibular suppressant medications for BPPV—they significantly increase fall risk in elderly patients, cause cognitive deficits and drowsiness, and may actually prolong recovery by interfering with central compensation. 1, 2
• Patients who underwent repositioning maneuvers alone recovered faster than those receiving concurrent vestibular suppressants. 1

Important counseling: Recurrence rates are 10-18% at 1 year and may reach 36% over time. 1, 2

Ménière's Disease

If episodes last 20 minutes to 12 hours with associated hearing symptoms (fullness, tinnitus, fluctuating hearing loss), consider Ménière's disease. 2

First-line treatment approach:

• Dietary sodium restriction (ideally <1500 mg daily, maximum 2300 mg) 6
• Adequate hydration throughout the day 6
• Avoid excessive caffeine, alcohol, and nicotine 6
• Stress management and adequate sleep 6
• Regular exercise 6

Medication considerations:

• Betahistine (16-48 mg three times daily) may be effective in specific subgroups, particularly patients over 50 with hypertension and symptom onset <1 month. 1 However, recent high-quality trials show no significant difference between betahistine and placebo for vertigo control. 1
• Vestibular suppressants should only be used short-term for severe autonomic symptoms during acute attacks, not as definitive treatment. 6, 1, 2

If symptoms persist despite conservative management: Consider intratympanic steroid therapy. 6, 1

Vestibular Neuritis

If constant vertigo developed acutely without hearing loss and persists continuously, vestibular neuritis is likely. 4

Treatment:

• Short course of vestibular suppressants for severe acute symptoms only 6, 1
• Vestibular rehabilitation therapy is the primary intervention for persistent symptoms—this promotes central compensation and long-term recovery. 1
• Steroids may be considered in the acute phase 3

Critical Medication Safety Warnings for This 65-Year-Old Patient

Vestibular suppressants pose significant risks in elderly patients:

• Significantly increase fall risk 1, 2
• Cause drowsiness and cognitive deficits 1
• Interfere with driving ability 1
• Benzodiazepines are an independent risk factor for falls and should be avoided or discontinued. 1
• Long-term use interferes with central compensation in peripheral vestibular conditions, potentially prolonging symptoms 1
• Polypharmacy increases fall risk—avoid adding vestibular suppressants to existing medication regimens 1, 2

Fall prevention is critical: 53% of elderly patients with chronic vestibular disorders had fallen at least once in the past year, and 29.2% had recurrent falls. 1 Provide fall prevention counseling including home safety assessment and activity restrictions. 1

When Symptoms Persist Beyond Initial Treatment

If dizziness persists after one month of appropriate treatment:

• Vestibular rehabilitation therapy is the primary intervention, significantly improving overall gait stability compared to medication alone. 1
• Vestibular rehabilitation is especially indicated when balance and motion tolerance do not improve despite initial treatment. 1
• Increased balance performance is achieved only with movement/habituation-based vestibular rehabilitation, not with repositioning procedures alone. 1

Mandatory Follow-Up

Reassess within 1 month after initiating treatment to document resolution or persistence of symptoms. 1, 2 This timing is critical to identify treatment failures and adjust management accordingly.

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants as long-term therapy under any circumstances. 1
• Do not assume all dizziness in elderly patients is benign—maintain vigilance for central causes. 5
• Do not use vestibular suppressants for BPPV—they worsen outcomes and increase fall risk. 1, 2
• Do not skip the Dix-Hallpike maneuver if BPPV is suspected—diagnosis requires confirmation. 2, 3
• Do not delay vestibular rehabilitation in patients with persistent symptoms after failed medication trials. 1