What is the best treatment approach for a 65-year-old female experiencing vertigo (dizziness) for one week?

Treatment Approach for Vertigo in a 65-Year-Old Female

The first priority is to perform a Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV), and if positive, immediately treat with the Canalith Repositioning Procedure (Epley maneuver), which has 90-98% success rates and should NOT be treated with vestibular suppressant medications. 1, 2

Immediate Diagnostic Steps

• Perform the Dix-Hallpike maneuver to identify posterior canal BPPV by looking for characteristic rotatory nystagmus and vertigo provoked by the positioning test 1, 2
• Perform the supine roll test if the Dix-Hallpike is negative, to identify lateral canal BPPV by observing for direction-changing horizontal nystagmus 1, 2
• Conduct a focused neurologic examination to rule out central causes—look specifically for motor palsy, sensory deficits, dysarthria, ocular motor abnormalities, or limb ataxia that would indicate brainstem or cerebellar pathology 3, 4

Treatment Algorithm Based on Diagnosis

If BPPV is Confirmed (Most Common in This Age Group):

For Posterior Canal BPPV:

• Perform the Canalith Repositioning Procedure (Epley maneuver) immediately as first-line treatment with number needed to treat of 1-3 1, 2
• The maneuver may need modifications in elderly patients with cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or morbid obesity 1

For Lateral Canal BPPV:

• Use the Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 2
• This involves rolling the patient 360 degrees in a series of steps 1

If repositioning cannot be performed:

• Prescribe home-based Brandt-Daroff exercises or Cawthorne-Cooksey exercises as an alternative 2, 5

If BPPV Tests are Negative:

• Consider acute vestibular neuronitis if there is unidirectional horizontal nystagmus without other neurologic signs 5, 6, 4
• Consider Ménière's disease if there is episodic vertigo lasting 20 minutes to 12 hours with hearing loss, tinnitus, or aural fullness 1, 5
• Consider central causes requiring urgent imaging if there are neurologic deficits, vertical or direction-changing nystagmus that doesn't lessen with visual fixation, or severe truncal ataxia 3, 4

Medication Management: What NOT to Do

Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV treatment 1, 2

• These medications have no evidence for effectiveness as primary BPPV treatment and are not a substitute for repositioning maneuvers 1
• Vestibular suppressants interfere with central compensation in peripheral vestibular conditions 1
• Only use meclizine or antihistamines for short-term management (days, not weeks) of severe nausea or vomiting in severely symptomatic patients 1, 2, 7
• Exercise extreme caution in elderly patients as benzodiazepines and antihistamines significantly increase fall risk in this population 2

Critical Safety Considerations for This 65-Year-Old Patient

Counsel immediately about fall risk:

• Elderly patients with BPPV have a 53% rate of falling at least once per year and 29.2% have recurrent falls 1
• Assess home safety, recommend activity restrictions, and arrange supervision until BPPV resolves, particularly in the interval between diagnosis and definitive treatment 1, 2
• The risk is highest in elderly and frail patients who are more susceptible to serious injury from falls 1

Counsel about recurrence:

• BPPV recurrence rates are 10-18% at 1 year and may reach 36% over time 1
• Early recognition of recurrent symptoms allows for earlier retreatment 1

Mandatory Follow-Up

Reassess within 1 month to confirm symptom resolution 1, 2

• If symptoms persist, reevaluate for persistent BPPV requiring repeat repositioning, canal conversion to a different semicircular canal, or other underlying vestibular or CNS disorders 2
• Watch for atypical symptoms including subjective hearing loss, gait disturbance, non-positional vertigo, or persistent nausea/vomiting that may indicate concurrent vestibular or CNS pathology 1

Common Pitfalls to Avoid

• Never rely solely on medications without performing diagnostic maneuvers and repositioning procedures 2
• Never use prolonged vestibular suppressants as they delay compensation and increase fall risk in the elderly 1, 2
• Never miss central causes by failing to perform a thorough neurologic examination—central vertigo may present without obvious neurologic signs in lower cerebellar lesions 3, 4
• Never discharge without fall prevention counseling in this high-risk elderly population 1, 2