What are the causes of dizziness and falls in elderly patients?

From the Guidelines

Dizziness and falls in older patients are most commonly caused by a combination of factors including medication side effects, inner ear problems, cardiovascular issues, and neurological conditions, with benign paroxysmal positional vertigo (BPPV) being a significant contributor, as evidenced by a study published in 2017 1. The causes of dizziness and falls in older patients can be multifactorial, and it is essential to consider various factors when evaluating these patients. Medications that frequently cause these symptoms include antihypertensives, sedatives, antidepressants, and diuretics. Inner ear disorders such as BPPV, Meniere's disease, and vestibular neuritis can disrupt balance. Cardiovascular causes include orthostatic hypotension, arrhythmias, and carotid sinus hypersensitivity. Neurological conditions like Parkinson's disease, stroke, normal pressure hydrocephalus, and peripheral neuropathy also contribute significantly. Some key points to consider when evaluating older patients with dizziness and falls include:

• Age-related changes in vision, proprioception, and muscle strength compound these risks
• Environmental hazards at home, dehydration, anemia, and vitamin B12 deficiency are additional factors
• Management should include medication review, treating underlying conditions, physical therapy focusing on balance exercises, and home safety modifications
• The Epley maneuver can help with BPPV, while compression stockings may benefit those with orthostatic hypotension
• A study published in 2012 by the US Preventive Services Task Force recommends vitamin D supplementation and multifactorial risk assessment with comprehensive management of identified risks to prevent falls in older adults 1
• The American Geriatric Society recommends that clinicians ask their patients yearly about falls and balance or gait problems
• A study published in 2014 highlights the importance of evaluating the cause of falls and estimating future fall risk in geriatric patients, and recommends a multifaceted and multi-disciplined approach to assessment and management 1 Therefore, a thorough evaluation and management plan should be implemented to address the underlying causes of dizziness and falls in older patients, with a focus on preventing future falls and related injuries, as supported by the most recent and highest quality evidence 1.

From the Research

Causes of Dizziness and Falls in Older Patients

• Dizziness is a common presenting complaint among older patients in primary care, and it can be caused by various underlying conditions, including vertigo, presyncope, dysequilibrium, and non-specific dizziness 2.
• The most common risk factors for falls in older adults are prior falls, balance disorders, fear of falling, and dementia 3.
• Regular physical activity can reduce the risk of falls, and identifying injuries is the first step in evaluating older adults who have fallen 3.
• Medication-related dizziness is also a significant cause of dizziness in older adults, with certain medications such as cardiovascular and central nervous system agents being highly associated with dizziness 4.

Risk Factors and Evaluation

• A thorough examination and history can identify the type of dizziness and point to a specific differential diagnosis 2.
• The physical examination may include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver, and the HINTS examination when indicated 5.
• Laboratory testing and imaging are usually not required but can be helpful in evaluating the cause of dizziness 5.
• The Centers for Disease Control and Prevention has developed an easy-to-use tool to screen for and reduce fall risk, known as STEADI (Stopping Elderly Accidents, Deaths, and Injuries) 3.

Management and Treatment

• The treatment for dizziness is dependent on the etiology of the symptoms, and canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 5.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies of dizziness 5.
• Management of acute vestibular syndrome requires ruling out dangerous causes, such as stroke, and chronic dizziness can reflect dysfunction in the vestibular, somatosensory, or visual systems or in their central integration 6.
• Multicomponent interventions, including evaluating environmental and home safety factors, optimizing care of chronic medical conditions, and avoiding polypharmacy and drugs that increase the risk of falls, can reduce future fall risk 3.