What is the initial workup for dizziness in an elderly male?

Initial Workup for Dizziness in an Elderly Male

Begin by determining whether the patient has true vertigo (spinning sensation) versus vague dizziness, lightheadedness, or presyncope, as this single distinction drives the entire diagnostic pathway and elderly patients often cannot articulate their symptoms clearly. 1

Step 1: Characterize the Symptom Type

• Ask the patient to describe the sensation precisely: A confident description of spinning is specific for inner ear dysfunction, while feeling faint suggests presyncope (not vertigo), and feeling unsteady without spinning represents disequilibrium. 1
• Elderly patients frequently present with atypical "vestibular disturbance" rather than classic spinning, making this initial characterization more challenging but critically important. 1, 2

Step 2: Obtain Targeted History

Duration of episodes is the single most discriminating historical feature:

• Seconds only (typically <1 minute): BPPV (benign paroxysmal positional vertigo) 1, 2
• Minutes duration: Stroke/TIA or vestibular migraine 1, 2
• Days to weeks: Vestibular neuritis versus posterior circulation infarction 2

Essential additional questions:

• Positional triggers: Head position changes strongly suggest BPPV 1, 2
• Migraine history: Vestibular migraine accounts for up to 14% of vertigo cases and has a lifetime prevalence of 3.2% 3
• Fall history: One-third of elderly patients fall annually, and dizziness increases fall risk 12-fold 3
• Medication review: Polypharmacy is a major contributor to dizziness in the elderly, particularly diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotics, tricyclic antidepressants, and antihistamines 3

Step 3: Perform Focused Physical Examination

The Dix-Hallpike maneuver is the single most important diagnostic test and should be performed on every elderly patient with dizziness:

• This bedside test diagnoses BPPV, the most common cause of vertigo in elderly patients 1, 2
• A positive test shows characteristic torsional, upbeating nystagmus and reproduces the patient's symptoms 2
• If positive, no imaging is necessary 3, 2

Assess for dangerous central causes:

• Examine nystagmus patterns carefully: Downbeating nystagmus, direction-changing nystagmus, or gaze-holding direction-switching nystagmus indicate brainstem or cerebellar stroke 1, 2
• Perform HINTS examination (Head Impulse Test, Nystagmus assessment, Test of Skew) if trained—this has 100% sensitivity for detecting stroke 1
• Complete posterior circulation neurologic assessment: Test cranial nerves, cerebellar function (finger-to-nose, heel-to-shin, rapid alternating movements), gait, and sensory/motor examination 1, 2

Critical pitfall to avoid: Up to 80% of posterior circulation stroke patients present with isolated dizziness WITHOUT focal neurologic deficits on standard examination, so absence of focal signs does not rule out stroke. 1, 2

Step 4: Fall Risk Assessment

All elderly patients with dizziness require fall risk screening:

• Ask: (1) Have you fallen in the past year? How many times? Were you injured? (2) Do you feel unsteady when standing or walking? (3) Do you worry about falling? 3
• Among elderly patients with BPPV, 9% had undiagnosed BPPV at geriatric clinic evaluation, and three-fourths had fallen within the prior 3 months 3
• Consider Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale for detailed assessment 3

Step 5: Determine Need for Imaging

Do NOT obtain radiographic imaging if the patient meets diagnostic criteria for BPPV without additional neurologic signs or symptoms inconsistent with BPPV:

• Neuroimaging has been shown to be of little value in BPPV, with magnetic resonance imaging testing not contributory to clinical diagnosis in a retrospective cohort of 2,374 patients 3
• Previous retrospective reviews of elderly patients with dizziness failed to detect significant differences in cranial MRI findings when comparing dizzy versus non-dizzy patients 3
• The pathology in BPPV occurs at a microscopic level beyond the resolution of current neuroimaging techniques 3

Reserve imaging for:

• Patients with additional neurologic symptoms atypical for BPPV 3
• Suspected BPPV but inconclusive positional testing 3
• Any focal neurologic deficits suggesting posterior circulation stroke 1, 2
• Atypical nystagmus patterns suggesting central pathology 1, 2

Step 6: Laboratory Testing

Routine laboratory testing has low yield and should be directed by history:

• Check glucose in all patients 4
• Monitor cardiac rhythm in patients age 45 and older 4
• Complete blood count, serum electrolytes, and BUN have low yield unless specifically indicated by history 4

Special Considerations in the Elderly

Multiple factors often coexist and require simultaneous attention:

• Age-related physiological changes predispose to syncope: reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress, and autonomic dysfunction 3
• Polypharmacy effects are exacerbated by loss of peripheral autonomic tone with aging 3
• Orthostatic hypotension, carotid sinus hypersensitivity, and autonomic dysfunction require specific evaluation 3
• Non-specific dizziness in the elderly is rarely from a single cause but rather an accumulation of physiological and pathological factors 5