What should be on the differential diagnosis for an elderly female presenting with dizziness?

Differential Diagnosis for Elderly Female with Dizziness

In an elderly female presenting with dizziness, your differential must prioritize audio-vestibular disorders (most common at 28.4%), followed by cardiovascular causes (20.4%) and neurological conditions including posterior circulation stroke (15.1%), with BPPV accounting for 42% of vertigo cases in primary care and representing 63% of vestibular causes in elderly dizzy patients. 1, 2, 3

Organize by Timing and Triggers (Not Symptom Quality)

Do not rely on the patient's description of "spinning" versus "lightheadedness"—elderly patients with significant inner ear pathology often describe only "vague dizziness." 4, 1, 5 Instead, categorize based on:

1. Triggered Episodic Vestibular Syndrome (Seconds to <1 Minute)

• Benign Paroxysmal Positional Vertigo (BPPV): Most common cause overall (42% of primary care vertigo cases), triggered by specific head position changes, no hearing loss 1, 6

  • Critical point: 9% of geriatric clinic patients have undiagnosed BPPV, and three-fourths of elderly BPPV patients have fallen within 3 months 6
  • Diagnose with Dix-Hallpike maneuver showing transient upbeating-torsional nystagmus 1

• Superior canal dehiscence: Pressure-induced (not position-induced) vertigo, often with conductive hearing loss on audiometry 1

2. Spontaneous Episodic Vestibular Syndrome (Minutes to Hours)

• Vestibular migraine: Episodes lasting 5 minutes to 72 hours, migraine features in ≥50% of episodes, photophobia more prominent than visual aura 4, 1

• Ménière's disease: Episodic vertigo (20 minutes to 12 hours), fluctuating low-to-mid frequency hearing loss, tinnitus, and aural fullness 4, 1, 6

  • Elderly-specific presentation: May present with "vague dizziness" rather than frank spinning vertigo 4, 6

• Transient ischemic attack (posterior circulation): Brief episodes with visual blurring, drop attacks, dysphagia, dysphonia, or other neurologic symptoms 4

3. Acute Vestibular Syndrome (Days to Weeks of Continuous Symptoms)

• Vestibular neuritis: Most common peripheral cause, acute prolonged vertigo (12-36 hours) with severe nausea/vomiting, NO hearing loss, decreasing disequilibrium over 4-5 days 4, 1, 6

• Labyrinthitis: Similar to vestibular neuritis but WITH sudden profound hearing loss 4

• Posterior circulation stroke: CRITICAL—75-80% have NO focal neurologic deficits on standard exam 1, 6, 5

  • Prevalence up to 25% in acute vestibular syndrome patients, 75% in high vascular risk cohorts 6
  • Do not assume normal neurologic exam excludes stroke 1, 5

4. Chronic Vestibular Syndrome (Persistent Symptoms)

• Medication adverse effects: Leading cause of chronic dizziness—review antihypertensives, cardiovascular medications, anticonvulsants, CNS depressants 1, 5

• Vestibular schwannoma: Chronic imbalance more than episodic vertigo, asymmetric hearing loss and tinnitus that doesn't fluctuate 4

Non-Vestibular Causes (Critical in Elderly)

• Cardiovascular causes (20.4% of elderly dizziness): 2

  • Postural hypotension: Provoked by moving supine to upright (distinct from BPPV's positional triggers) 1
  • Arrhythmias, orthostatic hypotension from medications

• Neurological diseases (15.1%): Parkinson disease, diabetic neuropathy, cerebellar degeneration 2, 7

• Psychiatric conditions (9.1%): Anxiety, panic disorder, depression—though high prevalence of actual vestibular dysfunction exists in these patients 1, 2

• Ophthalmologic disorders (7.5%) and musculoskeletal disorders (6.3%) 2

• Metabolic causes: Hypoglycemia, thyroid dysfunction 2

Critical Red Flags Requiring Urgent Evaluation

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes 1, 5
• Inability to stand or walk independently 1, 5
• New severe headache with dizziness 1, 5
• Sudden unilateral hearing loss with vertigo 1
• Downbeating nystagmus or other central nystagmus patterns 1, 5

Key Diagnostic Pitfalls to Avoid

• Do not dismiss isolated vertigo without focal findings as benign: 11% of such patients have acute infarct on imaging 6
• Do not order CT head for stroke evaluation: CT has <1% diagnostic yield for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts; MRI with diffusion-weighted imaging is required 5
• Do not assume elderly patients will describe "spinning": They often report only vague dizziness even with significant vestibular pathology 4, 6
• HINTS examination is only reliable when performed by trained practitioners: Non-expert performance is less reliable 5, 8

Age-Specific Morbidity Considerations

• One in three adults >65 years falls annually, with dizziness/vertigo the primary etiology in 13% of falls 6
• Fall-related costs exceed $20 billion annually in the United States 6
• Undiagnosed BPPV creates significant fall risk in elderly patients 6, 3