What is the initial approach for a patient presenting with dizziness and falls?

Initial Approach to Dizziness with Falls

Immediately categorize the patient by timing and triggers rather than asking about symptom quality, as elderly patients with dizziness and falls require urgent fall risk assessment and systematic evaluation to distinguish benign peripheral vestibular disorders from dangerous central causes like stroke. 1

Immediate Assessment Framework

Classify Into One of Three Vestibular Syndromes

• Acute Vestibular Syndrome (AVS): Constant vertigo lasting days to weeks—requires HINTS examination to rule out posterior circulation stroke 1
• Triggered Episodic Vestibular Syndrome: Brief episodes (seconds to <1 minute) triggered by head movements—perform Dix-Hallpike maneuver immediately 1
• Spontaneous Episodic Vestibular Syndrome: Episodes lasting minutes to hours without positional triggers—associated symptoms guide diagnosis 1

Critical History Elements

Ask these specific questions in order of priority: 2

• Age >65 years (12-fold increased fall risk with dizziness) 2
• Previous falls: "Have you fallen in the past year? How many times? Were you injured?" 2
• Duration of episodes: Seconds = BPPV; minutes to hours = vestibular migraine or Ménière's; days to weeks = vestibular neuritis or stroke 1, 3
• Triggers: Head position changes strongly suggest BPPV 1, 3
• Time spent on floor/ground after fall 2
• Loss of consciousness or altered mental status 2
• Near-syncope or orthostatic symptoms 2
• Associated symptoms: Hearing loss/tinnitus/aural fullness = Ménière's disease; headache/photophobia/phonophobia = vestibular migraine 1
• Feeling unsteady when standing or walking 2
• Worry about falling 2

Medication Review

Specifically assess for these high-risk medication classes: 2

• Vasodilators, diuretics, antipsychotics, sedative/hypnotics 2
• β-blockers, calcium antagonists, ACE inhibitors, nitrates 3
• Tricyclic antidepressants, antihistamines 3

Essential Physical Examination

Perform these maneuvers in sequence: 1, 3

1. Orthostatic vital signs: Measure blood pressure supine, then at 1 and 3 minutes standing 2
2. Dix-Hallpike maneuver: For any patient with triggered symptoms—diagnostic for BPPV with 90-98% treatment success rate 1
3. HINTS examination (if AVS present): Head Impulse, Nystagmus, Test of Skew—has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1
4. Complete neurologic examination: Cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), gait assessment 1
5. "Get Up and Go" test: Patient must rise from bed, turn, and steadily ambulate—if unable, reassess before discharge 2

Critical pitfall: Up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs—never rely on absence of focal deficits to rule out stroke 3

Fall Risk Stratification

If positive responses to screening questions, perform detailed assessment using: 2

• Get Up and Go test 2
• Tinetti Balance Assessment 2
• Berg Balance Scale 2

Key context: Among elderly patients with undiagnosed BPPV, 75% had fallen within the prior 3 months 2, 3

Imaging Decisions

No imaging indicated for: 1

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1

MRI brain (without contrast) indicated for: 1

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• High vascular risk patients with acute vestibular syndrome 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1

Never use CT head instead of MRI when stroke is suspected—CT has <1% diagnostic yield for isolated dizziness and frequently misses posterior circulation strokes 1, 3

Immediate Management Based on Diagnosis

BPPV (Most Common in Elderly)

• Epley maneuver immediately—90-98% success rate 1
• Posttraumatic BPPV requires repeated repositioning in up to 67% of cases 2

Orthostatic Hypotension

• Change positions slowly, stay hydrated, avoid prolonged standing 4
• Consider midodrine if non-pharmacologic measures fail (raises standing systolic BP by 15-30 mmHg at 1 hour) 5

Suspected Posterior Circulation Stroke

• Activate stroke protocol immediately 1
• Urgent neurology consultation 1

Vestibular Neuritis/Labyrinthitis

• Short-term vestibular suppressants (≤3 days only) 4
• Early vestibular rehabilitation 4

Safety Assessment Before Discharge

Patient must demonstrate: 2

• Ability to rise from bed independently 2
• Steady ambulation out of examination area 2
• Understanding of fall precautions 2, 4

Counsel specifically about: 4

• Sitting or lying down immediately when feeling dizzy 4
• Using assistive devices if balance affected 4
• Avoiding driving during acute episodes 4
• Home safety modifications (remove tripping hazards, adequate lighting, grab bars) 4