What causes vertigo in older adults?

Causes of Vertigo in Older Adults

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults, followed by vestibular neuritis, Ménière's disease, vestibular migraine, and importantly, stroke—which must be actively excluded given its life-threatening implications. 1

Peripheral Vestibular Causes

BPPV (Most Common)

• BPPV is the leading cause of peripheral vertigo, characterized by brief episodes (<1 minute) triggered by specific head position changes, with no hearing loss 2
• Most often idiopathic, though traumatic brain injury can be associated in specific cases 1
• Undiagnosed BPPV affects 9% of elderly patients referred to geriatric clinics, with three-fourths having fallen within the preceding 3 months 2

Vestibular Neuritis/Labyrinthitis

• Presents as acute spontaneous unilateral vestibular failure with unidirectional horizontal nystagmus 3
• Onset tends to be sudden with continuous symptoms, distinguishing it from episodic BPPV 4

Ménière's Disease

• Episodes last 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 2
• Accounts for approximately 10% of vertigo cases in general practice settings 1

Other Peripheral Causes

• Superior canal dehiscence syndrome: pressure-related triggers (e.g., Valsalva maneuver) differentiate it from BPPV 1
• Perilymph fistula: can occur post-surgery or spontaneously, with pressure-triggered episodes and fluctuating hearing loss 1
• Posttraumatic vertigo: presents with vertigo, disequilibrium, tinnitus, and headache due to peripheral or central damage 1

Central (Neurologic) Causes—Critical to Exclude

Stroke and Transient Ischemic Attack (Most Dangerous)

• Brainstem and cerebellar strokes are life-threatening causes that can mimic peripheral vertigo 1
• In one series, 10% of cerebellar strokes presented similar to peripheral vestibular processes 1
• 75-80% of stroke-related acute vestibular syndrome patients have no focal neurologic deficits, making stroke easy to miss 2
• Physical examination may reveal dysarthria, dysmetria, dysphagia, sensory or motor loss, or Horner's syndrome 1

Vestibular Migraine

• Very common with lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 1
• Episodes last 5 minutes to 72 hours with migraine features (photophobia, phonophobia, visual aura) 2
• Requires ≥5 episodes of vestibular symptoms with current or history of migraine 1

Other Central Causes

• Multiple sclerosis, intracranial tumors, and demyelinating diseases 1
• Vertebrobasilar insufficiency in older adults with vascular risk factors 1

Key Clinical Distinctions

Red Flags for Central Causes (Require Urgent Workup)

• Downbeating nystagmus on Dix-Hallpike without torsional component 1
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) 1
• Direction-switching nystagmus (beats right with right gaze, left with left gaze) 1
• Baseline nystagmus without provocative maneuvers (though this could also indicate vestibular neuritis) 1
• Failure to respond to conservative management (canalith repositioning or vestibular rehabilitation) should raise concern the diagnosis is not BPPV 1

Special Considerations in Older Adults

• Elderly menopausal patients may describe "vague dizziness" rather than true spinning vertigo, even with significant inner ear pathology like Ménière's disease 2
• Specific questioning about spinning sensation, duration, and associated symptoms is essential to avoid missed diagnoses 2
• Older adults have increased fall risk—12-fold increase among those with BPPV 1

Other Causes to Consider

Non-Vestibular Causes

• Postural hypotension: triggered episodes, particularly in older adults on multiple medications 1
• Anxiety or panic disorder: can present as chronic vestibular syndrome 1
• Medication side effects: common in polypharmacy situations 1
• Cervicogenic vertigo: variable presentation 1

Common Pitfalls

• In emergency department settings, nearly half of patients with dizziness have medical (non-vestibular, non-neurologic) diagnoses 1
• Timing (acute vs episodic vs chronic) and triggers are more diagnostically useful than the specific descriptor patients use 1
• The distinction between peripheral and central causes can usually be made clinically and guides management decisions 4