What is the workup for an older adult patient with chronic dizziness that worsens with position change and is accompanied by occasional falls?

Workup for Chronic Dizziness with Positional Changes and Falls

Begin with the Dix-Hallpike maneuver to diagnose BPPV, which is the most common cause of positional dizziness in older adults (36.3% of cases) and is present in 9% of elderly patients referred for geriatric evaluation—three-fourths of whom had fallen within the prior 3 months. 1, 2

Initial Clinical Assessment

Critical History Elements

• Duration of episodes: Seconds-only duration (<1 minute) strongly suggests BPPV, while minutes-duration suggests stroke/TIA or vestibular migraine 3, 4
• Specific positional triggers: Ask whether rolling over in bed, looking up, or bending forward provokes symptoms—these are classic BPPV triggers 3, 4
• Fall history: Document number of falls in the past year, circumstances, and injuries sustained, as dizziness increases fall risk 12-fold in elderly patients 1, 4
• Medication review: This is a leading reversible cause of chronic dizziness—specifically review antihypertensives (diuretics, β-blockers, calcium antagonists, ACE inhibitors), sedatives, anticonvulsants, and psychotropic drugs 3, 4
• Associated symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease; headache with photophobia/phonophobia suggests vestibular migraine 3
• Trauma history: Head trauma can cause persistent posttraumatic vertigo 3

Essential Physical Examination

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 3, 4. Positive findings include:

• Latency period of 5-20 seconds before symptoms begin
• Torsional, upbeating nystagmus toward the affected ear
• Vertigo and nystagmus that increase then resolve within 60 seconds 3, 4

Complete a focused neurologic examination including:

• Cranial nerve testing (particularly CN VIII)
• Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements)
• Gait assessment (observe for ataxia, wide-based gait)
• Nystagmus evaluation for central patterns (downbeating, direction-changing, or gaze-holding nystagmus suggest stroke) 3, 4

Conduct fall risk screening using standardized questions 1:

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?

If positive responses, perform detailed assessment with Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale 1, 4

Orthostatic Vital Sign Measurement

Perform orthostatic vital sign measurement (OVSM) for patients with simple orthostatic dizziness without clear positional triggers, as 38.5% of these patients have orthostatic intolerance versus only 13.5% when positional dizziness is present 2. Measure blood pressure and heart rate supine, then at 1 and 3 minutes after standing 2.

Look for:

• Orthostatic hypotension (most common finding)
• Orthostatic hypertension
• Orthostatic tachycardia (postural orthostatic tachycardia syndrome) 2

Diagnostic Testing Strategy

When Imaging is NOT Indicated

Do not order neuroimaging or vestibular testing for patients with:

• Positive Dix-Hallpike test consistent with BPPV
• No additional concerning neurologic features
• Normal neurologic examination 3, 4

Neuroimaging has no value in straightforward BPPV—a retrospective cohort of 2,374 BPPV patients showed MRI testing was not contributory to clinical diagnosis 4

When Imaging IS Indicated

Order MRI brain without contrast (NOT CT) for patients with: 3, 4

• Focal neurologic deficits on examination
• Atypical nystagmus patterns (downbeating, direction-changing, or central patterns)
• Progressive neurologic symptoms suggesting posterior fossa mass
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• High vascular risk factors (age >50, hypertension, diabetes, prior stroke) even with normal neurologic exam

Critical pitfall: CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts—MRI with diffusion-weighted imaging has 4% diagnostic yield and is essential for detecting stroke 3

Another critical pitfall: 75-80% of patients with posterior circulation stroke presenting as acute vestibular syndrome have NO focal neurologic deficits on examination 3

Audiologic Testing

Obtain comprehensive audiologic examination for patients with: 3

• Unilateral tinnitus
• Persistent symptoms despite appropriate treatment
• Associated hearing difficulties
• Suspected Ménière's disease

Common Diagnostic Pitfalls to Avoid

1. Never assume absence of focal neurologic signs rules out stroke—up to 80% of stroke patients with acute vestibular syndrome have no focal deficits 3, 4

2. Do not rely solely on patient descriptions of "spinning" versus "lightheadedness"—elderly patients often struggle to articulate symptoms clearly and may present with atypical vestibular disturbance rather than frank spinning 3, 4

3. Do not skip positional testing even when patients deny positional triggers—BPPV should be considered an essential diagnostic test for all patients with orthostatic dizziness 2

4. Never use CT instead of MRI when stroke is suspected—CT frequently misses posterior circulation strokes that cause dizziness 3, 4

5. Do not overlook medication-induced dizziness—this is one of the most common and reversible causes, particularly in elderly patients on polypharmacy 3, 4

Differential Diagnosis for Chronic Positional Dizziness with Falls

Most Common Causes in Order of Frequency:

1. BPPV (36.3% of cases): Diagnosed by positive Dix-Hallpike test 1, 2

2. Orthostatic intolerance (38.5% of simple orthostatic dizziness): Diagnosed by OVSM showing orthostatic hypotension, hypertension, or tachycardia 2

3. Vestibular migraine (14% of vertigo cases): History of migraine headaches, photophobia, phonophobia 3, 4

4. Medication side effects: Review all medications, particularly cardiovascular and psychotropic drugs 3, 4

5. Anxiety/panic disorder: Screen for psychiatric symptoms 3

6. Posttraumatic vertigo: History of head trauma with persistent symptoms 3

7. Ménière's disease: Fluctuating hearing loss, tinnitus, aural fullness 3

8. Posterior fossa pathology: Progressive symptoms, abnormal neurologic exam 3

Special Considerations for Elderly Patients

Age-related physiological changes increase vulnerability to dizziness and falls: 4

• Reduced thirst and impaired sodium/water preservation
• Diminished baroreceptor response
• Reduced heart rate response to orthostatic stress
• Autonomic dysfunction
• Polypharmacy effects exacerbated by loss of peripheral autonomic tone

Among community-dwelling adults aged >65 years, one in three falls annually, with estimated costs exceeding $20 billion annually in the United States 1. Dizziness and vertigo are the primary etiology of falls 13% of the time 1.

Management Considerations Based on Diagnosis

If BPPV is Confirmed:

Perform canalith repositioning procedures (Epley maneuver) immediately—this has 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 3. No medications or imaging are needed for typical BPPV 3.

Counsel patients about: 1

• Recurrence risk (10-18% at 1 year, up to 36% long-term)
• Fall risk, particularly in the interval between diagnosis and definitive treatment
• Home safety assessment and activity restrictions until resolved
• Need for home supervision if elderly and frail

If Orthostatic Intolerance is Confirmed:

Consider pharmacologic treatment with midodrine (alpha-1 agonist that increases vascular tone and elevates blood pressure by 15-30 mmHg at 1 hour after 10 mg dose) or fludrocortisone (mineralocorticoid for volume expansion) depending on the specific type of orthostatic dysfunction 5, 6.

If Vestibular Rehabilitation is Needed:

Refer for vestibular rehabilitation therapy for persistent dizziness that fails initial treatment—this significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk 3. VR includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 3.