What is the best course of action for an elderly lady experiencing dizziness?

Evaluation and Management of Dizziness in an Elderly Lady

The first critical step is to determine whether this elderly patient is experiencing true vertigo (spinning sensation) versus presyncope, disequilibrium, or vague lightheadedness, as this single distinction drives the entire diagnostic and treatment pathway. 1

Initial Characterization of Symptoms

Ask these specific questions to classify the dizziness type:

• Does the room spin around you? A confident description of spinning is specific for inner ear dysfunction and indicates true vertigo 1
• Do you feel like you might faint or pass out? This suggests presyncope, NOT vertigo, and requires cardiovascular evaluation 1
• Do you feel unsteady or off-balance without spinning? This represents disequilibrium rather than true vertigo 1
• What is the precise duration of episodes? This single feature distinguishes most causes: seconds indicate BPPV, minutes suggest stroke/TIA or vestibular migraine 1

Critical timing and trigger questions:

• Does changing head position trigger symptoms? This strongly suggests BPPV, the most common cause in elderly patients 1
• History of migraine headaches? Vestibular migraine accounts for up to 14% of vertigo cases 1
• Recent head trauma? Posttraumatic BPPV requires repeated treatments in up to 67% of cases 2

Essential Physical Examination

Perform the Dix-Hallpike maneuver immediately if positional symptoms are described, as this diagnoses BPPV—the most common cause of vertigo in elderly patients 1. The Epley maneuver shows 80% vertigo resolution at 24 hours versus 13% with sham treatment 3.

For acute continuous vertigo, perform the HINTS examination (Head Impulse Test, Nystagmus assessment, Test of Skew), which has 100% sensitivity for detecting stroke when performed by trained practitioners 1. Dangerous nystagmus patterns suggesting stroke include downbeating nystagmus, direction-changing nystagmus, and gaze-holding direction-switching nystagmus 1.

Complete neurologic examination must include:

• Cranial nerve testing
• Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements)
• Gait assessment
• Sensory and motor examination 1

Critical pitfall: Up to 80% of stroke patients with acute vestibular syndrome may have NO focal neurologic signs, so absence of deficits does NOT rule out stroke 1.

Fall Risk Assessment (Essential in Elderly)

Screen all elderly patients with dizziness for fall risk by asking about previous falls, unsteadiness, and fear of falling 1. Dizziness increases fall risk 12-fold in elderly patients, with one-third falling annually 1. Among elderly patients with BPPV, 9% had undiagnosed BPPV at geriatric evaluation, and three-fourths had fallen within the prior 3 months 1.

Medication Review (Critical in Elderly)

Review all medications immediately, as polypharmacy is a major contributor to dizziness in the elderly 1. Specific culprits include:

• Diuretics
• β-blockers
• Calcium antagonists
• ACE inhibitors
• Nitrates
• Antipsychotics
• Tricyclic antidepressants
• Antihistamines 1

Benzodiazepines are a significant independent risk factor for falls and should be discontinued 3.

Imaging Decisions

Do NOT obtain imaging for straightforward BPPV with typical presentation 2, 1. Neuroimaging has little value in BPPV, with MRI testing not contributory to clinical diagnosis in a retrospective cohort of 2,374 patients 1.

Reserve imaging for:

• Additional neurologic symptoms atypical for BPPV
• Suspected BPPV but inconclusive positional testing
• Any focal neurologic deficits suggesting posterior circulation stroke
• Abnormal cranial nerve findings, visual disturbances, or severe headache 2, 1

Critical pitfall: Never rely solely on CT imaging for suspected stroke, as it frequently misses posterior circulation strokes 1.

Treatment Approach

For BPPV (most common in elderly):

• Perform canalith repositioning procedures (Epley or Semont maneuver) immediately, which demonstrate 78.6%-93.3% improvement versus only 30.8% with medication alone 3
• The Semont maneuver shows 94.2% symptom resolution at 6 months versus 57.7% with flunarizine and 34.6% with no treatment 3
• Do NOT prescribe vestibular suppressants routinely, as patients who underwent repositioning maneuvers alone recovered faster than those who received concurrent vestibular suppressants 3

Regarding meclizine specifically:

While meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases 4, in frail elderly or those with limited life expectancy, meclizine is considered eligible for deprescribing and may be inappropriate 3. All vestibular suppressants may cause drowsiness, cognitive deficits, and significantly increase fall risk, especially in elderly patients 3.

For persistent dizziness after initial treatment:

• Refer for vestibular rehabilitation therapy, which significantly improves overall gait stability compared to medication alone 3
• Vestibular rehabilitation is especially indicated when balance and motion tolerance do not improve despite medication trials 3
• Reassess within 1 month to document resolution or persistence of symptoms 3

Special Elderly Considerations

Age-related physiological changes predispose to syncope, including reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress, and autonomic dysfunction 1. These factors are exacerbated by polypharmacy effects and loss of peripheral autonomic tone with aging 1.

Provide fall prevention counseling including:

• Home safety assessment
• Activity restrictions
• Need for supervision, particularly in frail patients 3