From the Guidelines
The workup for dizziness in an 83-year-old should begin with a thorough history and physical examination to distinguish between vertigo, disequilibrium, presyncope, or lightheadedness, as recommended by the most recent guidelines 1. The initial evaluation should include:
- Orthostatic vital signs
- Cardiovascular assessment
- Neurological examination
- Medication review, as polypharmacy is common in this age group Laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Vitamin B12 level
- HbA1c An ECG is essential to rule out arrhythmias, and consider 24-hour Holter monitoring if cardiac symptoms are present, as supported by the American College of Radiology guidelines 1. For suspected vestibular issues, perform the Dix-Hallpike maneuver and consider referral to ENT, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. Neuroimaging with MRI brain is warranted if there are focal neurological signs, new-onset severe headache, or recent falls, as it has a higher diagnostic yield compared to CT scans 1. Specialized tests may include:
- Carotid ultrasound if there's carotid bruit
- Audiometry for hearing loss
- Vestibular function tests for persistent vertigo Medication adjustment is often beneficial, particularly reviewing antihypertensives, sedatives, and anticholinergics which commonly cause dizziness in elderly patients, as highlighted in the clinical practice guidelines for benign paroxysmal positional vertigo 1.
From the Research
Evaluation of Dizziness
The evaluation of dizziness in an 83-year-old patient involves a thorough history and physical examination to determine the underlying cause of the symptom. According to 2, the distinction between different types of dizziness (vertigo, presyncope, disequilibrium, and light-headedness) is of limited clinical usefulness, and patients have difficulty describing the quality of their symptoms. However, patients can more consistently identify the timing and triggers of their symptoms.
Physical Examination
The physical examination for dizziness includes:
- Orthostatic blood pressure measurement
- A full cardiac and neurologic examination
- Assessment for nystagmus
- The Dix-Hallpike maneuver (for patients with triggered dizziness)
- The HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 3
Laboratory Testing and Imaging
Laboratory testing and imaging are usually not required and are often not helpful in the evaluation of dizziness 2. However, according to 3, laboratory testing and imaging can be helpful in certain cases.
Treatment
The treatment for dizziness depends on the underlying cause of the symptom. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver) 2, 3. Vestibular rehabilitation is helpful in treating many peripheral and central etiologies of dizziness 3. Other etiologies of dizziness require specific treatment to address the cause.
Considerations in Older Adults
Dizziness is a common presenting complaint among older patients in primary care, and a thorough examination and history can identify the type of dizziness and point to a specific differential diagnosis 4. A systematic approach to the assessment of patients with dizziness, including a thorough history and examination, can provide a clear direction as to the diagnosis and most appropriate management 5.