What are the potential causes and treatment options for dizziness in a 70-year-old patient with a history of chronic medical conditions, such as hypertension, diabetes, or cardiovascular disease, and taking medications like antihypertensives, sedatives, and antidepressants?

Causes of Dizziness in a 70-Year-Old

In a 70-year-old patient, dizziness most commonly stems from audio-vestibular disorders (28.4% of cases), followed by cardiovascular disease (20.4%) and neurological conditions (15.1%), with benign paroxysmal positional vertigo (BPPV) being the single most frequent vestibular cause, present in 38% of elderly dizzy patients. 1, 2

Primary Diagnostic Framework

The initial evaluation must determine whether the patient experiences true vertigo (spinning sensation, room moving) versus lightheadedness (impending faint, floating sensation), as this distinction fundamentally changes the diagnostic approach. 3, 4

Classification by Timing and Triggers

Rather than relying on patient descriptors, classify symptoms by timing and triggers: 3

• Triggered Episodic Vestibular Syndrome (TEVS): Episodes lasting <1 minute, triggered by specific head position changes—strongly suggests BPPV 3
• Spontaneous Episodic Vestibular Syndrome (SEVS): Episodes lasting minutes to hours without specific triggers—suggests Ménière's disease or vestibular migraine 3
• Continuous symptoms: Suggests vestibular neuritis, labyrinthitis, or central pathology 5, 4

Audio-Vestibular Causes (Most Common)

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV accounts for 63% of vestibular-related dizziness in elderly patients presenting with this complaint. 2 This represents the highest prevalence among all specific diagnoses.

• Perform the Dix-Hallpike maneuver to reliably identify BPPV, making medications and expensive radiologic testing unnecessary 6, 3
• Treat with canalith repositioning procedures (Epley maneuver), which show 93.3% improvement versus 30.8% with medication alone 6
• Do not use vestibular suppressants routinely—they are inferior to repositioning maneuvers and increase fall risk, particularly dangerous in elderly patients 6
• Counsel patients about 10-18% recurrence rate at 1 year, increasing to 36% over time 6

Ménière's Disease

• Characterized by episodic vertigo with hearing loss, tinnitus, and aural fullness 6, 3
• Vertigo episodes are unpredictable and have the most significant impact on quality of life 6
• Treatment includes salt restriction and diuretics 4
• Requires audiometric follow-up as hearing loss typically progresses with disease duration 6

Vestibular Neuritis/Labyrinthitis

• Presents with acute, continuous vertigo lasting days to weeks 5
• Hearing loss present = labyrinthitis; hearing loss absent = vestibular neuritis 5
• Vestibular suppressants should only be used for 3 days maximum to avoid impeding central compensation 5
• Oral corticosteroids within 3 days of onset may accelerate recovery 5

Cardiovascular Causes (Second Most Common)

Cardiovascular disease accounts for 20.4% of dizziness cases in the elderly. 1 This manifests as presyncope—the most frequent dizziness subtype in elderly patients (71.5% of cases). 7

• Perform orthostatic blood pressure measurements to identify orthostatic hypotension 4
• Evaluate for arrhythmias, valvular disease, and heart failure with full cardiac examination 4, 7
• In patients with hypertension and diabetes, antihypertensive medications are a significant contributory cause—adverse drug effects represent 20% of dizziness causes in elderly patients 7

Neurological Causes (Third Most Common)

Neurological disorders account for 15.1% of cases. 1

Critical Red Flags Requiring Urgent Evaluation

Approximately 25% of acute vestibular syndrome cases are actually cerebellar or brainstem stroke. 5 Immediately evaluate for:

• Severe postural instability with falling 5
• New-onset severe headache with vertigo 5
• Neurological symptoms: limb weakness, dysarthria, dysphagia, diplopia, sensory deficits 5
• Loss of consciousness 5

Common Neurological Etiologies

• Infratentorial ischemia (most common CNS lesion causing dizziness) 8
• Multiple sclerosis 8
• Cerebellar atrophy 8

Additional Contributing Factors

Medication-Related Causes

Adverse drug effects are the most common contributory cause of dizziness (20%). 7 In patients taking antihypertensives, sedatives, and antidepressants:

• Vestibular suppressants and benzodiazepines are significant independent risk factors for falls 6
• Risk increases with polypharmacy and use of antidepressants 6
• Psychotropic medications produce drowsiness, cognitive deficits, and interference with driving 6

Psychiatric Conditions

Psychiatric disorders account for 9.1% of cases. 1

Other Causes

• Ophthalmologic disorders: 7.5% 1
• Musculoskeletal disorders: 6.3% 1
• Metabolic diseases 1, 7

Multiple Contributory Causes

66% of elderly dizzy patients have more than one contributing cause for dizziness. 7 The most frequent pattern is three contributory causes (40.6% of patients). 7

Diagnostic Approach

Essential History Elements

• Timing and triggers of symptoms 3, 4
• Presence of hearing loss, tinnitus, or aural fullness 3, 4
• Associated neurological symptoms 5, 4
• Complete medication review 7
• Cardiovascular history including hypertension and diabetes 7

Physical Examination

• Dix-Hallpike maneuver for BPPV 6, 3
• Orthostatic blood pressure measurement 4
• Full cardiac examination 4
• Complete neurological examination including assessment for nystagmus 4
• HINTS examination (head-impulse, nystagmus, test of skew) to distinguish peripheral from central etiologies 4

Testing

• Laboratory testing and imaging are not required and usually not helpful for typical peripheral vestibular disorders 4
• Audiometry when hearing loss is suspected 6, 8
• Neuroimaging only for atypical symptoms or red flags suggesting central pathology 3

Management Priorities

Fall Risk Counseling

53% of elderly patients with chronic vestibular disorders have fallen at least once in the past year, with 29.2% having recurrent falls. 6 Counsel patients and families regarding:

• Home safety assessment 6
• Activity restrictions until symptoms resolve 6
• Need for home supervision, particularly between diagnosis and definitive treatment 6

Follow-Up

Reassess patients within 1 month after initial treatment or observation to document resolution or persistence of symptoms. 6 This allows for:

• Changes in therapy if control is inadequate 6
• Identification of atypical symptoms warranting further evaluation 6
• Assessment of treatment effectiveness 6

Common Pitfalls

• Do not routinely prescribe vestibular suppressants for BPPV—they are inferior to repositioning maneuvers and significantly increase fall risk in elderly patients 6
• Do not assume a single cause—anticipate multiple contributory factors in elderly patients 7
• Do not miss central causes—maintain high suspicion for stroke in acute vestibular syndrome, as 25% are cerebellar or brainstem strokes 5
• Do not delay evaluation of medication adverse effects—they represent the most common contributory cause 7