From the Guidelines
For a 60-year-old male experiencing dizziness, I recommend a comprehensive evaluation including complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12 and folate levels, and hemoglobin A1c, as well as a thorough review of medications and potential vestibular dysfunction, as suggested by 1 and 1. The evaluation should include:
- Cardiovascular assessment with an electrocardiogram, carotid ultrasound, and possibly echocardiogram to evaluate for cardiac causes
- Neurological testing with brain imaging (MRI preferred over CT) and vestibular function tests if vertigo is present
- Blood pressure measurements taken both sitting and standing to check for orthostatic hypotension
- Medication review to identify potential causes of dizziness, with specific attention to antihypertensives, sedatives, and antidepressants This approach is necessary because dizziness in older adults is often multifactorial, potentially involving vestibular dysfunction, cardiovascular issues, neurological problems, medication effects, or metabolic disturbances, as noted in 1 and 1. Early identification of the underlying cause is crucial as dizziness increases fall risk in this age group, which can lead to significant morbidity and mortality, as highlighted in 1 and 1. The use of bedside tests such as the Dix-Hallpike test and the HINTS examination can help differentiate between peripheral and central causes of vertigo, as discussed in 1 and 1.
From the Research
Evaluation of Dizziness
- The evaluation of dizziness in a 60-year-old male involves determining whether the etiology is peripheral or central, with peripheral etiologies being usually benign and central etiologies often requiring urgent treatment 2, 3.
- A thorough examination and history can identify the type of dizziness and point to a specific differential diagnosis, with vertigo, presyncope, dysequilibrium, and non-specific dizziness being associated with a variety of underlying causes 4, 5.
- The physical examination may include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver, and the HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 3.
Laboratory Tests and Imaging
- Laboratory testing and imaging are usually not required and are often not helpful in evaluating dizziness, but can be useful in certain cases 2, 3.
- The focus should be on determining the timing and triggers of the dizziness, as well as the patient's medical history and physical examination findings 3, 6.
Diagnostic Approach
- A timing-and-triggers approach can be used to characterize the patient's vestibular symptoms as continuous or episodic, and to determine whether symptoms are post-exposure or spontaneous 6.
- The patient can be classified as having post-exposure acute vestibular syndrome (AVS), spontaneous AVS, triggered episodic vestibular syndrome (EVS), or spontaneous EVS, to guide further evaluation and treatment 6.