Evaluation and Management of Positional Dizziness in Older Adults
Benign paroxysmal positional vertigo (BPPV) is the most likely diagnosis and should be confirmed with the Dix-Hallpike test at the bedside, followed immediately by canalith repositioning maneuvers if positive, as this achieves an 80% cure rate with 1-3 treatments and significantly reduces fall risk. 1
Initial Diagnostic Approach
Perform Bedside Positional Testing First
Execute the Dix-Hallpike maneuver to diagnose posterior canal BPPV by observing for characteristic nystagmus and vertigo when the patient's head is turned 45 degrees to one side and then rapidly moved from sitting to supine with the head hanging 20 degrees below horizontal 1
If the Dix-Hallpike test is negative but history suggests BPPV, perform the supine roll test to assess for lateral semicircular canal BPPV by rolling the patient's head rapidly from side to side while supine 1
BPPV affects 9% of elderly patients undergoing geriatric assessment and is frequently undiagnosed, with older patients experiencing symptoms for a median of 12 months before diagnosis compared to 6 months in younger patients 1, 2
Rule Out Volume Depletion
Assess for postural pulse change from lying to standing (≥30 beats per minute) or severe postural dizziness resulting in inability to stand, which indicates volume depletion following blood loss with 97% sensitivity and 98% specificity 1
Check for at least four of these seven signs if vomiting or diarrhea is present: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes 1
Treat confirmed volume depletion with isotonic fluids orally, nasogastrically, subcutaneously, or intravenously 1
Immediate Treatment When BPPV Confirmed
Perform Particle Repositioning Maneuver
Execute the Epley maneuver (canalith repositioning procedure) immediately at the same visit when BPPV is diagnosed, as this achieves approximately 80% success with only 1-3 treatments 1
The maneuver guides displaced otoconia (calcium carbonate crystals) back to their proper location in the inner ear 1
Patients may experience brief distress from vertigo, nausea, and disorientation during the procedure, with some reporting motion sickness-type symptoms for hours to days afterward 1
Do NOT Use Vestibular Suppressants
Avoid routinely treating BPPV with vestibular suppressant medications such as antihistamines (meclizine) or benzodiazepines, as these are not recommended by guidelines despite meclizine being FDA-approved for vertigo 1, 3
Medications may cause drowsiness and anticholinergic effects (dry mouth, blurred vision, urinary retention), which increase fall risk in older adults 3
Critical Fall Risk Assessment
Screen for Fall Risk Immediately
Ask these three CDC screening questions: (1) Have you had a fall 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? 1, 4
Among community-dwelling adults aged >65 years, 1 in 3 falls annually, with a 12-fold increased fall risk when vestibular symptoms are present 1, 4
53% of elderly patients with chronic vestibular disorders (including 36.7% with BPPV) had fallen at least once in the past year, with 29.2% experiencing recurrent falls 1
Assess Modifying Factors
Evaluate for impaired mobility or balance, CNS disorders, lack of home support, and increased fall risk, as these factors modify management and may require referral to physical therapy or vestibular rehabilitation 1
Patients with severe disabling symptoms, history of falls, fear of falling, or difficulty moving (joint stiffness in neck/back, weakness) should be referred to a specialist who can perform repositioning maneuvers 1
Avoid Unnecessary Testing
Do not order radiographic imaging (CT, MRI) or vestibular testing in patients with confirmed BPPV unless the diagnosis is uncertain or additional symptoms unrelated to BPPV are present 1
It is estimated that >65% of BPPV patients undergo potentially unnecessary diagnostic testing, with 70% receiving MRI and 45% receiving CT scans before diagnosis 1
Patient Counseling and Follow-Up
Educate About Natural History
BPPV can resolve spontaneously in 27-50% of cases, but this often takes significant time, and 86% of patients experience interrupted daily activities during this period 1
Recurrence rates are 5-13.5% at 6 months, 10-18% at 1 year, and may reach 36% over time, so patients should recognize symptoms for early retreatment 1
Provide Fall Prevention Counseling
Counsel patients to avoid sudden head movements, use assistive devices, ensure adequate home lighting, and remove tripping hazards until BPPV resolves 4
Assess home safety, consider activity restrictions, and evaluate need for home supervision, particularly in elderly and frail patients who are more susceptible to serious injury from falls 1
Schedule Reassessment
Reassess patients within a few days to a couple of weeks if symptoms of dizziness or instability do not improve after initial treatment 1
Persistent symptoms may indicate: (1) need for additional repositioning sessions, (2) different BPPV variant requiring specialized treatment, (3) BPPV in multiple canals simultaneously, or (4) residual dizziness requiring vestibular rehabilitation 1
Important Clinical Pitfall
Many older adults with BPPV do not report classic vertigo but instead describe vague unsteadiness or have no dizziness symptoms at all due to "vestibular agnosia" (impaired vestibular perception of self-motion), which dramatically increases missed diagnoses 5. Therefore, perform positional testing in all older adults (>60 years) with objective or subjective balance problems, regardless of whether they report vertigo 5.