How should I evaluate and manage disequilibrium in an older adult?

Evaluation and Management of Disequilibrium in Older Adults

Initial Diagnostic Approach

Begin by distinguishing true vertigo (spinning sensation) from non-vertiginous dizziness or disequilibrium, as this fundamentally changes your diagnostic pathway and determines whether you're dealing with a peripheral vestibular disorder versus multifactorial imbalance. 1

Critical History Elements

• Duration and timing: Seconds suggests BPPV, minutes to hours suggests vestibular migraine or Ménière's disease, days suggests vestibular neuritis, constant suggests multifactorial disequilibrium 1, 2
• Provocation: Head position changes point to BPPV; spontaneous episodes suggest central or peripheral vestibular pathology 1
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness suggest Ménière's disease 1
  • Neurologic symptoms (dysphagia, dysarthria, visual changes) suggest stroke 1
  • Loss of consciousness is never Ménière's disease and suggests syncope 1
• Medication review: Polypharmacy is a major contributor to disequilibrium in older adults and must be systematically reviewed 1

Essential Physical Examination Maneuvers

Every older adult with imbalance complaints requires a Dix-Hallpike maneuver and Head Impulse Test, regardless of whether they report vertigo, as vestibular dysfunction commonly causes imbalance without spinning sensations in this population. 3

• Dix-Hallpike maneuver: Identifies BPPV, which affects 40% of geriatric patients presenting with dizziness 1
• Head Impulse Test: Detects bilateral vestibulopathy, a frequently overlooked cause of disequilibrium without vertigo 3
• Orthostatic vital signs: Check for postural pulse change ≥30 beats/minute or severe postural dizziness preventing standing, indicating volume depletion 1
• Gait and balance assessment: Widened-based gait, truncal instability, and dysmetria suggest cerebellar pathology 4
• Romberg test: Worsening with eyes closed indicates sensory ataxia (proprioceptive/dorsal column dysfunction), not cerebellar or vestibular pathology 4

Key Clinical Pitfalls

• Elderly patients with long-standing vestibular disorders often report vague dizziness rather than classic vertigo, making diagnosis more challenging 1, 2
• Amnesia and cognitive impairment reduce accuracy of symptom recall in 30% of older adults presenting with falls who actually had syncope 1
• Multifactorial causes are the rule, not the exception in geriatric disequilibrium 1, 5

Diagnostic Testing Strategy

When to Order MRI Brain

Order MRI brain without contrast for:

• Cerebellar signs (dysmetria, dysdiadochokinesia, truncal ataxia, scanning speech, nystagmus) 4
• Progressive imbalance with neurologic deficits 6
• Chronic non-specific dizziness with vascular risk factors (to evaluate for lacunar infarcts and white matter disease) 7
• Asymmetric hearing loss or tinnitus (to exclude vestibular schwannoma) 1

Do not order CT head for isolated dizziness—diagnostic yield is <1% 7

Vestibular Function Testing

Quantitative vestibular testing should be considered when the cause remains unclear after initial evaluation, as reduced vestibular function correlates with increased postural sway and fall risk even in patients without obvious vestibular disease 8

• Bilateral vestibulopathy is a common but underdiagnosed cause of disequilibrium without vertigo 8, 3
• Rotational vestibular testing and posturography can identify subclinical vestibular dysfunction 8

Management Algorithm

1. BPPV (Most Common Treatable Cause)

Perform canalith repositioning maneuvers immediately—only 10-20% of patients with BPPV receive appropriate treatment, leading to unnecessary testing, prolonged disability, and fall risk 1

• Epley maneuver for posterior canal BPPV
• Avoid vestibular suppressant medications, which are ineffective and increase fall risk 1
• BPPV causes 9% of unrecognized balance problems in comprehensive geriatric assessments 1

2. Volume Depletion

Assess for moderate-to-severe volume depletion if ≥4 of these signs are present: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes 1

• Treat with isotonic fluids (oral, nasogastric, subcutaneous, or IV) 1
• Older adults have decreased fluid conservation and increased vulnerability to dehydration 1

3. Medication Optimization

Systematically reduce or eliminate medications that lower blood pressure or impair balance, considering age-related reductions in hepatic and renal clearance 1

• Polypharmacy and drug-drug interactions are major contributors to falls 1
• Vestibular suppressants (meclizine, benzodiazepines) worsen balance and should be avoided 1

4. Vestibular Rehabilitation

Refer for vestibular rehabilitation therapy, which significantly improves gait stability and balance in elderly patients with chronic dizziness 7

• Balance training programs improve stability 4
• Postural training improves trunk control 4
• Task-oriented training improves reaching and fine motor control 4

5. Vascular Risk Factor Management

For patients with chronic lacunar infarcts or white matter disease causing non-specific dizziness, implement aggressive vascular risk modification 7:

• Blood pressure control
• Antiplatelet therapy
• Statin therapy

6. Fall Prevention

Implement fall risk assessment and home safety modifications immediately—dizziness increases fall risk 12-fold in elderly patients 7

• Prescribe appropriate assistive devices and orthoses 4
• Falls are the leading cause of accidental death in people >65 years 2
• Recurrent syncope can lead to nursing home admission and loss of independence 1

Multidisciplinary Approach for Complex Cases

For older adults with persistent disequilibrium despite initial interventions, collaborate with geriatric specialists to address frailty, cognitive impairment, and multiple comorbidities that predispose to poor outcomes 1

• Screen for cognitive impairment annually in adults ≥65 years, as cognitive decline increases fall risk 1
• Assess for depression, which commonly coexists with balance disorders 1
• Consider comprehensive geriatric assessment to identify unrecognized contributing factors 1

Special Considerations

Hypoglycemia Risk

In diabetic older adults, avoid hypoglycemia by adjusting glycemic targets and pharmacologic regimens, as hypoglycemia increases fall risk and cognitive decline 1

Syncope vs. Falls

Consider syncope as a cause in approximately 30% of older adults presenting with non-accidental falls, particularly when amnesia or cognitive impairment limits history 1