What tests and laboratory evaluations are indicated for a 90-year-old male presenting with vertigo?

From the Guidelines

For a 90-year-old male with vertigo, I recommend a comprehensive evaluation including complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12 and folate levels, and electrocardiogram to assess for underlying causes.

Evaluation and Diagnosis

Specific vestibular tests should include the Dix-Hallpike maneuver to check for benign paroxysmal positional vertigo (BPPV) 1, videonystagmography (VNG), and audiometry to evaluate inner ear function.

• The Dix-Hallpike test is used to diagnose posterior semicircular canal BPPV, which is the most common type of BPPV 1.
• Videonystagmography (VNG) is used to evaluate the function of the vestibular system and to diagnose other vestibular disorders 1.
• Audiometry is used to evaluate hearing function and to diagnose hearing-related disorders 1.

Imaging and Further Testing

Brain imaging with MRI or CT is important to rule out stroke or other central nervous system pathologies, which are more common in elderly patients 1.

• Carotid ultrasound may be warranted to assess vascular supply 1.
• Medication review is essential as many drugs commonly prescribed to elderly patients can cause or exacerbate vertigo 1.

Management and Prevention

These tests help differentiate between peripheral causes (like BPPV or vestibular neuritis) and central causes (like stroke or tumor), which is crucial for proper management.

• Given the patient's advanced age, careful consideration of fall risk and functional status should be incorporated into the evaluation, as vertigo significantly increases fall risk in the elderly population 1.
• Patient education regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up is crucial 1.

From the Research

Diagnostic Approach for Vertigo in a 90-year-old Male

• The diagnostic approach for vertigo involves determining whether the etiology is peripheral or central, as central etiologies often require urgent treatment 2.
• A systematic approach can usually arrive at the diagnosis, starting with categorizing dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo 3.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies 2.

Common Causes of Vertigo

• Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, especially in the elderly, and can be treated with a canalith repositioning procedure (e.g., Epley maneuver) 2, 4, 5.
• Meniere disease and vestibular neuritis are other potential causes of vertigo, with distinct symptoms and treatment options 2, 3.

Diagnostic Tests and Labs

• Laboratory testing and imaging are not required and are usually not helpful in diagnosing vertigo 2.
• The Dix-Hallpike maneuver and the Timed Up & Go (TUG) test can be used to assess patients with suspected BPPV 4.
• The Clinical Test of Sensory Interaction and Balance (CTSIB) can also be used to evaluate balance and functional aspects of body balance in patients with vertigo 4.

Treatment Options

• The Epley maneuver is an effective treatment for BPPV, with studies showing significant improvement in symptoms and functional outcomes 4, 5.
• Vestibular rehabilitation is also a treatment option for BPPV, although the evidence is inconsistent regarding its effectiveness compared to the Epley maneuver 5.
• Treatment of Meniere disease includes salt restriction and diuretics, while symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation 2.