What is the most appropriate initial management for a 70‑year‑old woman with persistent dizziness and light‑headedness?

Initial Management of Persistent Dizziness in a 70-Year-Old Woman

The most appropriate initial management is to immediately perform the Dix-Hallpike maneuver at the first visit to diagnose benign paroxysmal positional vertigo (BPPV), which is the most common treatable cause of dizziness in older adults, and if positive, perform the Epley maneuver (canalith repositioning procedure) at the same visit, which has 80-90% success rates. 1, 2

Immediate Diagnostic Steps

History Taking: Focus on Timing and Triggers

• Determine if the dizziness is episodic versus constant, as patients struggle to describe quality but can identify timing reliably 1, 3, 4
• Ask specifically about head position changes triggering symptoms (turning in bed, looking up, bending over), which is pathognomonic for BPPV 2, 4
• Clarify duration of episodes: seconds-only duration indicates BPPV, while minutes suggest stroke/TIA or vestibular migraine 2
• Distinguish true vertigo (spinning sensation) from presyncope (feeling faint), as spinning is specific for inner ear dysfunction 2, 5
• Review all medications, particularly antihypertensives, diuretics, and CNS agents, which are common offenders in elderly patients 6, 7

Physical Examination: Targeted Maneuvers

• Perform the Dix-Hallpike maneuver immediately to diagnose BPPV, as this has the highest diagnostic yield in elderly patients with positional dizziness 1, 2, 3
• Measure orthostatic blood pressure (decline of ≥20 mmHg systolic or ≥10 mmHg diastolic within 2-5 minutes of standing), which is present in up to 40% of asymptomatic patients over age 70 but may explain symptoms 6
• Assess for nystagmus patterns: typical BPPV shows upbeating-torsional nystagmus with the Dix-Hallpike, while atypical patterns (downbeating, direction-changing, gaze-holding direction-switching) suggest dangerous central causes 2, 3
• Perform focused neurologic examination looking for focal deficits, ataxia, dysarthria, or diplopia that would indicate central etiology 2, 3

Treatment Algorithm Based on Findings

If Dix-Hallpike is Positive (BPPV Confirmed)

• Perform the Epley maneuver (canalith repositioning procedure) immediately at the same visit, as this is superior to observation or medication with 80-90% success rates 1, 2, 6
• Do not order imaging (MRI or CT) for typical BPPV, as neuroimaging has no value in these cases—a study of 2,374 patients showed MRI was not contributory 2
• Avoid vestibular suppressant medications (antihistamines, benzodiazepines, meclizine), as they delay central compensation and increase fall risk in elderly patients 1, 3, 4
• If the Epley maneuver cannot be performed due to physical limitations (cervical spine disease, severe kyphosis), refer immediately for vestibular rehabilitation 2

If Dix-Hallpike is Negative but Symptoms Persist

• Reassess for orthostatic hypotension and implement lifestyle modifications: gradual position changes, adequate hydration, compression stockings, and medication adjustments 6, 1
• Consider vestibular rehabilitation for chronic disequilibrium, which should include balance retraining, gait stability exercises, and habituation exercises for motion sensitivity 1, 3, 4
• Implement proprioceptive training with exercises on varying surfaces to improve balance 1

Critical Safety Counseling

Immediate Fall Prevention

• Counsel about dramatically increased fall risk: BPPV increases fall risk 12-fold, and 53% of elderly patients with vestibular disorders fall at least once yearly 2
• Assess home safety immediately and recommend activity restrictions until BPPV resolves, as patients are particularly vulnerable between diagnosis and definitive treatment 2
• Consider need for supervision, especially if the patient lives alone, as cerebral atrophy and white matter disease (common in this age group) independently increase fall risk 1
• Recommend home modifications: proper footwear, removal of throw rugs, adequate lighting, and grab bars 1

Recurrence Education

• Inform the patient that BPPV has a 30-50% recurrence rate within 5 years (10-18% at 1 year, up to 36% long-term) 2, 6
• Teach recognition of recurrent symptoms for earlier return for repeat canalith repositioning 2

Red Flags Requiring Urgent Neuroimaging

Order MRI (not CT) immediately if any of the following are present:

• Atypical nystagmus patterns (downbeating, direction-changing, or gaze-holding direction-switching) 2
• Any focal neurologic deficits, new headache, diplopia, dysarthria, or ataxia 2
• Negative or atypical Dix-Hallpike testing with persistent vertigo 2
• Neurological symptoms accompanying dizziness or symptoms suggesting central vertigo 1

Common Pitfalls to Avoid

• Do not prescribe meclizine or other vestibular suppressants as first-line treatment, as they delay compensation and worsen outcomes in elderly patients 1, 3
• Do not order routine laboratory testing or imaging for typical BPPV presentations, as these are rarely helpful and delay definitive treatment 3, 4
• Do not assume multifactorial dizziness without first ruling out BPPV, as 9% of elderly patients undergoing geriatric assessment have unrecognized BPPV 2
• Do not refer for standard physical therapy alone, as specific vestibular rehabilitation with movement/habituation-based exercises is required 1