How should vertigo in an older adult be evaluated and managed?

Evaluation and Management of Vertigo in Older Adults

Begin by performing the Dix-Hallpike maneuver bilaterally in every older adult with vertigo, because BPPV is the most common cause (accounting for 42% of all vertigo cases) and is immediately treatable with the Epley maneuver, which achieves 80% success after 1-3 treatments. 1, 2

Initial Clinical Assessment: Define the Symptom

Distinguish true vertigo from non-vestibular dizziness through specific questioning:

• True vertigo = sensation of spinning or rotational movement of self or environment, often with nausea and intolerance to head motion 2
• Lightheadedness/presyncope = feeling faint or about to pass out, suggests cardiovascular causes (orthostatic hypotension, arrhythmias, medication effects) 2, 3
• Disequilibrium = unsteadiness without spinning, suggests multisensory deficits or neurologic disease 2

Critical caveat: Up to 50% of older adults with BPPV describe their symptoms as "lightheadedness," "dizziness," or "being off-balance" rather than classic spinning, so proceed with positional testing even when the description is vague 2

Essential History: Duration and Triggers

The duration of vertigo episodes is the single most discriminating feature:

• Seconds (<1 minute) = BPPV, triggered by specific head position changes 2, 3
• Minutes to hours = vestibular migraine or Ménière's disease 2, 3
• Days to weeks (continuous) = vestibular neuritis or posterior circulation stroke 2, 3

Ask about specific triggers:

• Head position changes (rolling over in bed, looking up, bending forward) → BPPV 1, 2
• Standing from supine → orthostatic hypotension (cardiovascular, not vestibular) 2
• Spontaneous episodes → vestibular migraine, Ménière's, or stroke 2

Identify associated symptoms:

• Hearing loss, tinnitus, aural fullness → Ménière's disease 2, 3
• Headache with photophobia/phonophobia → vestibular migraine 2, 3
• Sudden unilateral hearing loss → urgent red flag requiring immediate imaging 2, 3

Critical Risk Stratification for Stroke

Older adults with vertigo have substantially higher stroke risk. Posterior circulation stroke accounts for 25% of acute vestibular syndrome overall, but rises to 75% in high-risk patients. 2, 3

High vascular risk profile (age >50 years PLUS any of):

• Hypertension 2, 3
• Diabetes 2, 3
• Atrial fibrillation 2, 3
• Prior stroke 2, 3

These patients require urgent MRI brain without contrast even with normal neurologic examination, because 11-25% harbor posterior circulation stroke. 2, 3

Physical Examination: Systematic Approach

1. Dix-Hallpike Maneuver (Bilateral)

Perform this first in all patients with episodic positional symptoms: 1, 2

Positive test shows:

• Latency of 5-20 seconds before symptoms begin 1, 2
• Torsional, upbeating nystagmus toward the affected ear 1, 2
• Vertigo and nystagmus that crescendo then resolve within 60 seconds 1, 2

If negative, perform supine roll test to assess for lateral canal BPPV (10-15% of BPPV cases). 1, 2

2. HINTS Examination (for Acute Continuous Vertigo)

When performed by trained neuro-otology specialists, HINTS has 100% sensitivity for stroke (superior to early MRI at 46% sensitivity). 2, 3

HOWEVER: Emergency physicians and non-specialists do NOT achieve comparable accuracy—do not rely on HINTS alone in the emergency department; obtain urgent MRI for any high-risk patient regardless of HINTS results. 2, 3

Central features suggesting stroke:

• Normal head impulse test 2, 3
• Direction-changing or purely vertical (downbeating/upbeating) nystagmus 2, 3
• Skew deviation on alternate cover test 2, 3

3. Focused Neurologic Examination

Assess for posterior circulation stroke signs:

• Cranial nerve deficits (dysarthria, dysphagia, diplopia, Horner's syndrome) 2, 3
• Cerebellar signs (ataxia, dysmetria, inability to stand or walk) 2, 3
• Limb weakness or sensory loss 2, 3

Critical pitfall: 75-80% of patients with posterior circulation stroke presenting as acute vestibular syndrome have NO focal neurologic deficits on examination—normal exam does not exclude stroke in high-risk patients. 2, 3

Red Flags Requiring Urgent MRI Brain Without Contrast

Any of the following mandate immediate imaging: 2, 3

• Age >50 years with vascular risk factors (even if exam is normal) 2, 3
• New severe headache accompanying vertigo 2, 3
• Focal neurologic deficits (dysarthria, limb weakness, diplopia, Horner's syndrome) 2, 3
• Sudden unilateral hearing loss 2, 3
• Inability to stand or walk 2, 3
• Downbeating or purely vertical nystagmus 2, 3
• Direction-changing nystagmus 2, 3
• Baseline nystagmus present without provocative maneuvers 2, 3
• Normal head impulse test (suggests central cause) 2, 3
• Skew deviation 2, 3

Imaging Decisions

When NOT to image:

• Typical BPPV with positive Dix-Hallpike test and no red flags 1, 2, 3
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern by trained examiner, and low vascular risk 2, 3
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2, 3

When imaging IS indicated:

• MRI brain without contrast is the first-line modality, with 4% diagnostic yield versus <1% for CT 2, 3
• CT head has only 10-20% sensitivity for posterior circulation strokes and should NOT be used instead of MRI when stroke is suspected 2, 3
• CT may be used as initial imaging in acute settings when MRI is unavailable, but recognize its severe limitations 2, 3

For chronic recurrent vertigo with unilateral hearing loss or tinnitus: MRI head and internal auditory canal WITH and WITHOUT contrast to exclude vestibular schwannoma 2, 3

Geriatric-Specific Considerations

Fall Risk Assessment

Dizziness increases fall risk 12-fold in older adults. BPPV is present in 9% of elderly patients referred for geriatric evaluation, and three-fourths had fallen within the prior 3 months. 2, 4, 5

Screen all older adults with vertigo for fall risk:

• Number of falls in past year 2
• Circumstances and injuries sustained 2
• Unsteadiness when standing or walking 2
• Fear of falling 2

Consider formal balance testing: Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale 2

Medication Review

Medication side effects are the most common reversible cause of chronic dizziness in older adults. 2, 6

Review these high-risk medications:

• Antihypertensives (diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates) 2
• Vestibular suppressants (antihistamines, benzodiazepines) 1, 2
• Antipsychotics 2
• Tricyclic antidepressants 2
• Anticonvulsants 2

Age-Related Physiologic Changes

Older adults have increased vulnerability to dizziness due to:

• Reduced thirst and impaired sodium/water preservation 2
• Diminished baroreceptor response 2
• Reduced heart rate response to orthostatic stress 2
• Autonomic dysfunction 2
• Fragmentation of otoconia (contributing to BPPV) 4, 7

Treatment Based on Diagnosis

BPPV (Most Common in Older Adults)

Perform the Epley canalith repositioning maneuver immediately after positive Dix-Hallpike test. 1, 2, 4

Expected outcomes:

• 80% success after 1-3 treatments 1, 2
• 90-98% success with repeat maneuvers if initial treatment fails 1, 2

Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV—they do not correct the mechanical pathology, delay central compensation, and carry significant side effects in older adults. 1, 6

Reassess within 1 month to confirm symptom resolution. 1

Counsel patients about:

• Recurrence risk 1
• Fall risk and home safety assessment 1, 2
• Activity restrictions until resolved 1
• Need for home supervision if elderly and frail 1

Vestibular Neuritis

Vestibular suppressants (antiemetics, benzodiazepines) should be limited to the acute phase only (first 2-3 days), followed by early vestibular rehabilitation to promote central compensation. 2, 6

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy when:

• Vertigo persists after 2-3 repositioning attempts 2
• Balance and motion tolerance do not improve despite initial treatment 2

Vestibular rehabilitation significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk. 2, 6

Common Diagnostic Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness"—50% of older adults with BPPV use atypical descriptors 2
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 2, 3
• Using CT instead of MRI for suspected stroke—CT misses most posterior circulation infarcts 2, 3
• Failing to perform Dix-Hallpike bilaterally—lateral canal BPPV requires supine roll test 1, 2
• Prescribing vestibular suppressants for BPPV—ineffective and harmful in older adults 1, 6
• Ordering routine imaging for typical BPPV—diagnostic yield <1% without red flags 2, 3