What is the appropriate history, physical examination, and diagnostic workup for a 78-year-old female presenting with dizziness?

Approach to a 78-Year-Old Female with Dizziness

Begin by categorizing the dizziness using timing and triggers rather than symptom quality, as this approach is evidence-based and distinguishes benign from dangerous causes more effectively than traditional descriptors like "vertigo" or "lightheadedness." 1

History: Key Elements to Obtain

Timing and Trigger Classification

Classify the patient into one of three categories based on timing and triggers 1:

• Acute Vestibular Syndrome: Continuous dizziness lasting days, sudden onset
• Spontaneous Episodic: Recurrent episodes without positional triggers
• Triggered Episodic: Episodes provoked by head position changes

Specific Questions to Ask

Duration and Frequency 2:

• How long do episodes last? (Seconds suggest BPPV; 20 minutes to 24 hours suggest Ménière's; hours suggest vestibular migraine; days suggest vestibular neuritis or stroke) 2
• How often do symptoms occur?
• Is dizziness continuous or episodic?

Triggers and Onset 2:

• Does changing head position trigger symptoms? (suggests BPPV) 2
• Is onset spontaneous or provoked?
• Does movement worsen symptoms?

Associated Otologic Symptoms 2:

• Hearing loss (fluctuating vs. persistent)?
• Tinnitus (ringing, buzzing)?
• Ear fullness or pressure?
• Do these occur before, during, or after dizziness?

Neurologic Red Flags 2:

• Headache during episodes?
• Visual changes or photophobia?
• Dysarthria, dysphagia, or dysphonia?
• Facial numbness?
• Limb weakness or sensory changes?
• Loss of consciousness? (never occurs with Ménière's) 2

Fall Risk Assessment 2:

• Has the patient fallen in the past year? (53% of elderly with vestibular disorders have fallen) 2
• Drop attacks during episodes?
• Gait instability between episodes?

Medical History 2:

• Prior ear surgery or chronic ear infections
• Migraine history (vestibular migraine is common) 2
• Cardiovascular disease or stroke risk factors
• Current medications (antihypertensives, diuretics, vestibular suppressants)
• Recent head trauma 2

Physical Examination: Targeted Approach

Neurologic Examination

General neurologic assessment 3:

• Limb weakness/hemiparesis (sensitivity 11.4%, specificity 98.5% for central cause) 3
• Dysmetria/finger-to-nose testing (sensitivity 24.6%, specificity 97.8% for central cause) 3
• Truncal/gait ataxia (increasing severity correlates with central etiology; sensitivity 69.7%, specificity 83.7%) 3

Positional Testing for BPPV

Dix-Hallpike Maneuver (if triggered episodic pattern) 2:

• Rotate head 45° to one side while seated
• Move patient to supine position with head extended 20° below horizontal
• Observe for latency period (5-20 seconds, rarely up to 60 seconds) 2
• Look for torsional upbeating nystagmus that crescendos then resolves within 60 seconds 2
• Repeat on opposite side if first side negative 2

Supine Roll Test (if Dix-Hallpike shows horizontal or no nystagmus) 2:

• Assess for lateral semicircular canal BPPV 2

HINTS Examination (if Acute Vestibular Syndrome)

Perform HINTS only in continuous dizziness lasting >24 hours 3:

• Head Impulse Test (HIT): Sensitivity 76.8%, specificity 89.1% for central cause 3
• Nystagmus assessment: Bidirectional, vertical, direction-changing, or pure torsional nystagmus indicates central cause (sensitivity 50.7%, specificity 98.5%) 3
• Test of Skew: Skew deviation indicates central cause (sensitivity 23.7%, specificity 97.6%) 3

Complete HINTS examination: Sensitivity 92.9%, specificity 83.4% for central cause 3

HINTS+ (HINTS with hearing assessment): Sensitivity 99.0%, specificity 84.8% for central cause 3

Orthostatic Vital Signs

• Measure blood pressure and heart rate supine and after 1-3 minutes standing 4

Diagnostic Testing: When to Order

Imaging - Generally NOT Indicated

Do NOT obtain imaging if patient meets diagnostic criteria for BPPV without additional neurologic signs 2:

• Radiographic imaging is not recommended for isolated BPPV 2
• CT positivity rate in emergency department dizziness is only 2% 2

Consider MRI with DWI if 2:

• Neurologic symptoms present (increases yield to 12% vs. 4% for isolated dizziness) 2
• HINTS examination suggests central cause 3
• Acute vestibular syndrome with concerning features 2

Vestibular Testing - Selective Use

Do NOT order vestibular testing for patients meeting BPPV criteria without additional vestibular symptoms 2

Consider audiogram and vestibular function testing if 2:

• Fluctuating hearing loss with episodic vertigo (Ménière's disease suspected) 2
• Symptoms persist despite appropriate BPPV treatment
• Asymmetric hearing loss (rule out vestibular schwannoma) 2

Laboratory Testing

• Generally not required for typical presentations 4
• Consider if systemic causes suspected based on history

Critical Safety Considerations

This 78-year-old is at HIGH RISK for falls 2:

• 36.7% of elderly with chronic vestibular disorders have BPPV 2
• 53% have fallen at least once in the past year 2
• Counsel on home safety, activity restrictions, and need for supervision until resolved 2

Red flags requiring urgent evaluation 2:

• New neurologic deficits
• Severe headache
• Inability to walk
• Dysarthria, dysphagia, or diplopia
• Acute hearing loss with vertigo lasting >24 hours (labyrinthitis) 2

Common pitfall: Do not rely on symptom quality ("spinning" vs. "lightheadedness") to guide diagnosis, as this approach is outdated and inconsistent with current evidence 1. Instead, use timing and triggers to categorize the presentation 1.