Dizziness in the Elderly

Dizziness in the Elderly Coverage note: the uploaded textbooks address dizziness within the chapters on falls, syncope and comprehensive geriatric assessment rather than as a dedicated chapter. Points 1–14 are textbook-derived; points 15–20 and the manoeuvre details are drawn from current peer-reviewed guidance, which is stated explicitly.

Dizziness in the elderly is a geriatric syndrome, not a single diagnosis — it usually results from the accumulation of deficits in the visual, vestibular, proprioceptive, cardiovascular and cognitive systems, aggravated by drugs.

The classical classification distinguishes four types: vertigo (a sensation of rotational movement), presyncope/light-headedness, disequilibrium (unsteadiness on standing or walking), and non-specific dizziness (often psychogenic).

Vertigo is a more specific symptom and is most commonly associated with inner ear disorders. Light-headedness is non-specific and should be interpreted with caution.

Screening question in comprehensive geriatric assessment: "Do you get dizzy, or does your head spin around?" The recommended assessments are checking for postural hypotension, the Hallpike manoeuvre for BPPV, haemoglobin, and the Geriatric Depression Scale.

Benign paroxysmal positional vertigo (BPPV) is the commonest cause in older people — brief episodes triggered by head position change, from otoconial debris in the posterior semicircular canal. Diagnosed by the Dix-Hallpike manoeuvre, which reproduces vertigo with characteristic upbeating-torsional nystagmus.

Other inner ear causes: acute labyrinthitis and vestibular neuritis (single prolonged episode with nausea and vomiting) and Ménière's disease (episodic vertigo with fluctuating hearing loss and tinnitus).

Nystagmus can be demonstrated at the bedside by having the patient lie down quickly with the head turned to one side in a single motion; patients with vertigo from organic disorders often have nystagmus.

Patients with symptoms suggestive of vertigo benefit from a thorough otological examination including auditory testing, which helps differentiate inner ear from central nervous system involvement.

Orthostatic hypotension is best detected by measuring blood pressure and pulse supine, after one minute sitting, and after one and three minutes standing. A fall of more than 20 mmHg systolic is significant; many cases are asymptomatic.

Causes of orthostatic hypotension: low cardiac output from heart failure or hypovolaemia, overtreatment with cardiovascular drugs, autonomic dysfunction (diabetes, Parkinson's disease), impaired venous return, and prolonged bed rest with deconditioning. Postprandial hypotension is a distinctly geriatric cause — simply eating a full meal can lower blood pressure enough to precipitate a fall on standing.

Carotid sinus hypersensitivity and reflex (vasovagal) syncope become increasingly common with age; carotid sinus syndrome is a modifiable risk factor for non-accidental falls, and carotid sinus massage should be considered in unexplained or recurrent falls.

Cardiac causes include bradyarrhythmias, tachyarrhythmias and aortic stenosis. In general, cardiac monitoring should document a temporal association between a specific arrhythmia and the symptom before it is accepted as causal. A precise cause for syncope remains unidentified in 40–60% of older patients.

Central causes: vertebrobasilar ischaemia and infarction, cerebellar infarction, cerebellar degeneration, posterior fossa tumour, and multiple sclerosis. Cerebellar stroke is the diagnosis that must not be missed in an older patient with sudden isolated vertigo.

Drugs are the most important reversible cause. Culprits are diuretics (hypovolaemia), antihypertensives, antidepressants (postural hypotension), sedatives, antipsychotics (sedation, rigidity, hypotension), hypoglycaemics, anticonvulsants, aminoglycosides (ototoxicity) and alcohol. Combinations greatly increase the risk.

Psychological factors: many older patients with dizziness and unsteadiness are anxious, depressed and chronically afraid of falling, which makes evaluation difficult and means that mood must always be assessed. Drop attacks — sudden leg weakness causing a fall without loss of consciousness — are often attributed to vertebrobasilar insufficiency but are poorly understood and over-diagnosed.

The single most useful clinical discipline is to distinguish falls from syncope from seizure, and "dizziness" from true vertigo. Take a detailed history of timing, triggers, duration and associated symptoms, and always seek a witness account.

Core examination: postural blood pressure, cardiovascular examination including murmurs, cranial nerve and cerebellar examination, gait and balance assessment (Timed Up and Go, gait speed over 10 metres), visual acuity, otoscopy with removal of cerumen, and the Dix-Hallpike manoeuvre.

Targeted investigation only: haemoglobin, glucose, electrolytes, renal and thyroid function, vitamin B12, ECG; ambulatory monitoring or an implantable loop recorder for suspected arrhythmia; tilt-table testing and carotid sinus massage for unexplained syncope; MRI where central pathology is suspected. Do not send all patients for extensive diagnostic studies.

Management principles: treat the specific cause; rationalise medications; correct visual and hearing impairment; ensure adequate hydration and salt intake; use compression stockings and counter-pressure manoeuvres for orthostatic hypotension; refer for rehabilitation with strengthening, balance and gait training; and address environmental hazards.

Specific therapies (current literature): the Epley canalith repositioning manoeuvre is the treatment of choice for posterior canal BPPV; vestibular rehabilitation exercises for unilateral vestibular hypofunction; a short course of vestibular sedatives only for acute vestibular neuritis, since drugs such as meclizine and benzodiazepines compromise alertness and cognition and delay central compensation; midodrine or fludrocortisone for refractory orthostatic hypotension; and pacing for documented carotid sinus syndrome with cardioinhibition.