Evaluating Vertigo in the Elderly

Critical First Step: Define True Vertigo vs. Vague Dizziness

The American Academy of Otolaryngology-Head and Neck Surgery recommends determining whether the patient is experiencing true vertigo (a sensation of spinning or rotational movement) versus vague dizziness, lightheadedness, or presyncope, as elderly patients often struggle to articulate their symptoms clearly and may present with atypical "vestibular disturbance" rather than frank spinning sensations 1, 2
A confident description of spinning is specific for inner ear dysfunction, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
The American Academy of Otolaryngology-Head and Neck Surgery suggests that feeling like one might faint or pass out suggests presyncope, NOT vertigo 1
The American Academy of Otolaryngology-Head and Neck Surgery states that feeling unsteady or off-balance without spinning represents dizziness rather than true vertigo 1

The American Academy of Otolaryngology-Head and Neck Surgery recommends asking about the precise duration of vertigo episodes, as this single feature distinguishes most causes 1, 3
The American Academy of Otolaryngology-Head and Neck Surgery suggests that seconds-only duration is indicative of BPPV (positional vertigo lasting <1 minute) 1
The American Academy of Otolaryngology-Head and Neck Surgery states that minutes-duration is possible stroke/TIA or vestibular migraine 1, 3
The American Academy of Otolaryngology-Head and Neck Surgery recommends asking about triggering factors, such as changing head position, which can trigger BPPV 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery suggests that a history of migraine headaches is relevant, as vestibular migraine is very common (34% of BPPV patients have migraine history) 4, 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing the Dix-Hallpike maneuver to diagnose the most common cause of vertigo in elderly patients 6
The American Academy of Otolaryngology-Head and Neck Surgery suggests that the HINTS examination (Head Impulse Test, Nystagmus assessment, and Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners 7
The American Academy of Otolaryngology-Head and Neck Surgery states that nystagmus patterns suggesting central (stroke) causes include downbeating nystagmus, direction-changing nystagmus, and gaze-holding, direction-switching nystagmus 6, 8, 7

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing a focused posterior circulation assessment, including cranial nerves, cerebellar testing, gait assessment, and sensory and motor examination 6, 4
The American Academy of Otolaryngology-Head and Neck Surgery suggests that detecting focal deficits is crucial, as up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs 7

The American Academy of Otolaryngology-Head and Neck Surgery warns that never relying solely on CT imaging for suspected stroke, as it frequently misses posterior circulation strokes 7
The American Academy of Otolaryngology-Head and Neck Surgery cautions that assuming absence of focal neurologic deficits rules out stroke is incorrect, as up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs 7

The American Academy of Otolaryngology-Head and Neck Surgery suggests that vestibular migraine accounts for up to 14% of vertigo cases and has a lifetime prevalence of 3.2% 9
Dizziness increases fall risk 12-fold in elderly patients, with one-third of elderly patients falling annually 9
Polypharmacy is a major contributor to dizziness in the elderly, particularly with medications such as diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotics, tricyclic antidepressants, and antihistamines 10

The American Academy of Otolaryngology-Head and Neck Surgery recommends fall risk screening for all elderly patients with dizziness, including questions about previous falls, unsteadiness, and fear of falling 9
Among elderly patients with BPPV, 9% had undiagnosed BPPV at geriatric clinic evaluation, and three-fourths had fallen within the prior 3 months 9
Consider using the Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale for detailed fall risk assessment 9

The American Academy of Otolaryngology-Head and Neck Surgery states that neuroimaging has little value in BPPV, with magnetic resonance imaging testing not contributory to clinical diagnosis in a retrospective cohort of 2,374 patients 11
Reserve imaging for patients with additional neurologic symptoms atypical for BPPV, suspected BPPV but inconclusive positional testing, or any focal neurologic deficits suggesting posterior circulation stroke 11

Age-related physiological changes predispose to syncope, including reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress, and autonomic dysfunction 10
Polypharmacy effects are exacerbated by loss of peripheral autonomic tone with aging, and orthostatic hypotension, carotid sinus hypersensitivity, and autonomic dysfunction require specific evaluation 10