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Managing Dizziness & Vertigo in an 80-Year-Old Woman

Why Age Matters

• Decreased visual acuity
• Reduced proprioception
• Declining vestibular input
• Accumulation of free-floating otoconia (predisposing to BPPV)
• Polypharmacy (many medications cause dizziness)

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Step 1: Clarify the Type of Dizziness

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Step 2: History — Key Questions

• Seconds — triggered by head movement or getting in/out of bed → think BPPV
• Hours — with hearing loss/tinnitus → Ménière's disease
• Hours — without hearing symptoms → vestibular migraine
• Minutes — with neurological symptoms → TIA (posterior circulation)
• Constant for days — with or without viral prodrome → vestibular neuritis
• On standing up → orthostatic hypotension

• Unilateral hearing loss, ear fullness, tinnitus → peripheral cause
• Double vision, facial numbness, dysarthria, limb ataxia, headache → central cause / stroke (emergency)
• Neck pain → vertebral artery dissection
• Palpitations → cardiac arrhythmia

• Antihypertensives, diuretics, sedatives, antiepileptics, aminoglycosides, loop diuretics

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Step 3: Examination

• Nystagmus — direction, persistence, fixation suppression
• Peripheral nystagmus: unidirectional, suppressed by fixation
• Central nystagmus: direction-changing with gaze, NOT suppressed by fixation; vertical nystagmus is a red flag

• Positive = upbeat-torsional nystagmus with latency, fatigable → posterior canal BPPV

• Head Impulse (normal = central), INdirection-changing nystagmus (central), Test of Skew (vertical misalignment = central)
• A normal head impulse + direction-changing nystagmus + skew deviation = posterior circulation stroke (more sensitive than MRI in first 24–48 h)

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Step 4: Differential Diagnosis & Management by Cause

A. BPPV (Most Common in Elderly)

• Brief episodes (<1–2 min), triggered by head/position change
• Dix-Hallpike test positive
• Treatment: Epley Maneuver (Canalith Repositioning) — first-line, highly effective
• Do NOT prescribe vestibular suppressants for classic BPPV (episodes too brief)
• Repeat maneuver if needed; instruct home exercises (Brand-Daroff)

B. Vestibular Neuritis

• Constant vertigo lasting days, worse with movement, no hearing loss
• Treatment: Symptomatic (vestibular suppressants short-term), corticosteroids (methylprednisolone) may improve recovery, vestibular rehabilitation exercises
• Avoid prolonged use of suppressants — they impair central compensation

C. Ménière's Disease

• Recurrent episodes (20 min–hours) + low-frequency hearing loss + tinnitus + ear fullness
• Treatment: Low-salt diet, diuretics (hydrochlorothiazide), betahistine; ENT referral

D. Orthostatic Hypotension

• Very common in elderly (medications, dehydration, autonomic dysfunction)
• Treatment: Review/reduce offending medications, adequate hydration, compression stockings, rise slowly, consider fludrocortisone or midodrine if severe

E. Central Vertigo / Posterior Circulation Stroke

• Red flag — must rule out emergently
• Persistent vertigo + any of: new headache, diplopia, dysarthria, ataxia, facial palsy, limb weakness
• Action: Urgent MRI brain (CT may miss posterior fossa infarct), neurological referral

F. Medication-Induced

• Antihypertensives, sedatives, antiepileptics — review and rationalize the medication list

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Step 5: Investigations (Selective, Not Routine)

Routine MRI, audiogram, and vestibular tests are NOT recommended in unselected dizzy patients — they are no more likely to be abnormal than in age-matched controls. — Bradley and Daroff's Neurology in Clinical Practice

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Step 6: Pharmacotherapy for Symptomatic Relief

Important: Benzodiazepines and antihistamines with anticholinergic properties should be used with caution and only short-term in elderly patients due to fall risk, sedation, confusion, and urinary retention.

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Step 7: Vestibular Rehabilitation

• Cawthorne-Cooksey exercises or formal vestibular rehabilitation therapy (VRT)
• Proven to improve balance, reduce dizziness, and decrease fall risk
• Particularly important in elderly patients to prevent falls

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Summary Algorithm

Dizziness in 80-year-old woman
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Characterize: Vertigo / Presyncope / Disequilibrium?
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If VERTIGO:
  ├── Central red flags? → Urgent MRI + Neurology
  ├── Positional (seconds, Dix-Hallpike +ve)? → Epley Maneuver (BPPV)
  ├── Constant (days, no hearing loss)? → Vestibular neuritis Rx
  ├── Episodic (hours + hearing sx)? → Ménière's workup
  └── Episodic (minutes) + neuro sx? → TIA workup
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If PRESYNCOPE:
  ├── Orthostatic? → Medication review, hydration
  └── Cardiac? → ECG, Holter
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Review ALL medications
Vestibular rehabilitation for all chronic cases
Fall risk assessment mandatory

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1. BPPV is the single most common cause of vertigo in the elderly — always test with Dix-Hallpike
2. Never miss posterior circulation stroke — use the HINTS exam
3. Orthostatic hypotension and medication side effects are extremely prevalent in this age group
4. Avoid or minimize sedating vestibular suppressants in the elderly
5. Vestibular rehabilitation reduces fall risk — critical in an 80-year-old