n estimated 12.5 million Amer-icans over age 65 are affected

by dizziness; in fact, dizziness has beenreported to have a prevalence of 28 to34% in adults over age 60 in several epi-demiologic studies of dizziness in thecommunity and primary care settings.1

The majority of older patients who pre-sent with dizziness have an identifiablecause that is benign and self-limited.

The primary care physician must befamiliar with the differential diagnosis,evaluation, and management of dizzi-

ness in order to identify and treat un-derlying, potentially life-threateningconditions. It is inappropriate to at-tribute dizziness to the normal agingprocess. Referrals to an otolaryngolo-gist, neurologist, cardiologist, psychia-trist, or neurosurgeon may be neces-sary as dizziness may be caused by adisturbance in any of the balance con-trol systems managed by these special-ists.

This two-part article will discuss thediagnosis and management of the mostcommon causes of dizziness in theolder adult. In part 1, we review theevaluation of dizziness in the older pa-tient and make general recommenda-tions for managing symptoms. In part2 (page 46), we discuss in detail the fourmost common dizziness symptom cat-egories in the older adult (vertigo, pre-syncope, dysequilibrium, non-specificdizziness) and the underlying causesof each, as well as make specific treat-ment recommendations for each type.

Scope of dizzinessThe prevalence of dizziness increaseswith age and is more common inwomen. In one study of 1,000 adultsage 65 and older, 30% reported dizzi-ness.2 Another study found that 47%of men and 61% of women over age70 are affected by dizziness.3 Falls, fearof falling, and secondary limitation ofactivity are consequences of dizzinessin the older population.4 Dizziness wasdirectly associated with 6.4 to 7.2% offalls in one large study of older pa-tients.2

Postural stability involves the com-plex integration of visual, proprio-ceptive, somatosensory, and vestibu-lar signals; therefore, pathology ofany of these signals may lead to thesensation of altered orientation inspace typically perceived as dizziness.Unless otherwise specified, the generalterm“dizziness” will be used in thesearticles to mean vertigo, presyncope,dysequilibrium, and non-specific dizzi-ness.

Although a large number of disor-ders may contribute to dizziness, ap-proximately 90% of identified causesof dizziness fall into one of seven broadcategories (table 1).5 A recent prospec-tive study of ambulatory older patients(mean age 74) with dizziness of morethan 1 year’s duration identified a car-diovascular cause in 28%, peripheralvestibular disorder in 18%, centralneurologic disorder in 14%, more thanone diagnosis in 18%, and no attrib-utable cause in 22%.6

ENT SeriesENT Series

Dizziness is one of the most common complaints among patients age50 and older who present to primary care physicians. The evaluation ofdizziness is challenging due to the wide range of diagnosticpossibilities, including four symptom categories each with multiplepotential underlying causes. Although each cause has specifictreatment options, general management strategies can be applied toall patients presenting with dizziness. These strategies include use ofmedications to control acute vestibular and autonomic symptoms aswell as vestibular rehabilitation exercises. Difficult cases that do notrespond to treatment efforts should be referred to an otolaryngologistfor further evaluation and treatment.

Eaton DA, Roland PS. Dizziness in the older adult, part 1: Evaluation and general treat-ment strategies. Geriatrics 2003; 58(April):28-36.

Key words: dizziness • vertigo • presyncope • dysequilibrium

Deborah A. Eaton, MD • Peter S. Roland, MD

Dizziness in the older adult, part 1Evaluation and general treatment strategies

28 Geriatrics April 2003 Volume 58, Number 4

Dr. Eaton is chief resident, depart-ment of otolaryngology—head andneck surgery, University of TexasSouthwestern Medical Center, Dal-las.

Dr. Roland is professor and chair-man, department of otolaryngolo-gy—head and neck surgery, Universi-ty of Texas Southwestern MedicalCenter, Dallas.

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Physiology and changeswith agingThe maintenance of postural stabilityinvolves the central nervous integrationof five sensory modalities: vestibular,visual, proprioceptive, touch and pres-sure, and hearing. Adults tend to relymore heavily on visual cues (such as thelocation of stable surroundings) for themaintenance of balance, whereas chil-dren rely more on proprioceptive (suchas footing) and vestibular (such as headposition) cues. In the normal state,vestibular receptors in each labyrinthgenerate resting activity; subsequenthead movement produces equal andopposite alterations in the activity ineach ear. This in turn leads to the ap-propriate compensatory eye and mus-cle movements for the maintenance ofgaze and posture. Therefore, the pro-duction of spontaneous false or inade-quate information by any of the in-volved sensory organs may producedizziness and disorders of balance. Anydiscrepancy between the senses, slow orinaccurate central integration, or ab-normal motor function (caused by or-thopedic or neurologic disease in olderpatients such as arthritis or Parkinson’sdisease) may lead to a mismatch ininput causing dizziness and subsequentimbalance.

Changes with aging. Normal aging in-creases the older individual’s suscepti-bility to dizziness and contributes to aslower recovery from diseases thatcause dizziness. Normal aging, how-ever, is never the cause of dizziness.Well-described anatomic and physio-logic changes associated with aging thatmake older adults susceptible to dizzi-

ness include a reduction in sensory re-ceptors located in the semicircularcanals, saccule, utricle, proprioceptiveend organs, and retina.7 Vision and vi-sual-vestibular reflexes are known todecline with advancing age. Becauseadults rely heavily on vision to com-pensate for vestibular and postural con-trol deficits, a decline in vision con-tributes significantly to dizziness andsubsequent imbalance in older indi-viduals.

Symptom categoriesA key aspect in the evaluation of adizzy patient is eliciting a detailed de-scription of the character of the sen-sation in the patient’s own words. Al-though dizziness can be classified intothe following four broad symptom cat-egories,8 it is important to keep inmind that the clinician may be unableto assign the older adult’s symptom toa single category. Also, more than onesymptom type may be present.

Vertigo is a sensation in which pa-tients feel that their environment ismoving. Although the sensation isoften rotational, patients also may feelas though they are falling. Vertigo isusually episodic, begins abruptly, andis often associated with nausea or vom-iting when it is severe. Vertigo is typi-

cally caused by a disturbance of the pe-ripheral vestibular apparatus (innerear or eighth cranial nerve) or con-nections in the CNS. Differences in themanifestations of peripheral and cen-tral vertigo are provided in table 2.Common causes of peripheral vertigoinclude benign paroxysmal positionalvertigo (BPPV), acute labyrinthitis,and Meniere’s disease. Central causesof vertigo include mass lesions locatedin the CNS, and vascular, compromise,and inflammatory disorders involvingthe CNS. These diseases will be dis-cussed in detail in part 2.

Presyncope is usually described as asensation of impending faint or loss ofconsciousness, and may begin with di-minished vision or roaring in the ears.The presyncope symptom complex de-notes diffuse cerebral ischemia, due tocardiac causes (eg, dysrhythmias or aor-tic stenosis), non-cardiac causes (eg,postprandial hypotension, vasovagalepisodes, orthostatic hypotension, med-ications), or both.

Dysequilibrium is a feeling that a fallis imminent and is characterized byunsteadiness or imbalance that occursonly when erect and primarily involvesthe trunk and lower extremities ratherthan the head; the sensation disap-pears when sitting or lying. Dysequi-

Table 1 Seven broad causes of dizzinessPeripheral vestibular disorders Central and primary neurologic Cardiovascular disorders disordersMultisensory dizziness Psychiatric diseaseBrainstem cerebrovascular disease Hyperventilation syndrome

Source: Prepared for Geriatrics by Deborah A. Eaton, MD, and Peter S. Roland, MD.

Table 2 Manifestations of peripheral and central vertigoNausea Neurologic

Cause and vomiting Ataxia Hearing loss symptoms Compensation

Peripheral vertigo

Severe Rare Common Rare Rapid

Central vertigo

Moderate Common Rare Common Slow

Source: Prepared for Geriatrics by Deborah A. Eaton, MD, and Peter S. Roland, MD.

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30 Geriatrics April 2003 Volume 58, Number 4

librium is often continuous (ie, no in-tervening periods of a normal senseof balance) and only uncommonly oc-curs in paroxysms. Dysequilibrium isoften caused by dysfunction of morethan one sensory modality and fre-quently involves some deteriorationor injury to the nervous system. Com-mon causes of dysequilibrium includesevere bilateral vestibular disease,stroke, neurosensory deficits, cerebel-lar disease, or peripheral neuropathies.

Non-specific dizziness is described bythe patient as a vague sensation oflight-headedness, and includes symp-toms that cannot be distinctly identi-fied as vertigo, presyncope, or dyse-quilibrium. Patients may use termssuch as “heavy-headedness” or “woozi-ness” to describe this sensation. Thistype of dizziness may be caused by lesssevere forms of the above-mentioneddisorders, but is often due to anxiety,phobic disorders, or hyperventilation.

Time courseIn addition to the patient’s descriptionof the dizziness, the time course of thepatient’s symptoms can provide im-portant clues to diagnosis. It is help-ful to elicit the temporal componentof individual attacks as well as the entire course of the disorder. At thesimplest level, one can distinguish between episodic (ie, symptoms thatcome and go) or continuous sympto-matology.

● Less than 1 minute. Episodes ofacute, rotational vertigo lasting lessthan 1 minute are most commonly as-sociated with disorders of the periph-eral vestibular system such as BPPV.

● Less than 1 hour. Dizziness lastinga few minutes to 1 or 2 hours can becaused by Meniere’s disease, transientcerebral hypoperfusion (causing pre-syncope), or phobic/anxiety disorders.

● Several hours to 24 hours. This typeof dizziness indicates processes thatcause continuous dysequilibrium orMeniere’s disease. Viral or vascularlabyrinthitis usually presents withacute rotational vertigo of several days’duration with gradual improvement.

HistoryA complete medication history is crit-ical to the evaluation. Cardiovasculardrugs including diuretics, beta block-ers, and vasodilators may producepresyncope. Ototoxic drugs (eg, as-pirin, aminoglycosides) typicallycause dysequilibrium and oscillopsia(ie, oscillating vision in which objectsseem to jerk or wiggle with headmovement). Psychotropic medica-tions, muscle relaxants, and anticon-vulsants in therapeutic and toxicdosages have also been associated withdysequilibrium. Alcohol, caffeine, andover-the-counter drug use (includingdietary supplements) should also beassessed.

The history should specifically seekinformation about systemic disordersthat interfere with cerebral blood sup-

ply (such as vasculitis) and may pro-duce vertigo due to either focal brainstem involvement or diffuse cerebralischemia. Non-specific constant dizzi-ness can follow head trauma. Cardiacabnormalities (such as arrhythmia orvalvular stenosis) may cause recurrentpresyncopal episodes.

Associated symptoms such as hear-ing loss, tinnitus, nausea and vomiting,and cranial nerve deficits should also benoted because the presence of suchsymptoms localizes the pathology to thelabyrinth, neurovascular bundle, orbrainstem. Hearing loss and tinnitus sug-gest a labyrinthine source, whereas cra-

nial nerve deficits tend to localize pathol-ogy to the brainstem or peripheral nerve.

It is also important to determine therelationship between dizziness and po-sition and motion. For example, BPPVoccurs with a rapid change in positionwhereas orthostatic hypotension occurswhen the patient is standing. Symptomsfrom Meniere’s disease, stroke, or car-diac disease are unrelated to positionor motion. Dysequilibrium due to mul-tisensory loss occurs when the patientis moving (typically during ambula-tion) but is absent when the patient issitting still.

ExaminationThe dizziness simulation battery hasbeen advocated for the office evaluationof dizziness (table 3).5 Patients are askedto identify which of eight different ma-neuvers most closely reproduces theirdizziness. This test battery includes anassessment of hyperventilation, ortho-static hypotension, peripheral vestibu-lopathy, and carotid sinus stimulationas well as multisensory disturbances.

The eight tests are designed to be eas-ily administered in the office setting.After performing one or more maneu-vers, the patient is asked to identifywhich maneuvers most closely repro-duced his dizziness symptoms. Ortho-static blood pressure testing can iden-tify orthostatic hypotension if there isa significant decrease in systolic bloodpressure (20 to 25 mm Hg decrease) be-tween the first blood pressure mea-surement (taken when the patient islying down) and the second blood pres-sure measurement (taken when the pa-tient is standing). This test can identifypatients with presyncope. The potenti-ated Valsalva maneuver is also designedto cause presyncope symptoms, and re-quires the patient to squat for 30 sec-onds then stand and blow into a sphyg-momanometer at 40 mm Hg for 15seconds. Straining against a closed glot-tis and carotid sinus stimulation mayalso produce presyncope symptoms.

The head-hanging positioning ma-neuver (Dix-Hallpike) is a simple in-office screen for BPPV. The patient is

It is important todetermine therelationshipbetween dizziness,position, and motion

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April 2003 Volume 58, Number 4 Geriatrics 33

Table 3 Dizziness simulation batteryManeuver Description Dizziness produced

1. Orthostatic blood pressure testing

Patient’s blood pressure is measured Produces presyncope resulting fromfirst while the patient is lying down, orthostatic hypotension.and then while the patient is standing.

A 20 to 25 mm Hg decrease in systolic blood pressure indicates orthostatichypotension.

2. Potentiated Valsalva maneuver

Patient squats for 30 seconds then Produces presyncope indicatingstands up and blows into a presence of orthostatic hypotension,sphygmomanometer at 40 mm Hg vasovagal attacks, or decreasedfor 15 seconds. cardiac output.

3. Carotid sinus stimulation

Gently massage the area of the patient’s Produces presyncope indicatingcarotid bulb for a few seconds with presence of orthostatic hypotension,continuous ECG monitoring. vasovagal attacks, or decreased

cardiac output.

4. Dix-Hallpike maneuver

Patient is seated on a table and is rapidly Produces vertigo in patients with BPPV.lowered until the head hangs over thetable.

The position is held for at least10 seconds.

See www.geri.com for an animatedillustration of this maneuver.

5. Barany rotation

Patient is seated in a swivel chair with Produces vertigo in anyone whothe head tilted down 30 degrees. The maintains some vestibular function.chair is then spun 10 times.

6. Walk and turn

Patient walks 6 to 10 feet, turns around, Produces dysequilibrium caused byand walks back to the starting point. multisensory loss.

7. Seated head turn

While seated in a chair, patient is asked Produces dysequilibrium caused byto turn the head as if watching an multisensory loss.airplane fly across the sky. Having thepatient perform this maneuver once isenough to elicit symptoms.

8. Hyperventilation (30 seconds)

Patient breathes into a paper bag for Produces non-specific dizziness caused30 seconds. by hyperventilation, indicating the

possible presence of anxiety or aphobic disorder.

Source: Prepared for Geriatrics by Deborah A. Eaton, MD, and Peter S. Roland, MD, using information from reference 5.

continued

placed in a seated position on a tableand then rapidly lowered until the headhangs over the table (figure). The po-sition is held for at least 10 seconds. Adelayed (few seconds) onset of brief,fatigable horizontal-rotary nystagmusis diagnostic of BPPV. An animated il-lustration of the Dix-Hallpike maneu-ver can be viewed on the Geriatrics website at www.geri.com.

The Barany rotation is conductedby spinning the patient in a swivelchair 10 times while the patient’s headis tilted down 30 degrees. This ma-neuver is designed to stimulate thehorizontal semicircular canals and willproduce vertigo in anyone who retainssome vestibular responsiveness. Thewalk and turn assessment and seatedhead turn will identify patients withdysequilibrium due to multisensoryloss. Having the patient breathe into apaper bag for 30 seconds will causedizziness due to hyperventilation.

Cardiac arrhythmias, murmurs—particularly aortic stenosis, and evidenceof peripheral vascular disease shouldalso be carefully assessed during the pri-mary evaluation, as these signs will fur-ther focus the differential diagnosis andguide the diagnostic evaluation.

Diagnostic testingThe evaluation often can be limited toa careful history and physical examina-

tion, particularly in straightforwardcases of BPPV, which can be identifiedby conducting the Dix-Hallpike ma-neuver.

An audiogram is helpful in the eval-uation of Meniere’s disease and acousticneuroma. Abnormalities in brainstemauditory evoked potentials may indicatethe presence of suspected eighth-nervediseases such as multiple sclerosis andacoustic neuroma. Specific screeninglaboratory tests, which may be helpfulin difficult cases of dizziness, includecomplete blood cell count, blood glu-cose, blood urea nitrogen, calcium, liverfunction, VDRL, and thyroid function.

MRI is the diagnostic procedure ofchoice for the detection and evaluationof tumors. The use of Holter monitor-ing to identify arrhythmias that may becontributing to presyncope is contro-versial, as one report found that only7% of exams showed abnormalities inthe absence of other cardiac symptoms.6

Symptoms suggesting transient is-chemic attacks should be evaluated withcarotid and vertebral artery Dopplerexaminations.

A vestibular assessment includingelectronystagmography (ENG), rota-tional testing, and posturography maybe helpful in select cases of dizzinesswhere the diagnosis is still unclear afterhistory and physical exam. The ENGrecords eye movements by measuring

corneoretinal potentials during dif-ferent maneuvers. The entire ENGevaluation consists of several subtests:the Dix-Hallpike maneuver, calorictesting (which assesses the horizontalsemicircular canals), and the saccade,tracking, and optokinetic tests. Thecaloric test is very sensitive in identi-fying unilateral peripheral vestibulardeficits, and is not affected by aging.7

Rotational chair testing assesses thevestibulo-ocular reflex whereas pos-turography tests the integrity of thevestibulospinal tracts. Test results in-dicate dysfunction in these areas andhelp to focus rehabilitation efforts.

Consultation with a neurologist orotolaryngologist should be consideredin patients with chronic dizziness andno apparent underlying cause.

General managementstrategiesWhen possible, treatment should be di-rected at the underlying cause of thedizziness and will be discussed furtherin part 2 of this article. In general, med-ical treatment for patients with a sud-den loss of vestibular function is aimedat controlling the acute vestibular andautonomic symptoms. Five main classesof drugs are used: antihistamines (eg,meclizine), phenothiazines (eg, promet-hazine), anticholinergics (eg, scopo-lamine), 5-HT3 antagonists (eg, on-

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34 Geriatrics April 2003 Volume 58, Number 4

Figure. The Dix-Hallpike maneuver is one component of the dizziness simulation battery. It begins with the patient seated on atable with the head turned 45 degrees (A). The examiner then rapidly brings the patient to a supine head-hanging position (B). Ananimated illustration of this maneuver can be viewed on the Geriatrics web site at www.geri.com.Illustrations by Medical Imagery

A B

dansetron), and benzodiazepines (eg,diazepam). All medications should beadministered sparingly and for shortdurations, however, as they cause a re-duction in central nervous system com-pensation in all patients. Meclizine istypically administered orally in doses of12.5 to 25 mg tid as needed for acute pe-ripheral vertigo only (such as acute at-tacks of labyrinthitis, vestibular neu-ronitis, or Meniere’s disease). Olderpatients should be started on the low-est dose of this medication. Benzodi-azepines (usually diazepam prescribedorally at 2.0 to 7.5 mg/d) are helpful insuppressing the central response tochronic vestibular vertigo. 5-HT3 an-tagonists may be quite helpful if nauseais a significant component of the clini-cal picture but are not helpful in reduc-ing vestibular symptoms. All of thesemedications should be used cautiouslyin older individuals in order to avoidsedative side effects. Use the lowest dosepossible to achieve symptom control.

Vestibular rehabilitation has beenused as adjunctive therapy in the UnitedStates since the 1940s. It involves spe-cific habituation exercises designed toenhance the normal adaptive mecha-nisms in the central nervous system.Program strategies vary depending onthe patient’s primary problem, but areaimed at stabilizing gaze and posture,improving central nervous systemadaptation, and reconditioning. Essen-tial components of effective vestibularrehabilitation include gaze stabilization,balance retraining, and desensitization.Each aspect is addressed separatelyusing different exercises.

● Gaze stabilization exercises pro-mote vestibular adaptation throughexercises that stimulate the vestibularocular reflex (such as moving the headwhile reading text and vice versa).

● Balance retraining starts with ac-tivities that progressively decrease thepatient’s base of support and progressesto gait exercises performed on variedsurfaces (such as stairs, balance beams,etc.). The tandem gait is an appropri-ate alternative for older patients whohave difficulty on the balance beam.

Having patients attempt to walk whilereading, carry objects while walking,and walk through crowded hallwayschallenges the balance system. Strength-ening exercises are prescribed to im-prove muscle weakness and flexibility.

● Repetitive head and eye move-ments designed to provoke vertigo andunsteadiness enhance the central ner-vous system adaptive mechanisms.

● These exercises are usually repeateduntil they are no longer tolerated, andthe number of repetitions is slowly in-creased over a 6- to 8-week period.Vestibular rehabilitation is usually ad-ministered as adjunctive therapy by aphysical therapist with experience treat-ing older patients. These habituationstrategies have been found most effec-tive in patients with positional vertigoor a sudden loss of vestibular function.9

●A patient handout on the Geriatricsweb site (www.geri.com) provides ex-amples of these exercises that older pa-tients can do at home. Physicians candownload the handout and print outcopies for their patients.

Most cases of dizziness in older adultscan be treated once the cause(s) have beenidentified. Often, simple measures suchas correcting vision, modifying a drugregimen,balance retraining,or treating acardiac arrhythmia are all that is neces-sary to improve the patient’s quality oflife.A minority of patients, however, willhave no single identifiable cause for theirdizziness and will be impossible to cure.These patients typically have multiplemedical problems with significant im-pairment and are most appropriatelytreated with supportive measures such asvestibular rehabilitation exercises, physi-cal therapy, and tools that provide addi-tional proprioceptive input, such as canesand walkers.Particularly challenging casesshould be referred to an otolaryngologistfor further work-up and possible chem-ical or surgical ablative therapy.

ConclusionDizziness is a common presentingcomplaint among older patients in pri-mary care. Physicians investigatingcomplaints of dizziness can use the four

dizziness symptom categories to nar-row down the possible causes. Thor-ough history, examination, and diag-nostic testing help to tease out thedifferential diagnosis. General man-agement strategies that can be appliedto all older adults include use of med-ications to control acute vestibular andautonomic symptoms as well as vestibu-lar rehabilitation exercises. In part 2, wediscuss in detail the underlying causesof the four symptom categories andprovide specific treatment approachesfor each cause.

References1. Sloane PD, Coeytaux RR, Beck RS,

Dallara J. Dizziness: State of thescience. Ann Intern Med 2001; 134(9Pt 2):823-32.

2. Colledge NR, Wilson JA, Macintyre CC,MacLennan WJ. The prevalence andcharacteristics of dizziness in an elderlycommunity. Age Ageing 1994;23(2):117-120.

3. Luxon LM. Disturbances of balance inthe elderly. Br J Hosp Med 1991;45(1):22-6.

4. Dominguez RO, Bronstein AM.Assessment of unexplained falls andgait unsteadiness: The impact of age.Otolaryngol Clin North Am 2000;33(3):637-57

5. Drachman DA. A 69-year-old man withchronic dizziness. JAMA 1998;280(24):2111-8.

6. Lawson J, Fitzgerald J, Birchall J, AldrenCP, Kenny RA. Diagnosis of geriatricpatients with severe dizziness. J AmGeriatr Soc 1999; 47(1):12-7.

7. Isaacson JE, Rubin AM. Otolaryngologicmanagement of dizziness in the olderpatient. Clin Geriatr Med 1999;15(1):179-91.

8. Sloane PD. Evaluation and managementof dizziness in the older patient. ClinGeriatr Med 1996; 12(4):785-801.

9. Herdman SJ. Treatment of benignparoxysmal positional vertigo. Phys Ther1990; 70(6):381-8.

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