Vertigo: Considerations for management in older adults

Contributed by:

Peter George Tian, MD, MSc, DPBO-HNS - View bio
Lesley Charles, MBChB, CCFP(COE) - View bio

See also related OPS article: Too dizzy to walk: Managing dizziness in the elderly

Case

“…a 71-year-old man turned over in bed onto his left side and experienced sudden onset of dizziness, described as if the bed was moving. Although lasting only 10-15 seconds, he became sweaty afterwards without nausea and vomiting…The intense vertigo resolved if he stayed still, but similar brief episodes recurred several times when he laid supine in the hospital.”^{1 pE182} Physical examination was normal but vertigo recurred upon head movements.¹

Issue

What are the considerations in the management of vertigo in the older adult? This article will provide an overview.

Background

Definitions

The Barany Society provides separate definitions for dizziness and vertigo. Dizziness is defined as the “sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion.”^{2 p.7} Vertigo, on the other hand, is the “sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement.”^{2 p.5} Although vertigo involves the perception of motion, older adults may not report it as motion but as unsteadiness and falling.³

Prevalence

The lifetime prevalence for vertigo is estimated to be between 3-10%. One study estimated the lifetime prevalence for Benign Paroxysmal Positional Vertigo (BPPV) to be 2.4%. The lifetime prevalence of Meniere’s Disease is estimated to be 0.12-0.5%.⁴

Etiology of Vertigo

In primary care, the etiologies of vertigo span across a broad range of diagnoses, including nonspecific diagnoses. A systematic review on the etiologies of dizziness and vertigo in primary care found the most common etiologies to be cardiovascular and otologic diseases, including BPPV and vestibular neuritis. Furthermore, 46-80% of cases had unspecified diagnoses.⁵ This finding was reflected in a Dutch study (n=1708 older adults) wherein 39% had unspecific diagnoses; 14% had cardiovascular conditions (e.g., stroke); and 11.9% had peripheral vestibular disease (including BPPV, labyrinthitis, Meniere’s disease and vestibular neuritis).⁶

Cost

A systematic review outlined the direct and indirect costs of vertigo. Direct costs include expenses from consultations, emergency room visits, hospitalizations, diagnostic procedures, therapy and medications. Indirect costs result from loss of workdays, compromised productivity and impacts to employment and lifestyle. The estimated costs of vertigo per patient could add up to thousands of dollars.⁷

Management Approaches and Guidelines

An Approach to Vertigo in Primary Care

In 2017, Muncie et al. published in the American Family Physician an approach to vertigo or dizziness. Considerations for history, physical examination, and medications are outlined, including an algorithm for assessment. A patient may have difficulty and may be inconsistent in the description of symptoms; hence, physicians are warned of overly relying on symptoms. Instead, physicians are encouraged to ask about the timing and triggers of vertigo and perform targeted examination.⁸ Some recommendations include the following:

1. “The physical examination in patients with dizziness should include orthostatic blood pressure measurement, nystagmus assessment, and the Dix-Hallpike maneuver for triggered vertigo.” ^{8 p155}
2. “Laboratory testing and imaging are not recommended when no neurologic abnormality is found on examination.”^{8 p155}< A study among dizziness in the emergency department found that dizziness was often benign; however, the following factors were associated with serious neurologic diseases: age 60 years or older, a chief complaint of imbalance and focal examination abnormality.⁹

Diagnostic Approaches to Common Causes of Vertigo

1. Benign Paroxysmal Positional Vertigo: Transient vertigo triggered by positional change; diagnosed with Dix-Hallpike maneuver.⁸
2. Vestibular Neuritis. Spontaneous vertigo worsened with gaze;⁸ diagnosis aided by HINTS plus examination.¹
3. Meniere Disease. Episodic vertigo (at least two episodes lasting at least two minutes); hearing loss on audiometry.⁸ Recommendation: “Vertigo associated with unilateral hearing loss should raise suspicion for Meniere disease.” ^{8 p155}
4. Stroke. Stroke may not show focal neurologic deficits. “The use of the HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish a possible stroke (central cause) from acute vestibular syndrome (peripheral cause).” ^{8 p157} The HINTS examination is better than MRI in ruling out stroke. ⁸ Furthermore, a systematic review comparing vestibular neuritis and stroke by Tarnutzer et al. found the following red flags for stroke: “history of multiple transient prodromal episodes of dizziness over weeks or months, auditory symptoms, headache, neck pain or recent trauma.” ^{10 E585}

Clinical Practice Guidelines for Benign Paroxysmal Positional Vertigo

The American Academy of Family Physicians affirmed the value of the clinical practice guidelines on BPPV by the American Academy of Otolaryngology – Head and Neck Surgery.¹¹ Among the recommendations are the following:

1. Clinicians should diagnose BPPV using the Dix-Hallpike maneuver.
2. Clinicians should differentiate BPPV from other causes of vertigo.
3. Clinicians should not request for imaging or vestibular testing unless warranted.
4. Clinicians should treat BPPV with canalith repositioning.
5. Clinicians should not treat routinely with vestibular suppressants.

The treatment recommendations for BPPV above are also echoed by the Alberta College of Family Physicians’ Tools for Practice. For BPPV, applying Epley maneuver will resolve vertigo in every two-to-three persons.¹² For BPPV, without applying Epley maneuver, betahistine may help.¹³

Differentiating BPPV from Vestibular Neuritis (synonyms. vestibular neuronitis, labyrinthitis)

There are no clinical practice guidelines yet for vestibular neuritis. Johns’ article tabulated the differences between BPPV and vestibular neuritis. Compared to BPPV, vestibular neuritis is prolonged, occurs even when the patient’s head is not moving, and nystagmus may be spontaneous or gaze-provoked. Moreover, for examination, HINTS plus examination is appropriate (rather than Dix-Hallpike test).¹ Treatment is supportive and may include antiemetics, antinausea medications and vestibular rehabilitation.⁸

Clinical Practice Guidelines for Meniere’s Disease

The American Academy of Otolaryngology – Head and Neck Surgery, affirmed by the American Academy of Neurology, created practice guidelines for Meniere’s disease.¹⁴ Among the recommendations are the following:

1. Clinicians should consider the diagnosis in patients presenting with vertigo, fluctuating hearing loss, tinnitus or pressure in the affected ear.
2. Clinicians should obtain an audiogram. MRI may be done to visualize or exclude cochlear and retrocochlear lesions (e.g., cerebellopontine angle tumors).
3. Clinicians should offer a limited course of vestibular suppressants.

These recommendations are also specified in the Approach to Meniere Disease Management published in the Canadian Family Physician.¹⁵

Information for Patients or Caregivers

Here are some online resources on vertigo for patients and caregivers.

1. Lightheadedness and Vertigo by My Alberta Health¹⁶
2. Vertigo (Dizziness) by the Canadian Society of Otolaryngology – Head and Neck Surgery¹⁷
3. Benign Paroxysmal Positional Vertigo by HealthLink BC¹⁸
4. Meniere's Disease by the University Health Network¹⁹

Back to the Case

The patient, upon Dix-Hallpike test on the left, had vertigo and nystagmus. He was diagnosed with left-sided benign paroxysmal positional vertigo and subjected to Epley’s maneuver. After 15 minutes, the Dix-Hallpike test on the left became negative and the patient was discharged. Two weeks later, in a follow-up phone call, the patient reported no further vertigo.¹

Summary

In primary care, the older patient’s vertigo can be attributed to various disease processes, most commonly cardiovascular or vestibular disease. Among the vestibular diseases, benign positional paroxysmal vertigo and Meniere’s disease are the most common. The clinician needs to navigate among the various diagnostic and treatment options.

References

1. Johns P, Quinn J. Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis. CMAJ. 2020 Feb 24;192(8):E182-E186. doi: 10.1503/cmaj.190334. PMID: 32094268; PMCID: PMC7043823.
2. Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009;19(1-2):1-13. doi: 10.3233/VES-2009-0343. PMID: 19893191.
3. Piker EG, Jacobson GP. Self-report symptoms differ between younger and older dizzy patients. Otol Neurotol. 2014 Jun;35(5):873-9. doi: 10.1097/MAO.0000000000000391. PMID: 24759419.
4. Murdin L, Schilder AG. Epidemiology of balance symptoms and disorders in the community: a systematic review. Otol Neurotol. 2015 Mar;36(3):387-92. doi: 10.1097/MAO.0000000000000691. PMID: 25548891.
5. Bösner S, Schwarm S, Grevenrath P, Schmidt L, Hörner K, Beidatsch D, Bergmann M, Viniol A, Becker A, Haasenritter J. Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review. BMC Fam Pract. 2018 Feb 20;19(1):33. doi: 10.1186/s12875-017-0695-0. PMID: 29458336; PMCID: PMC5819275.
6. Maarsingh OR, Dros J, Schellevis FG, van Weert HC, Bindels PJ, Horst HE. Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics. BMC Fam Pract. 2010 Jan 11;11:2. doi: 10.1186/1471-2296-11-2. PMID: 20064231; PMCID: PMC2817676.
7. Kovacs E, Wang X, Grill E. Economic burden of vertigo: a systematic review. Health Econ Rev. 2019 Dec 27;9(1):37. doi: 10.1186/s13561-019-0258-2. PMID: 31883042; PMCID: PMC6933936.
8. Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017 Feb 1;95(3):154-162. PMID: 28145669.
9. Navi BB, Kamel H, Shah MP, Grossman AW, Wong C, Poisson SN, Whetstone WD, Josephson SA, Johnston SC, Kim AS. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. 2012 Nov;87(11):1080-8. doi: 10.1016/j.mayocp.2012.05.023. Epub 2012 Oct 12. PMID: 23063099; PMCID: PMC3541873.
10. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92. doi: 10.1503/cmaj.100174. Epub 2011 May 16. PMID: 21576300; PMCID: PMC3114934.
11. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RW, Do BT, Voelker CC, Waguespack RW, Corrigan MD. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47. doi: 10.1177/0194599816689667. PMID: 28248609.
12. Braschi E, Korownyk C. Evaluating the Epley Maneuver: When one good turn deserves another. Alberta College of Family Physicians – Tools for Practice [Internet]. 2015 Aug 4. Last Accessed 2022 May 23. Available from: https://gomainpro.ca/wp-content/uploads/tools-for-practice/1438702049_tfp144epleyfv.pdf
13. Lindblad AJ, Lu S, Craig R. Making your head spin: Betahistine for benign paroxysmal positional vertigo. Alberta College of Family Physicians – Tools for Practice [Internet]. 2020 Oct 5. Last Accessed 2022 May 23. Available from: https://gomainpro.ca/wp-content/uploads/tools-for-practice/1601673584_tfp274betahistine.pdf
14. Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, Bush ML, Bykowski J, Colandrea M, Derebery J, Kelly EA, Kerber KA, Koopman CF, Kuch AA, Marcolini E, McKinnon BJ, Ruckenstein MJ, Valenzuela CV, Vosooney A, Walsh SA, Nnacheta LC, Dhepyasuwan N, Buchanan EM. Clinical Practice Guideline: Ménière's Disease. Otolaryngol Head Neck Surg. 2020 Apr;162(2_suppl):S1-S55. doi: 10.1177/0194599820909438. PMID: 32267799.
15. Wu V, Sykes EA, Beyea MM, Simpson MTW, Beyea JA. Approach to Ménière disease management. Can Fam Physician. 2019 Jul;65(7):463-467. PMID: 31300426; PMCID: PMC6738466.
16. My Health Alberta. Dizziness: Light-Headedness and Vertigo [Internet]. Last accessed 2022 May 23. Last modified 2021 Jul 1. Available from: https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=dizzi
17. Canadian Society of Otolaryngology – Head and Neck Surgery. Dizziness (Vertigo) [Internet]. Last accessed:2022 May 23. Available from: https://www.entcanada.org/learning/general-public/public-information-sheets-2/ears/dizziness-vertigo/
18. HealthLink BC. Benign Paroxysmal Positional Vertigo [Internet]. Last updated 2020 April 15. Last accessed 2022 May 23. Available from: https://www.healthlinkbc.ca/health-topics/benign-paroxysmal-positional-vertigo-bppv