Medicosnext
Dr. Sangya Paudel & Dr. Shiwani Rai Yogi
They are ENT specialists with a focused expertise in the diagnosis and management of vertigo and balance disorders. They co-lead the Vertigo Clinic at UDM-NINAS, where they have successfully evaluated and treated over a thousand cases in the past year alone. With a patient-centered approach and access to advanced diagnostic tools, they are at the forefront of providing specialized care for patients suffering from dizziness and vestibular disorders.
Dizziness and vertigo are often mixed up in everyday language, but medically, they refer to distinct sensations. Vertigo is described as the illusion of movement, either of one’s self or the surroundings—often a spinning sensation. In contrast, dizziness is a broader term encompassing feelings of imbalance, lightheadedness, or a floating sensation.
A Common but Overlooked Complaint in the Elderly
Dizziness is among the most frequent complaints in the elderly population, with a global prevalence ranging from 20% to 30%. Notably, its incidence increases with age. A population-based study in the United States found that 24% of individuals over the age of 72 reported at least one episode of dizziness in the previous two months. Similarly, a UK study reported a 30% prevalence in those over 65, and a Swedish study found that the rate approached 50% in individuals over 85.
Beyond being a discomfort, dizziness is a leading contributor to disability in older adults. It significantly increases the risk of falls – major causes of hip and wrist fractures—and is the leading cause of accidental death in people over 65.Key Disorders Behind Dizziness in the Elderly
Benign Paroxysmal Positional Vertigo (BPPV)
Among the most frequently diagnosed causes of vertigo in older adults is Benign Paroxysmal Positional Vertigo. It remains the most common vestibular disorder across all age groups, peaking around the age of 60 with an estimated prevalence of 2.4%. BPPV is characterized by brief episodes of vertigo triggered by changes in head position, caused by dislodged otoconia (calcium carbonate crystals) in the semicircular canals. Recurrent episodes are more commonly observed in postmenopausal women, especially those with osteoporosis or vitamin D deficiency.
Meniere’s disease
Meniere’s disease accounts for approximately 3–11% of vertigo cases. It is classically characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness. While more prevalent in middle-aged males, in individuals over 65, it occurs more frequently in females. A distinct feature in elderly patients is the occurrence of Tumarkin’s drop attacks, which are sudden falls without loss of consciousness. The pathophysiology involves excessive endolymphatic fluid accumulation in the inner ear. Management includes dietary sodium restriction, diuretics, vestibular suppressants, etc. Surgical interventions such as labyrinthectomy are reserved for refractory cases, while vestibular rehabilitation remains a cornerstone of functional recovery.
Vestibular neuronitis
Vestibular neuronitis is seen in 3–10% of neurotology clinic diagnoses, resulting from inflammation of the vestibular nerve, often due to a viral infection. Patients present with acute, severe vertigo accompanied by nausea, vomiting, and unsteady gait, but notably without hearing loss. Treatment includes corticosteroids, antivirals, and vestibular suppressants during the acute phase, followed by vestibular rehabilitation exercises.
Vestibular migraine
Vestibular migraine accounts for 14–20% of dizziness cases in the elderly. Patients experience episodic vertigo lasting from five minutes to 72 hours, with or without concurrent headache. Associated symptoms may include photophobia, phonophobia, tinnitus, visual disturbances, and general fatigue. When present, headaches are typically unilateral, pulsating, moderate to severe in intensity, and exacerbated by physical activity. Diagnosis is clinical, based on symptom patterns, and management involves lifestyle modifications and prophylactic medications such as beta-blockers, calcium channel blockers, and tricyclic antidepressants.
Other Contributing Factors to Dizziness
Beyond the vestibular system, musculoskeletal disorders—particularly sarcopenia, which involves the progressive loss of muscle mass and function—can contribute significantly to imbalance in older adults. This condition is identified in approximately 6.3–7.5% of elderly individuals presenting with dizziness. Muscle weakness, impaired posture, and slower reflexes reduce physical stability, increasing fall risk. Targeted physiotherapy and strength training programs tailored to individual needs have shown promising results in mitigating symptoms and restoring functional independence.
Psychiatric and cognitive factors also play a crucial role, with up to 9.1% of elderly patients experiencing dizziness associated with anxiety, depression, or early cognitive decline. Often, these patients report a subjective sense of imbalance without clear vestibular findings. Their difficulties in walking, particularly when multitasking, may be misinterpreted as purely neurological. Early recognition and intervention are vital, as untreated psychological conditions can lead to social isolation, diminished quality of life, and loss of autonomy.
Another major contributor is polypharmacy, a prevalent issue in geriatric care. The concurrent use of more than three medications is strongly associated with increased incidence of dizziness and falls. Common culprits include antihypertensives, sedative-hypnotics, antidepressants, and anticholinergics. Therefore, a thorough medication review is essential during clinical evaluations to identify potential drug interactions or adverse effects. Rationalizing prescriptions can significantly reduce symptom burden.
Lastly, metabolic and endocrine disorders—especially diabetes—must be considered. Fluctuations in glucose levels, as seen in hypoglycemia or poorly controlled diabetes, can impair cerebral perfusion and neural function, manifesting as dizziness. These conditions account for approximately 3.6% of cases in the elderly and require appropriate endocrine workup and management to prevent recurrent symptoms.
Conclusion
Dizziness in the elderly is rarely the result of a single cause—it is most often the product of a complex interplay between age-related physiological changes, multisystem comorbidities, and environmental or pharmacological factors. This multifactorial nature calls for a comprehensive and individualized approach to diagnosis and management.
Rather than focusing solely on symptom control, clinicians need to assess each patient’s clinical history, functional status, mental health, medication use, and lifestyle. Only through this personalized care model can we effectively reduce the burden of dizziness, prevent falls, and improve overall quality of life.
