Don’t overlook subtle signs for vertigo in the elderly

 At least once a shift, an elderly patient comes through the doors complaining of dizziness. Dizziness in elderly patients could mean anything. Is it their heart? Is their brain okay? Are they anemic? How is their urine? Do they have pneumonia?

Unfortunately, geriatric patients often require an extensive workup to rule out these problems, before they are given the diagnosis of vertigo.  Far too often, benign paroxysmal positional vertigo (BPPV) is low on my list of differential diagnoses, and it isn’t until all of their other tests come back negative that I try the Epley maneuver or give them a dose of meclizine to see how they respond.

Surprisingly, many of them respond well, are able to ambulate without difficulty, and are stable for discharge.  I constantly have to remind myself not to overlook the subtle signs that it may be nothing more than vertigo after all:

First and foremost, what were they doing when the dizziness started? A key indicator with vertigo is that it involves some sort of change in positioning of the head, and symptoms are exacerbated with head movement. Many times patients will tell me the symptoms began or were made worse when they were rolling over in bed.

Is there a spinning component? A lot of patients confuse dizziness and lightheadedness. If they feel that either they are spinning or the room is spinning, it is a good indicator it may be BPPV. If there is no spinning component, there is a chance it may be something more.

Is it accompanied with eye movements? Almost all cases of BPPV are accompanied by nystagmus when the Dix-Hallpike maneuver is performed. However, not all cases of nystagmus are from BPPV. Nystagmus can be caused by alcohol intoxication, certain medications including selective serotonin reuptake inhibitors (SSRIs), sedative, and anti-seizure medications, and even nicotine.

True BPPV nystagmus is characterized by a delayed onset with head positioning during the Dix-Hallpike maneuver, it immediately begins to slow in intensity, becomes less reproducible with each change in positioning, and should elicit vertigo from the patient.[1]

I should go on to mention that the older patients are, the less likely I am to perform the actual Dix-Hallpike maneuver, as positioning can be difficult and uncomfortable for them and therefore less accurate. In addition, if they have any comorbities, no history of vertigo, or any other indicator that it may be something other than BPPV, I do not perform this mechanism until the other causes are ruled out first.

I can guarantee you that an elderly patient who is dizzy from a urinary tract infection most certainly does not want their head hanging off of the table. In addition, I also make sure there was no prior history of trauma or neck injury before performing this maneuver.

When it comes to BPPV, it is necessary to get a detailed history about the type of symptoms the patient is experiencing. Correctly diagnosing and administering proper care allows you to provide instant relief for an extremely uncomfortable situation, which, in my opinion, is one of the greatest parts of our profession.

Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.