Dizziness and imbalance are frequent complaints that bring older people to a healthcare provider. It is helpful to distinguish between two main sensations in the context of aging. Dizziness often refers to lightheadedness, faintness, or general unsteadiness. Vertigo is a specific illusion of movement, typically described as the room spinning or whirling. This symptom is highly prevalent, affecting approximately 30% of individuals over 60, making it a significant public health issue that increases the risk of falling.
Benign Paroxysmal Positional Vertigo
The single most common cause of true vertigo in the elderly population is Benign Paroxysmal Positional Vertigo (BPPV). This condition results from a mechanical issue within the inner ear’s balance system: the displacement of tiny calcium carbonate crystals, known as otoconia. Normally, these crystals are embedded in a gelatinous membrane in the utricle, one of the inner ear organs.
With BPPV, these crystals become dislodged and migrate into one of the semicircular canals, usually the posterior canal. When the head changes position—such as rolling over in bed, looking up, or bending over—the free-floating crystals move, inappropriately stimulating the sensory hair cells. This causes the characteristic symptom: a brief but intense spinning sensation that typically lasts less than one minute.
BPPV becomes more prevalent with advanced age due to the natural degeneration of the utricle’s otoconia. Episodes are often accompanied by nausea or unsteadiness, which can persist for a short time after the spinning stops. The condition is generally considered benign because it is not caused by a serious underlying disorder and is highly treatable through specific repositioning maneuvers.
Dizziness Caused by Blood Pressure and Medications
Systemic issues outside the inner ear are prominent causes of lightheadedness in older adults. Orthostatic hypotension (OH) is a frequent culprit, defined as a significant drop in blood pressure shortly after standing up. This sudden decrease in pressure reduces blood flow and oxygen to the brain, manifesting as a woozy, faint, or lightheaded sensation.
The risk for lightheadedness is frequently exacerbated by polypharmacy. Many drug classes commonly prescribed to the elderly have dizziness or OH as a side effect, including cardiovascular agents like diuretics and vasodilators. Psychoactive drugs can also impair the central nervous system, leading to drowsiness, reduced coordination, and unsteadiness. A comprehensive medication review is often necessary to identify and adjust medications contributing to blood pressure instability or direct central nervous system effects.
Other Inner Ear and Neurological Sources
Beyond BPPV, other inner ear disturbances can cause more prolonged or distinct episodes of vertigo. Vestibular neuritis, for instance, is thought to be caused by inflammation of the vestibular nerve, often due to a viral infection. This condition typically presents as a sudden, severe, and persistent episode of vertigo that can last for days, often accompanied by severe nausea and vomiting, but usually without hearing changes.
Ménière’s disease is another inner ear disorder characterized by episodic vertigo. Symptoms include fluctuating hearing loss, a roaring sound in the ear (tinnitus), and a feeling of fullness in the affected ear. Dizziness can also signal a more serious neurological event, such as a transient ischemic attack (TIA) or stroke affecting the brainstem or cerebellum. Neurological disorders like Parkinson’s disease or demyelinating conditions can cause chronic unsteadiness and imbalance due to the progressive deterioration of central balance pathways.
Warning Signs Requiring Immediate Medical Attention
Although most causes of dizziness are benign, certain associated symptoms serve as “red flags” that indicate a potentially life-threatening event requiring immediate medical care. The sudden onset of dizziness or vertigo, especially if it is the first such episode, should be treated with caution.
Neurological Red Flags
Symptoms suggesting a central nervous system problem warrant immediate attention:
- New or sudden severe headache
- Double vision
- Slurred speech
- New weakness or numbness in the face or limbs
Cardiovascular Red Flags
Dizziness accompanied by signs of an acute cardiovascular event also warrants an emergency room visit:
- Chest pain
- Shortness of breath
- An irregular heartbeat
- Fainting
These combined symptoms suggest a possible stroke or an acute cardiac issue that is compromising blood flow to the brain, and rapid evaluation is essential for diagnosis and treatment.