Dizziness & Balance (MoE)

Dizziness, light-headedness and vertigo are common with multiple and often multi-factorial causes. People may mean different things by “dizziness”. This page relates to the assessment and management in Older Adults.

Common Presentations of dizziness in the Elderly

There are a number of conditions that can contribute to the symptom of dizziness in any group of patients. The two most common contributing factors in Older Adults are BPPV and Postural Hypotension:

1) Benign Paroxysmal Positional Vertigo (BPPV)

The most common vestibular disorder in the elderly, brought on by a change in head position e.g. turning head or turning over in bed, often accompanied by a sensation of “true vertigo” (the room moving or the patient moving) but can be also described as general dizziness or light headedness.

2) Postural (Orthostatic) hypotension

Defined as a significant drop in blood pressure on standing of systolic BP>20mmHg or diastolic >10mmHg or any systolic drop to less than 90mmHg. Symptoms are of dizziness or light headedness on standing, either rapidly from sitting/lying down, or on prolonged stand. Baroreflexes are less sensitive in older people, reducing the compensatory increase in heart rate in response to a fall in BP, making them more susceptible to postural hypotension.

Exacerbating factors:

Dehydration; anaemia; Addison’s disease

Medications: antihypertensives; anti-anginals; diuretics; anti-depressants; anticholinergics; anti-Parkinsonian therapy; anti-psychotics; alpha-blockers; alcohol.
Prolonged bed rest e.g. following post-viral syndrome.
Autonomic neuropathy seen in Parkinson’s disease, diabetes, and alcohol excess

There are other causes of dizziness in older adults that cause dizziness in isolation, or as part of a multifactorial presentation:

3) Cardiovascular causes other than postural hypotension

Any other factor which can reduce cerebral perfusion can also cause dizziness, for example:

Severe aortic stenosis (associated with shortness of breath on exertion, chest pain and syncope; light headedness and pre-syncope may be features.)
Cardiac arrhythmias – tachyarrhythmias, bradyarrythmias and heart block

4) Vertigo (Peripheral or Central) other than BPPV

Symptoms of continuous dizziness, nausea and/or vomiting, unsteady gait and nystagmus lasting over24 hours are classified as an Acute Vestibular Syndrome (AVS). This can be caused by either peripheral or central causes.

Peripheral cause: BPPV, Vestibular Neuronitis, Meniere’s, Labyrinthitis
Central cause: Stroke, migraine, MS, cerebella tumour, acoustic neuroma, other rarer brain stem conditions

5) Other conditions

There are a number of other conditions which contribute to a patient feeling “off balance” include

Peripheral neuropathy e.g. B12/folate deficiency, diabetic neuropathy
Visual impairment
Musculoskeletal problems e.g. osteoarthritic joint deformities

JB and AS 24-09 2025

Who to refer:

Frail patients over age 65 with CFS ³ 4 with dizziness, light headedness or vertigo, and who have:

A need for Multidisciplinary assessment, including falls assessment and/or specialist physiotherapy BPPV management including vestibular rehabilitation.
Patients who understand and are willing to participate in assessment and management that will involve physiotherapy
Significant orthostatic hypotension ~~that might require fludrocortisone~~ not improving with better fluid intake and review of medication
An uncertain cause of symptoms, or potentially more than one cause of dizziness.

Who not to refer:

Patients under 65
Patients with ENT Red Flags should be referred to ENT
Patients with likely BPPV and no ENT red flags who do not respond to Primary Care treatment, and who do not require the comprehensive MDT approach offered by MOE can be referred to Audiology
Patients with Cardiology Red Flags should be referred to Cardiology (Any patient with CFS ³ 6 should be considered for referral to MOE in the first instance)
Patients thought to be having an acute cerebellar stroke – please discuss with Stroke / TIA Hotline
Patients with Neurology Red Flags should be discussed with Neurology (Any patient with CFS ³ 6 should be considered for referral to MOE in the first instance)
Patients with Vestibular Migraine should be managed as per Migraine advice on RefHelp

How to refer:

Services at Liberton Day Hospital (IOPS)

SCI Gateway referral: Liberton Hospital >> Geriatric Medicine >> LI Basic Sign Referral

Services at Western General Hospital (ARC)

SCI Gateway referral: Western General Hospital >> Geriatric Medicine >> LI Basic Sign Referral

Services at Leith CTC (OPRA)

SCI Gateway referral: Leith Community Treatment Centre >> Geriatric Medicine >> LI Basic Sign Referral

Services in Mid Lothian (IOPS)

SCI Gateway referral: Liberton Hospital >> Geriatric Medicine >> LI Basic Sign Referral

Services in East Lothian (MOE OPD)

SCI Gateway referral: East Lothian Community Hospital >> Geriatric Medicine >> LI Basic Sign Referral

Services in West Lothian

SCI Gateway referral: St John’s Hospital >> Geriatric Medicine >> LI Templar Day Hospital

SCI Gateway referral: St John’s Hospital >> Geriatric Medicine >> LI WL Geriatric Medicine

Assessment in Primary care

People often mean different things by the word “dizzy”, and many have more than one type of dizziness.

One approach is to try and assess whether they mean:

Light headedness or presyncope “as if you might faint”
Feeling off balance “as if you might fall”
“A sensation of everything, or yourself, moving or spinning”, often in relation to head movement or change in posture

Many will experience more than one of these sensations, and some feel them all.

Presyncope is associated with Orthostatic hypotension, severe aortic stenosis and arrythmias.
Being “off balance” is extremely common, and often relates to musculoskeletal (OA joint deformities, commonly severe bilateral hallux valgus) or neurological problems (peripheral neuropathy associated with visual impairment is particularly debilitating.

All patients should have:

Examination

Assessment for clinical hypovolaemia or anaemia
Pulse check for arrhythmias
Auscultation for heart murmurs (in particular aortic stenosis)
Lying and standing blood pressure after 10 minutes lying down (ideally quietly, not talking).

Investigations

FBC, U&Es, Blood glucose (and if a known diabetic, check blood sugar at time of dizzy spells), Vit B12 and folate
Up-to-date ECG
If significant orthostatic hypotension despite stopping BP lowering medication please complete an early morning random cortisol;
- If cortisol level > 300nM adrenal insufficiency unlikely assuming patient is not on glucocorticoid containing medication
- If cortisol level < 300nM patient requires SST and should be discussed with MOE/endocrinology

(Biochemistry advice re timing of cortisol: cortisol levels peak between 6am and 9am – early morning random cortisol should ideally be sampled between 7am and 9am and definitely before 9.30am)

Other possible investigations

Dix-Hallpike Hallpike Test to diagnose BPPV
The HiNTS test (Head impulse, Nystagmus; Test of Skew) can be useful to distinguish between central and peripheral causes of vertigo and guide further investigation, in patients with nystagmus.

HiNTS in someone with vertigo is reassuring if they have all of unidirectional nystagmus (i.e. fast phase always in one direction); normal test of skew and Abnormal Head impulse (indicating a peripheral rather than central cause). HiNTS is concerning if they have any of: bi-directional nystagmus or abnormal test of skew or normal head impulse test in the context of vertigo

A video and explanation of the HiNTS test can be found in the resources section.

Management in General Practice

BPPV

Please see BPPV page for diagnosis, management and patient information leaflets

Postural (Orthostatic) hypotension:

Measures are aimed at maintaining adequate cerebral perfusion.

Reduce or stop blood-pressure lowering medication, aiming for systolic BP 130-140mmHg (see list of drugs under ‘Exacerbating factors’ above).
Note in patients with supine hypertension and postural hypotension, NICE guidelines recommend treating blood pressure to the level of the standing systolic BP.
To ensure adequate hydration – take a large glass of water (400-500ml) before getting out of bed in the morning and ensure liberal fluid intake throughout the day aiming for 2L.
Elevating the head of the bed at night by 10-20 degrees (10cm) (reduces nocturnal diuresis and fluid loss).
Counter pressure manoeuvres
Full length compression stockings and /or abdominal binders are options but can be difficult to put on and may not be well tolerated.
Avoid straining during bowel movements or performing other Valsalva-like manoeuvres.
Eating frequent, small meals is often effective in reducing postprandial hypotension

Patient advice on fluid intake and self-help tips can be found Postural hypotension patient leaflet