Dizziness is a frequently occurring disorder of older individuals that can result in serious functional deficits. Dizziness negatively affects quality of life (White et al., 2005). Older adults often visit their physicians with nonspecific complaints of dizziness; it is the most common complaint of adults over the age of 75 and the third most common complaint in outpatient settings, regardless of age (Kroenke et al., 1992). In a recent national health survey, 35% of persons over the age of 40 reported vestibular dysfunction (Agrawal et al., 2009). People who reported dizziness were 12 times more likely to have reported a fall (Agrawal et al., 2009). As dizziness is a subjective experience, it is difficult to determine whether the patient and the examiner agree on what the symptoms are. The most common new onset cause of dizziness is a change in medication in older persons.

Dizziness is interpreted differently by various people and is often difficult to describe. Commonly, people complain of a sense of giddiness, floating, lightheadedness or a sensation of being drunk. Table 58.1 includes other common descriptors used by patients to explain their complaints to their practitioners.

Patients also describe symptoms of vertigo, which is classically defined as an illusion of movement that usually has a rotatory component (Furman et al., 2010). People who experience vertigo often have a sensation of turning. Vertigo has been described as rotational, as translational and as a sense of being tilted. It does not matter whether the patient or their world is spinning, as both are considered to be vertigo. The sensation of vertigo usually indicates an inner ear problem, although occasionally it can be related to an anterior inferior or posterior inferior cerebellar stroke.

Most patients who experience dizziness or vertigo modify their activity levels even when they are not having symptoms. Fear of falling is often associated with the symptoms of dizziness or imbalance in elderly people (Bronstein & Lempert, 2010). They become noticeably less active over time because of the fear of experiencing dizziness or imbalance, especially in unfamiliar environments. This fear leads to inactivity, which can start a downward decline in function. Falls have been related to the most common cause of dizziness, which is benign paroxysmal positional vertigo (BPPV) (Katsarkas, 1999). BPPV can cause people to fall and BPPV may also be caused by a fall (Katsarkas, 1999). The otoconia within the otolith organs can become dislodged with head trauma (Katsarkas, 1999).

Several other disease processes or conditions have been associated with BPPV, including diabetes, migraine, Menière’s disease and post viral infection. It is also suspected that BPPV may be caused by damage over time to the otolith production area. Benign paroxysmal positional vertigo runs in families (Gizzi et al., 1998) and has a recurrence rate of approximately 15% per year, increasing to a 40–50% chance of recurrence 3–4 years after the initial episode (Nunez et al., 2000). The spinning is often brought on by a change of head position, most commonly in moving from supine to sitting first thing in the morning or rolling over in bed at night (Whitney et al., 2005). Epley or Semont maneuvers are commonly used to move the otoconia out of the semicircular canal and back into the otolith organ (Epley, 1980, 1992; Semont et al., 1988; Hillier & McDonnell, 2011a; Chen et al., 2012😉 There is recent evidence that by moving the otoconia out of the semicircular canal one can decrease the risk of falling (Gananca et al., 2010). Treatment of BPPV has been shown to be highly effective in older persons. Both the Epley and the Semont maneuvers are equally effective at causing the vertigo associated with a change of head position to stop. Two recent practice guidelines suggest that BPPV is very common in older people but can be ‘fixed’ with the repositioning maneuvers (Bhattacharyya et al., 2008; Fife et al., 2008). BPPV has been associated with being older, with diabetes and with falling (Bhattacharyya et al., 2008).

There are numerous possible causes of dizziness, as noted in Table 58.2, rendering it impossible to determine the cause without testing. Laboratory and clinical tests that are performed in the attempt to diagnose the cause of the dizziness are included in Table 58.3. Although thorough testing is crucial to obtain an accurate diagnosis, most physical therapists will not have the benefit of such an extensive workup before seeing a patient. By being aware of the various causes of and tests for dizziness, the physical therapist is more likely to make appropriate clinical decisions about referrals and care. The head thrust or head impulse test is a particularly useful tool for us in the clinical diagnosis of peripheral vestibular disorders (Halmagyi & Curthoys, 1988). One moves the head quickly to both the right or the left, and if the eyes cannot stay focused on a distant target throughout the rapid head movement, it suggests that the person has a peripheral vestibular disorder (Halmagyi & Curthoys, 1988). If the person exhibits a skew deviation, direction-changing nystagmus in eccentric gaze and a normal head thrust test, there is a 100% sensitivity and 96% specificity for the identification of stroke (Kattah et al., 2009).

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