Vertigo in the Elderly: Causes, Treatment, and Physiotherapy Management

Vertigo — the sensation that you or the room around you is spinning — affects up to 30% of adults over 65 and becomes increasingly common with advancing age. For elderly patients, vertigo is not merely uncomfortable; it is a major fall risk factor that can lead to hip fractures, head injuries, and loss of independence. The good news is that the most common causes of vertigo in older adults respond remarkably well to vestibular physiotherapy, often producing complete resolution within just a few treatment sessions.

Common Causes of Vertigo in Older Adults

Benign Paroxysmal Positional Vertigo (BPPV) is the single most common cause, accounting for approximately 50% of vertigo in the elderly. It occurs when tiny calcium carbonate crystals (otoconia) become dislodged from the utricle and migrate into the semicircular canals of the inner ear. This causes brief but intense spinning episodes triggered by specific head movements — typically rolling over in bed, looking up, or bending forward. BPPV episodes usually last 10-60 seconds but can provoke nausea and severe unsteadiness for hours afterward.

Vestibular hypofunction — reduced function of the balance organs in one or both inner ears — is the second most common cause. This can result from viral infections (vestibular neuritis), reduced blood flow to the inner ear, medication side effects (particularly aminoglycoside antibiotics and certain diuretics), or age-related degeneration. Symptoms include constant or intermittent dizziness, difficulty focusing during head movement, and unsteadiness during walking.

Other causes include Meniere's disease (episodic vertigo with hearing loss and tinnitus), cervicogenic dizziness (from neck joint dysfunction), and central vestibular disorders related to stroke or neurological conditions. Accurate diagnosis is essential because each cause requires a different treatment approach.

Vestibular Physiotherapy: How It Works

For BPPV, the treatment is a specific repositioning manoeuvre — most commonly the Epley manoeuvre or Semont manoeuvre — which guides the displaced crystals out of the affected semicircular canal and back to their correct position. These manoeuvres are performed by a trained physiotherapist and resolve symptoms in 80-90% of cases within 1-3 sessions. The posterior canal is most commonly affected, but your physiotherapist will test all three canals to ensure accurate diagnosis and treatment.

For vestibular hypofunction, treatment involves a structured programme of vestibular rehabilitation exercises that retrain the brain to compensate for the impaired inner ear. These include gaze stabilisation exercises (maintaining visual focus while moving the head), habituation exercises (repeated exposure to movements that provoke dizziness, allowing the brain to adapt), and balance retraining on progressively challenging surfaces and conditions.

For cervicogenic dizziness, treatment targets the cervical spine with joint mobilisation, soft tissue work, and specific neck stabilisation exercises to restore normal afferent input from the cervical proprioceptors.

What to Expect During Assessment

A vestibular physiotherapy assessment is thorough and may take 45-60 minutes. Your physiotherapist will take a detailed history of your symptoms — when they started, what triggers them, how long episodes last, and whether you experience hearing changes or nausea. They will then perform specific positional tests (such as the Dix-Hallpike test and supine roll test) to identify BPPV and determine which canal is affected.

Oculomotor testing (examining eye movements during head motion) reveals whether the vestibular system is functioning normally. Balance assessments — including standing with eyes closed, tandem stance, and walking with head turns — quantify the impact of vestibular dysfunction on your stability. Based on these findings, your physiotherapist will explain the diagnosis and begin treatment immediately in most cases.

Living with Vertigo: Safety and Self-Management

While undergoing treatment, certain precautions reduce fall risk: move slowly when changing positions (especially from lying to sitting and sitting to standing), avoid sudden head movements, ensure adequate lighting in your home, and keep pathways clear. If you experience a vertigo episode, sit or lie down immediately until it passes — do not try to walk through it. Avoid driving during active vertigo episodes.

Some patients develop avoidance behaviour — restricting head movements and activities to prevent triggering dizziness. While understandable, this actually delays recovery because the brain needs controlled exposure to challenging movements in order to recalibrate. Your physiotherapist will guide you through the appropriate level of challenge at each stage of recovery.