Vertigo and balance problems in older adults: BPPV, inner ear causes and red flags

The NHS says a vertigo attack can last from a few seconds to hours, and in severe cases many days or months. Inner ear problems affecting balance are the most common causes, and it lists benign paroxysmal positional vertigo (BPPV), labyrinthitis (an inner ear infection caused by a cold or flu virus), vestibular neuritis (inflammation of the vestibular nerve) and Ménière's disease. Migraine and some medicines can also cause vertigo, and sometimes no cause is found.

For older people, the practical point is that vertigo, unsteadiness and falls often travel together. If dizziness is more of a faint or light-headed feeling on standing, a blood-pressure cause may be more likely, which is covered in our guide to postural hypotension.

A hospital audiology leaflet explains that BPPV causes short episodes of intense vertigo when the head moves in certain directions, such as rolling over in bed or looking up. It is thought to be caused by tiny solid fragments (otoconia) in the inner ear labyrinth. Benign means it is not due to cancer or another serious cause; the leaflet notes that most cases occur in people over 40, that it may be age-related, and that women are affected about twice as often as men. Nausea is common though actual vomiting is not.

The leaflet says the condition often gets better by itself after several weeks. If not, the Epley manoeuvre, a series of head movements held for around 30 seconds each, uses gravity to move the fragments away from where they cause trouble. It can be tried by a clinician and the leaflet describes how to do it at home, recommending a friend or family member is present for the first few times in case the person becomes unsteady. Some studies report success in about eight in 10 cases with one treatment, it can be repeated a week or so later, and it can be repeated if symptoms return. Surgery is described as extremely rare. Because the manoeuvre involves lying back with the head hanging, older people with neck problems or unsteadiness should ask a clinician or physiotherapist to show them first.

The NHS says labyrinthitis and vestibular neuritis are inner ear infections that affect balance and usually get better on their own within a few weeks. Labyrinthitis can cause hearing loss and tinnitus, whereas vestibular neuritis does not. Symptoms can start suddenly; balance usually returns over 2 to 6 weeks, although it can take longer. A GP may prescribe antihistamines, motion sickness tablets or anti-sickness medicines for up to 3 days only, because longer use can slow recovery; antibiotics are not usually helpful as the cause is usually viral. Sudden hearing loss in one ear needs an urgent GP appointment or NHS 111.

Ménière's disease, the NHS says, is a rare inner ear condition with episodes of vertigo, balance loss, tinnitus, hearing loss, ear pressure and nausea that start suddenly and can last from a few minutes to 24 hours. It cannot be cured but treatment helps; hearing may gradually worsen. GPs may refer for blood tests and an MRI scan, and treatment includes medicines for vertigo and sickness, hearing aids, tinnitus therapy, vestibular rehabilitation and, rarely, inner ear surgery. A low-salt diet and avoiding caffeine are among suggestions to discuss with a GP.

The NHS says to call 999 or go to A&E if vertigo comes with double vision or loss of vision, hearing loss, trouble speaking, or leg or arm weakness, numbness or tingling. Its Ménière's page adds that spinning with a drooping face, being unable to hold both arms up, slurred speech, sudden vision problems in one eye or feeling very off-balance may be signs of a stroke, a medical emergency. It says to ask for an urgent GP appointment or NHS 111 if vertigo comes with a severe headache, being sick or feeling very sick, or a very high temperature or feeling hot, cold or shivery.

The NHS says not to drive to A&E, and to bring any medicines. Always take someone who cannot be woken to A&E or call 999. An older person with sudden severe dizziness and a new headache, difficulty walking or speech change should be assessed as a possible stroke rather than assumed to have an inner ear problem.

The NHS suggests lying still in a quiet, dark room during an attack, moving the head slowly and carefully, sitting down straight away when dizzy, turning on lights if you get up at night, using a walking stick if at risk of falling, sleeping with the head slightly raised on two or more pillows, getting out of bed slowly and sitting on the edge of the bed before standing, and trying to relax as anxiety can worsen vertigo. It advises squatting rather than bending to pick things up and avoiding stretching the neck, for example to reach a high shelf.

The leaflet adds that you should avoid jobs that involve looking upwards, and tell your employer if BPPV could pose a risk, for example when using ladders or driving. The NHS says that if you drive you must tell the DVLA about vertigo, and the audiology leaflet says the DVLA recommends stopping driving if you have sudden, unexpected and disabling attacks of dizziness.

The NHS says balance problems after labyrinthitis or vestibular neuritis can last for months or even years. Vestibular rehabilitation, a series of exercises that can help restore balance and ease dizziness, nausea and anxiety, should only be done under supervision of a specialist such as a physiotherapist or audiologist, which a GP can arrange or sometimes you can refer yourself. The NHS notes NHS physiotherapy waiting lists can be long and that some people choose private treatment. A GP will ask about symptoms and may do a simple test moving you quickly from sitting to lying to see if it brings on symptoms, and may refer you to a specialist for further tests.