Dizziness and Imbalance in Older Adults

Dizziness and imbalance are common concerns in older adults and are related to an increase in falls risk and fear of falling.  An estimated 24% of individuals over 72 years of age experience dizziness. There are many potential causes of dizziness and imbalance in older adults but vestibular dysfunction is a frequent and often overlooked contributor.

The human balance system is comprised of a complex relationship between what we feel (pressure on the skin, pulling of muscles, movement of joints), what we see (static and dynamic visual acuity, aligning with the horizon), and inner ear vestibular input (head movements in relation to gravity).  Not only do all of these sensory systems need to be in good working order, but the central nervous system (CNS) must be able to receive, integrate, and act on this information appropriately, and we must have the strength, motor control, and flexibility to respond to the messages sent from the central nervous system effectively in order for balance to be maintained. 

Unfortunately, the functioning of all three sensory systems mentioned above deteriorates to some degree with advancing age. Loss of sensation and detection of joint movements as a result of peripheral neuropathy commonly occurs in older adults.  Age-related vision changes including presbyopia (farsightedness caused by loss of elasticity of the lens of the eye) and cataracts can significantly affect the accuracy and efficiency of visual processing.  Additionally, age-related hair cell and neuronal loss in the vestibular system can lead to an impaired ability to stabilize gaze, detect and react to head movements, and can lead to symptoms of dizziness and disequilibrium.  These deteriorations in the vestibular system can also increase the likelihood of developing peripheral vestibular disorders and vertigo, which is defined as the perception of motion when no motion is present. 

Peripheral vestibular dysfunction was found to be the principal cause of dizziness in 56% of patients older than 50 years.  However, in 20-30% of older adults with dizziness, no specific diagnosis to explain dizziness symptoms could be made.  Age-related dizziness that cannot be attributed to any known cause is often referred to as presbystasis (presby means elder; stasis means balance).

Two peripheral vestibular disorders that frequently occur in older adults are benign paroxysmal positional vertigo (BPPV) and vestibular neuritis.  BPPV is characterized by short duration vertigo with positional changes like rolling over in bed or sitting up after laying down.  BPPV can also cause general dizziness and lightheadedness throughout the day as well as significantly increase risk for falls. Additionally, some types of BPPV can cause longer lasting vertigo which is quite debilitating and can lead to an incorrect diagnosis.  BPPV is easily assessed and treated by a qualified vestibular physical therapist with 80% of individuals experiencing significant relief in symptoms after 1-2 treatments. 

Vestibular neuritis, simply put, is damage to the vestibular nerve in one or both ears with resulting vertigo, nystagmus (abnormal eye movements), and imbalance. This condition can be caused by inflammation, viral infection, and vascular issues to name a few, but often has no identifiable cause.  In younger people, vertigo and nystagmus with a bout of neuritis is usually very severe and leads to emergency room visits. In older adults, however, the vertigo and nystagmus with neuritis can be much less significant or even absent with dizziness and imbalance being the main symptoms. This is due in part to the age related decline in the functioning of the vestibular system and the central processing of vestibular input. Since healthy vestibular input is necessary to experience the symptom of vertigo, using vertigo as diagnostic criteria for either BPPV or vestibular neuritis in older adults can lead to mis-diagnosis and improper treatment.

Not only can the normal, age-related decline in the balance system lead to peripheral vestibular dysfunction, it can also make compensating for this dysfunction much more difficult.  Ideally, we are able to compensate for impaired vestibular function by reweighting how much we use our other sensory systems, such as vision or proprioception, to maintain balance and a sense of equilibrium.  In order for this to be successful, these other sensory systems need to be intact and working well.  As mentioned previously, vision and sensation are also impaired with age so sensory reweighting is a less effective compensatory strategy for vestibular impairment. Decline in the balance-related sensory systems as well as muscle strength, flexibility, and reaction time can also lead to a phenomenon called decompensation.  Decompensation happens when compensatory efforts made to overcome vestibular dysfunction experienced in youth fail with advancing age and dizziness, vertigo, and/or imbalance return.  Vestibular neuritis, BPPV, migraine associated vertigo, frequent ear infections, and/or concussion are all diagnoses experienced in youth that can become decompensated with age. 

A qualified vestibular therapist can thoroughly evaluate an individual of any age to discern the cause of dizziness and imbalance.  Vestibular rehabilitation (VR) has been shown to be effective in improving postural control and reducing dizziness in older adults.  VR includes exercises that help promote central nervous system adaptation to vestibular loss, promote normal head, eye, and body movement and habituate symptoms associated with these movements; and optimize the function of remaining sensory systems in balance to allow for improved compensation or to reverse decompensation.

If you are experiencing imbalance or dizziness and you haven’t been evaluated by a qualified vestibular physical therapist, contact me at Jessica@mainstaypt.com or 970-818-0235 for more information. 


Iwasaki S, Yamasoba T (2014) Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System. AD, 6(1): 38-47.

Anson E, Jeka J (2016) Perspectives on Aging Vestibular Function.  Fneur, 6: 1-7.