Unsteadiness
Unsteadiness is a common presenting complaint, especially in older adults.
It refers to a sensation of imbalance or difficulty maintaining posture and gait, without vertigo (spinning).
Causes range from benign anxiety-related imbalance to serious neurological or vestibular disease.
A structured approach through history, examination, and targeted investigations is essential.
🗣️ History of Present Illness (HPI)
- Describe onset and duration: acute vs chronic.
- Character: “feeling unsteady” vs vertigo (room spinning).
- Triggers: standing, walking in the dark, turning head, stress/anxiety.
- Associated features:
- Hearing loss/tinnitus → vestibular disease.
- Visual disturbance → sensory ataxia.
- Numbness, weakness, slurred speech → neurological disease.
- Falls history, injuries, or fear of falling.
- Past medical history: diabetes, neuropathy, stroke, B12 deficiency, Parkinson’s, thyroid disease.
- Drug history: sedatives, antihypertensives, polypharmacy in older patients.
🔎 Clinical Examination
- General: Gait observation, tandem walking, use of aids.
- Neurological exam:
- Cranial nerves: eye movements, nystagmus, dysarthria.
- Motor: tone, power, reflexes.
- Coordination: finger–nose, heel–shin, dysmetria.
- Sensation: proprioception, vibration sense (peripheral neuropathy).
- Romberg test: worsens with eyes closed → sensory ataxia.
- ENT exam: Tympanic membranes, vestibular signs.
- Cardiovascular: Postural BP, heart sounds, rhythm (arrhythmia if syncope suspected).
⏱️ Time Course & Common Causes
| Time Course | Likely Causes |
|---|
| Acute (hours–days) |
Vestibular neuritis, labyrinthitis, stroke (cerebellar/brainstem), drug toxicity |
| Subacute (weeks) |
B12 deficiency, thyroid dysfunction, polypharmacy, anxiety-related imbalance |
| Chronic (months–years) |
Peripheral neuropathy, Parkinson’s disease, cerebellar ataxia, MS, visual impairment, frailty |
🧪 Investigations
- Blood tests: FBC, U&E, glucose, thyroid, B12/folate.
- Imaging: MRI brain if neurological suspicion; CT head if trauma.
- Vestibular tests: Caloric testing, audiometry if ENT suspected.
- Other: ECG, postural BP, gait/balance assessments (e.g., Timed Up & Go).
🛠️ Management
- Treat underlying cause:
- B12 replacement, thyroid correction.
- Vestibular rehab for labyrinthitis.
- Medication review (avoid sedatives, polypharmacy).
- Symptomatic management:
- Physio-led balance training.
- Occupational therapy → home adaptations, grab rails, good lighting.
- Mobility aids: frame/stick can transform confidence in older patients.
- Address psychological contributors (anxiety management, reassurance).
- Referral:
- Neurology: if cerebellar ataxia, MS, or progressive neurological features.
- ENT: if vestibular disease suspected.
- Falls clinic / geriatrics: if multifactorial in elderly.
🚨 Red Flags
- Acute unsteadiness + focal neurology → posterior circulation stroke.
- Unexplained falls with loss of consciousness → cardiac arrhythmia or seizure.
- Progressive worsening with neurological signs → tumour, MS, degenerative ataxia.
✅ Take-Home Messages
- Unsteadiness ≠ vertigo → think balance/gait disorders, not spinning.
- In older adults, often multifactorial (vision, proprioception, medications, frailty, anxiety).
- Always check B12, thyroid, medications before over-investigating.
- Acute onset + neurological features → stroke until proven otherwise.
