Download Orthostatic hypotension

DIZZINESS
Module # 3
Management
Ed Vandenberg MD CMD
Geriatric section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha NE
68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
PROCESS
Series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Objectives
Upon completion of the module the learner
will be able to:
1) Describe the management of the most
common causes of dizziness
2) Describe the Epley maneuver
3) List the physiology blood pressure
maintenance and the changes with
aging
MANAGEMENT
“Tincture of time”
– spontaneously resolution in > 50%
or
– substantially improves within 2 weeks.
– Often associate with viral or other selflimited illnesses
50 % or more will be MULTIFACTORAL
MANAGEMENT
Acute vertigo attacks
Treatment
occur with peripheral vestibular
disorders such as
• labyrinthitis
• Meniere's disease
• First choice avoid
medications, hydrate
SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and
treatment of the dizzy patient. Prim Care Case Rev.
1999;2(1}:9
Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003.
Vol 58, No 4, 46-52
• Second choice trial of “Epley
Maneuvers
• If fails may benefit from
meclizine
or
• Prednisone
or
• if needed, a benzodiazepine.
Often “trade” vertigo for
increased fall risk, sedation
and anticholinegic effects
Meclizine overprescribed for
chronic vestibulopathies and
non-vertiginous dizziness.
MANAGEMENT
Benign positional vertigo
usually can be treated with simple
reassurance
For severe or persistent symptoms:
the canalolith repositioning procedure
(Epley's maneuver)
home habituation exercises
SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case
Rev. 1999;2(1}:9
MANAGEMENT
Meniere's disease
If attacks are frequent or disabling
• may benefit from prophylactic treatment
with salt restriction or diuretic therapy or
both.
• Occasional require referral to
otolaryngology for consideration of
surgery
SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case
Rev. 1999;2(1}:9
Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003. Vol 58, No 4, 46-52
Orthostatic hypotension
Correct reversible causes of Syncope
Etiologies:
•
•
•
•
P
A
S
S
P-A-S-S O-U-T (mnemonic)
ressure (hypotensive causes)
rrhytmias
eizures
ugar (hypo/hyperglycemia)
• O utput (cardiac) /O2 (hypoxia)
• U nusual causes
• T ransient Ischemic Attacks & Strokes
P ressure
(Hypotensive induced causes)
Why elderly are predisposed to
hypotension problems
Mechanisms of compensation for
gravitational effects of standing
Autonomic
Endocrine
Carotid/aortic baroreceptors
sympathetic tone
 renin release
 angiotensin II
 aldosterone
vasoconstriction  sodium retention
peripheral vasoconstriction
& heart rate
Atrial
Natriurectic
factor
 vasodilator
 renin-angiotensin
Aging, Physiology and Blood
Pressure
Physiology of Pressure
maintenance
Baroreceptors sensitivity
Aging Physiologic changes
Decreased sensitivity
Volume (fluid)
Decreased reserve
Vascular tone
Decreased tone
B-receptor responsiveness
Decreased B-receptor
responsiveness
Decreased tone
Muscle tone and therefore venous
return
Physiology of Pressure maintenance
Aging Physiologic changes
Disease changes that
predispose
Incidence
Autonomic Nervous System
dysfunction
(e.g.DM)
increased
Cerebrovascular auto-regulatory
dysfunction (HTN)*
increased
Medications
increased
*(20-30% of HTN pop. Age > 65 can have orthostatic hypotension (O.H.))
( 7% of Normotensive pop. age > 65 can have orthostatic hypotension )
General Causes of P ressure
Problems:
1)Vasovagal
• 1-29 % of all causes syncope.
2) Orthostatic Hypotension
• 5-29 % of all causes syncope
Orthostatic Hypotension
CAUSES
The List of causes:
a) Volume loss
b) Medications
c) Situational
d) Primary Autonomic
Disease
e) Secondary Autonomic
Disease
f) Adrenal
Insuffiency
a)Volume Loss
• blood loss
• fluid loss (diarrhea, sweating,
diuresis, dehydration)
b) Medications;
•
•
•
•
•
•
•
antihypertensives
B-blockers
alcohol
anticholinergics
antianginals
vasodilators
antiparkinsonian
Orthostatic Hypotension
CAUSES continued
c)Situational
(many of these involve the Vasovagal mechanism)
•
•
•
•
•
•
micturition
postprandial*
cough
carotid sinus sensitivity
defecation
laughing
Orthostatic Hypotension
CAUSES
continued
d) Primary
Autonomic
Disease
• Idiopathic
• Multi-System
Atrophy (e.g.ShyDragger)
• Parkinson’s disease
e) Secondary
Autonomic disease
• Neuropathic
– e.g.DM, amyloid,
alcoholism, autoimmune
– Cancer, B12 def.,
porphyria
• CNS
– e.g. CVA’S, MS,
Tumors, Wernickes,
spinal cord lesions
• Renal failure
MANAGEMENT
Disequilibrium:
Vision
Improve MSK
Re-strengthening
Gait evaluation
and therapy
Balance training
Assistive device
evaluation and use
Chronic vestibulopathy:
 Vestibular
rehabilitation?
SOURCE: Adapted from Khan A, Kroenke K.
Diagnosis and treatment of the dizzy patient.
Prim Care Case Rev. 1999;2(1}:9.
MANAGEMENT
Lightheadness
Psychiatric issues
depression, anxiety & somatoform
disorders
Antidepressants?
Counseling?
Prescription drug toxicity
usually cardiovascular, antihypertensive,
psycho-tropic and diuretics.
MANAGEMENT
Lightheadness
Other causes
Treatment
• cervical arthritis: pain control, ROM
• visual disorders: maximize vision
• carotid sinus
hyper-sensitivity: Avoid neck pressure,
Medication review
Practical Approach to Evaluating the Dizzy
Patient
History ( start with Brief, focused evaluation and simple follow-up)
Step #1; Describe symptoms
Step #2: Pass out? ( syncope often requires early cardiac w/u)
Step # 3: Classify* into 3 key sensations:
(spinning, fainting, or falling?)
Step #4: Positional effect on symptoms?
•
worsen with head movements?
(eg, benign positional vertigo),
•
standing up
(eg, orthostatic hypotension)
•
associated with ambulating
(eg, disequilibrium)
Step # 5; Associated symptoms?
• syncope
( needs syncope eval.)
• nausea or vomiting,
( vertigo)
• hearing, ear symptoms
( Meniere's disease, acoustic neuroma)
• ataxia or focal neurologic deficits
(central neurological cause)
• multiple somatic complaints
(depression, anxiety, somatoform disorder)
Step #6: Medications review: (especially new around the time of onset )
•
•
•
•
•
•
*CLASSIFICATION
Symptom-oriented approach--- Classify as:
Vertigo (rotational sensation), …………………….“spinning”
Presyncope (impending faint),…………………… “fainting”
Disequilibrium (loss of balance without head sensation)“falling”
Lightheadedness (ill-defined, not otherwise classifiable).
Practical Approach to Evaluating the
Dizzy Patient
Physical examination
• Orthostatic blood pressure and pulse
• Nystagmus exam:
1st: Primary position.
2nd: Gaze-evoked
3rd: Dix-Hallpike test,
4th Head-shaking.
• Cardiovascular exam
• Neurologic
(cerebellar, propioceptive, motor, sensory)
( include “Up and go test”)
• Vision & Hearing
Diagnosis & Treatment
• Assume multi-factorial
• Classify Symptoms
• List Factors derived from “ Classification”) and their etiologies
• Treat multiple factors and the easiest first
• Time is on your side ( go slow), see patient back often
The End of Dizziness Modules
Request “Dizzy Pearls” summary card from
402.559.3964 or [email protected]
•
Credits:
Adapted with permission from;
Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter
23, ppg 159-165