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Dizziness in the Elderly Steven Zweig, MD Family and Community Medicine MU School of Medicine Objectives • Learn the definitions of dizziness. • Use acute or chronic course, continuous or episodic nature, and key elements in PE for differential diagnosis. • Recognize value or lack of value in testing. • Make diagnosis specific treatment recommendations. Epidemiology • Over one year 18% of 65+ complained to a physician or had loss of usual activities due to dizziness • 30% prevalence in community survey • Most common complaint over age 75 • Risk factor for functional decline Types of Dizziness • Vertigo - spinning or motion • Presyncopal lightheadedness - impending faint • Dysequilibrium - unsteadiness, off balance • Other dizziness - vague, difficult to describe, “floating” Vertigo • Due to an imbalance in vestibular system, arising from inner or middle ear, brainstem or cerebellum • Common causes include benign paroxysmal positional vertigo, cerebrovascular dx, and acute labyrinthitis and vestibular neuronitis Presyncopal lightheadedness • Due to diffuse cerebral ischemia typically arising from vascular or cardiac causes • Common causes include vasovagal episodes, postural hypotension, cardiac dx (such as arrhythmia, CHF, low output), and carotid sinus sensitivity Dysequilibrium • Perceived as body rather than head sensation arising from motor control system (vision, vestibulospinal, proprioceptive, sensory, cerebellar or motor function) • Common causes include stroke, sensory deficits, severe vestibular loss, peripheral neuropathy, and cerebellar disease Other causes of dizziness • These are vaguely described and may be associated with anxiety and other psychological disorders • Less common cause of dizziness in older than younger persons Multiple Causes • Subtyping may be useful in only about half the cases • Older persons often describe several subtypes • Most have dysequilibrium along with some other type of dizziness - vertigo or presyncope Temporal Pattern of Symptoms • Continuous - psychological, medications, permanent structural damage (e.g. stroke, cerebellar atrophy, vestibular damage, peripheral neuropathy, deconditioning) • Episodic - BPPV, recurrent vestibulopathy, TIAs, Meniere’s dx, migraine Common Problems in Aging • Greater sway during platform studies with known loss of hair in semicircular canals, utricle, and saccule of vestibular system • Progressive decline in baroreflex sensitivity • Resting cerebral blood flow close to threshold for cerebral ischemia Key Dizziness Syndromes • • • • • • • Postural dizziness Positional vertigo Labyrinthitis Vestibular neuronitis Meniere’s disease Vertebrobasilar TIAs Stroke • Cervical dizziness • Physical deconditioning • Drug induced • Multiple sensory impairments • Psychological Key Factors in the History • • • • • • Try to categorize the subtype Episodic or continuous Onset Precipitating or aggravating factors Contributing conditions Drug history Physical Examination • BP and pulse in recumbent and upright position - immediate, 1 and 3 minutes • Cranial nerves - including vision, hearing, nystagmus • Neck, cerebellar, leg-neuromuscular, sensation • Cardiovascular • Hallpike maneuver (if indicated) Other Evaluation (if needed) • • • • • • • CBC, thyroid, glucose, RPR, liver/kidney Audiometry MRI, cervical spine x-rays Holter/event monitor, carotid sinus massage Electronystagmography Doppler of carotid and vertebral arteries Brainstem auditory-evoked potentials Postural Dizziness • Very common - but rarely meet criteria of 20mmHg drop in systolic 10 in diastolic • Some symptomatic with lesser drop • Others BP drops after 10 to 30 minutes • RX- delete drugs, support stockings, head of bed elevation, prevent dehydration, cardioselective B-blockers, fludrocortisone Positional Vertigo • Head turning causes severe vertigo which resolves within a minute • BPPV most common cause usually resolving within 4-6 weeks • Dx - Hallpike - seated to head hanging, tilted 30 degrees • RX - exercises - falling or rolling to cause vertigo, while on bed, 4 x daily Labyrinthitis, vestibular neuronitis • Abrupt onset, lasting several days imbalance may last months/years • Labyrinthitis (if hearing affected),vestibular neuronitis (if hearing not affected) • May be caused by virus or infarction • RX - meclizine or promethazine for acute, low dose lorazapam for chronic Meniere’s Disease • Recurrent episodes of vertigo with tinnitus and unilateral low frequency hearing loss • Ear stuffiness may precede attack - episodes may last hours to days • RX - diuretics, endolymphatic shunt for severe Vertebrobasilar TIAs • Presents as vertigo subtype (rotatory dizziness is risk factor for stroke) • More likely if visual blurring, diploplia, numbness, dysarthria • Can be caused by emboli, thrombocytosis, polycythemia, subclavian steal , migraine • RX- ASA, warfarin, surgery Stroke • Occlusion of vertebral artery (dorsolateral medulla) - vertigo, nausea, ipsilateral facial numbness, Horner’s syndrome, contralateral loss of pain and temp, falling to affected side • Occlusion of ant. inf. cerebellar artery (labyrinth, pons, cerebellum) - vertigo, unilateral hearing loss, unilateral facial paralysis and cerebellar findings • Lacunar infarcts Cervical Dizziness • Vascular - motion induced, temporary block of blood flow caused by arthritic spur • Proprioceptive - facet receptors are over stimulated causing lightheadedness or vertigo • Carotid sinus syndrome • Suspect if recurrent with movement or constant with injury • RX- avoidance, traction Physical Deconditioning • Caused by bed rest, lack of exercise resulting in postural dizziness, muscle weakness, and reduced coordination • RX - exercise, muscle strengthening, strategies to prevent falls to gain confidence Drug-Induced Dizziness • Drugs that cause hypovolemia or decrease blood pressure (antihypertensives, tricyclics, psychotropics, muscle relaxants) • Ototoxic drugs (ASA, aminoglycosides) • NSAIDs (including COX2 inhibitors) • Alcohol - postural hypotension with high levels, vertigo when levels decline Multiple Neurosensory Impairments • Visual, proprioeptive, vestibular, cerebellar, and neuromuscular systems required • Worse when trying to stand or walk • Vestibular dysfunction, vision loss, deconditioning, c-spine, peripheral neuropathy • RX - ID and correct those you can Psychological Factors and Dizziness • Common, but rare as primary cause • 38% of elderly with dizziness have anxiety, depression, or adjustment disorders • May be more susceptible to impairment or dizziness syndromes contribute to psychological symptoms Dizziness in Elderly People (Colledge et al, 1996) • Recent controlled study examining 149 dizzy (greater than 3 mos) and 97 control subjects from community • Compared findings on PE, lab, ECG (rest and 24 hr), electronystagmography, posturography, MRI, hyperventilation, Hallpike, carotid massage Results • More dizzy subjects smoked, had hx of MI, stroke, ear and eye disease • More had decreased strength, increased tone, cerebellar and brainstem dysfunction, limited neck movement, carotid bruit, Romberg, postural symptoms; anxiety, depression, and impaired cognitive function Results (cont.) • No differences in blood tests or ECGs • 80% of both groups had two or more electronystagmography abnormalities • 70% and 66% (controls) had facet joint abnormalities • 84% and 81% had cerebral atrophy • 68% and 74% had white matter lesions • Posturography not specific Health, Functional and Psychological Outcomes (Tinetti et al, JAGS 2000) • 261 of 1087 (24%) community living elderly (>71 years) had chronic dizziness • Dizziness = “Episodes of feeling dizzy,unsteady, or like you were spinning, moving, light-headed, or faint.” • Had to be present for at least a month • Measured death, hospital, falls, syncope, worsening health, worse depression, decreased confidence and function in ADLs and social activities Results • Duration of dizziness > 1 yr in 164 (63%) • Episodes daily (31%), weekly (13%), and monthly (49%) • At baseline, no difference in age, gender, race, MMSE • More chronic conditions, meds, impairments in hearing or balance, depressive sx, falls Results (cont.) • Longitudinally (over 1 year), dizzy no more likely to die, be hospitalized, suffer a new MI or stroke, of lose ADLs • Chronic dizziness was associated with falls, syncope, worsening depression, and selfrated health decline Tinetti Recommendations • When failing to diagnose a single entity, goals of care should be redirected to attempts to ameliorate contributing factors and symptoms – by addressing anxiety, depressive symptoms, hearing impairment, balance impairment, postural hypotension, and reduction in medications Summary of Treatments • • • • • • • Try to identify specific dx and treat Stop all nonessential meds Correct vision problems if possible Use cane for impaired proprioception Try vestibular desensitization if cause Exercise and balance training Make home hazard-free as possible