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‘Dizziness’ David Bourne Consultant Physician and Geriatrician UHSM 5th March 2007 Agenda • Dizziness • Orthostatic and Postprandial Hypotension • Blackouts • Summary and discussion Dizziness • • • • Nonspecific term Vertigo ~50% Presyncope Disequilibrium – Presyncope and disequilibrium ~25% • Nonspecific dizziness ~15% • Psychiatric ~10% Dizziness History • • • • Open ended questions Positional changes in symptoms Rx Presyncome – Prodrome to fainting – Lasts seconds to minutes • History most most sensitive: – Vertigo 87% – Presyncope 74% – Psychiatric 55% – Disequilibrium 33% Dizziness Vertigo • Acute asymmetry of the vestibular system – Illusion of motion – Whirling – Tilting – Moving – Imbalance – Panic attacks – Agoraphobia / Fear of falling Dizziness Examination • Confirms the diagnosis • Most useful components – Orthostatic BP – Pulse changes – Systolic murmur ?AS – Gait observation – Eye movements – Romberg’s Test • Peripheral neuropathy • Hallpike’s Test • Psychological testing • No patient volunteered a psychiatric explanation Dizziness in the elderly • ~1/3 elderly • Multiple pathology – Geriatric syndrome (5th Geriatric Giant) • Associations – Postural hypotension – 5 or more medications – Hearing impaired – Impaired balance – Anxiety / depression – Previous MI Disequilibrium • Sense of imbalance/ unsteadiness • Often multifactorial – Peripheral neuropathy – Visual impairment – Muscular skeletal – Gait – Vestibular – Do they cause dizziness? • Vertebrobasilar insufficiency • Cervical spondylosis Nonspecific dizziness • • • • Arrhythmias PE Head injury Psychiatric – Major depression 25% – Generalised anxiety 25% – Somatisation • Hyperventilation – Mildly stressful situations – Purposeful hyperventilation while observing for nystagmus Dizziness Medications • • • • • Antidpressants Hypnotics Anticholinergics Antihypertensives Lots more Orthostatic and Postprandial Hypotension • Orthostatic hypotension ~20% >65yrs • Postprandial (15-90mins) ~30% NH residents • Symptoms – – – – – – – Light-headed Generalised weakness Blurred vision Legs buckling Neck pain / headaches Stroke Angina Orthostatic and Postprandial Hypotension • BP on standing and at 2 and 5mins • Fall in BP + symptoms – Systolic 20mmHg – Diastolic 10mmHg • Many will have systolic hypertension • Assosciations – Anti hypertensives – Oral hypoglycaemics – Antidepresants – Opiates – Alcohol Orthostatic and Postprandial Hypotension Normal response to orthostatic stress • Normal response to standing • 500-1000ml pool in lower extremities and splanchnic (most) circulation VR – SBP 5-10mmHg – DBP 5-10mmHg – HR 10-25/min • Baroreceptor reflex SNS + PSNS • PR VR CO • ADH Orthostatic and Postprandial Hypotension Mechanism of autonomic failure • Autonomic failure – NA Na in prox renal tubule Na excretion new steady state plasma vol – Absent HR (except POTS young tilt) Orthostatic and Postprandial Hypotension Causes of autonomic failure • Autonomic failure – Neurological conditions • • • • • • Impaired baroreceptor response in the elderly Postprandial hypotension PD MSA DM Paraneoplastic syndromes – Neurogenic syncope / CSH – Micturition / defaecation syncope – Rx • antidpressants often overlooked Orthostatic and Postprandial Hypotension Cause of volume depletion • Volume depletion – Hyperglycamia – Haemorrhage – D+V – Rx • Diuretics Orthostatic and Postprandial Hypotension Treatment • Nonpharmacological • Pharmacological Orthostatic and Postprandial Hypotension Treatment - Nonpharmacological • Volume replacement • Rx review – blockers – Antidepressants • Education and physical manoeuvres – Standing – Weather – Meal times • • • • • • Salt Water with a meal Small meals Low carbohydrate Alcohol Avoid standing quickly and exercise Orthostatic and Postprandial Hypotension Treatment - Nonpharmacological • Education and physical manoeuvres – – – – Leg crossing CO ~15% Clench fists Squatting Straining • Rx chronic cough – Tilt bed renin system nocturnal diuresis – Compression stockings to lower abdomen – Exercise • Cardiac reconditioning Orthostatic and Postprandial Hypotension Treatment - pharmacological • Fludrocortisone – Long t½ – Blood volume – vessel sensitivity to catecholamines – ? NA release – 50ug titrated weekly max 500ug – SE oedema / supine HT / K / CCF Orthostatic and Postprandial Hypotension Treatment - pharmacological • Sympathomimetics • Midodrine – Doesn’t cross BBB avoiding some SE – agonist 2.5mg od 10mg tds – SE supine HT / GI / urinary retention • • • • • • Caffeine NSAIDS Desmopressin blockers eg pindolol DA antagonists Erythropoitin in context of anaemia Blackouts • Abrupt loss of consciousness and loss of postural tone • Rapid and complete recovery • ~ 3% A+E attendances • ~1% hospital admissions • Cardiac syncope risk of sudden death • Lifetime risk 30% • Framingham rise >70yrs Blackouts Risk factors • • • • • • IHD CVD HT Low body mass index Alcohol DM Blackouts Cause • Vasovagal • Cardiac • Unknown 30% Blackouts Cardiovascular • Arrhythmia – Cf vasovagal without warning • Well tolerated – Persistent arrhythmia – Bradycardias Blackouts Cardiovascular • Blood flow obstruction – AS – HOCM – PS – PE Blackouts Noncardiac • Neurocardiogenic • Orthostatic hypotension • CSH – Relatively benign nb injuries • Seizures • Metabolic • CVD Blackouts Noncardiac • Seizures – 5-15% syncope – Post ictal • Metabolic – Hypoglycaemia • CVD Summary and discussion • • • • • History Targeted examination Undertake simple interventions Consider appropriate referral Discussion
