Dizziness ion Elderly

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Dizziness in the Elderly :

Dizziness in the Elderly Steven Zweig, MD Family and Community Medicine MU School of Medicine

Objectives:

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:

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:

Types of Dizziness Vertigo - spinning or motion Presyncopal lightheadedness - impending faint Dysequilibrium - unsteadiness, off balance Other dizziness - vague, difficult to describe, “floating”

Vertigo :

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:

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:

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:

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:

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:

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:

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:

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:

Key Factors in the History Try to categorize the subtype Episodic or continuous Onset Precipitating or aggravating factors Contributing conditions Drug history

Physical Examination:

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):

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:

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:

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:

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:

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:

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:

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:

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:

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:

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:

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:

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):

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:

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.):

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):

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:

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.) :

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 self-rated health decline

Tinetti Recommendations:

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:

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

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