Transcript Dizziness in the Elderly

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
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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
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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)
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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
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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