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DIZZINESS IN AN OLDER ADULT
10/12/05
MARY JO WILLIS MS, APRN, BC
CLINICAL PROFESSOR
NURSE PRACTITIONER

I have no financial interest to
report
OBJECTIVES
Review common causes of
dizziness/vertigo
 Describe clinical pearls of vertigo
testing/treatment
 Discuss the issues of vertigo testing

THE CASE
79 year old with Hx postural
hypotension
 Sudden onset of dizziness 2 weeks
ago
 Two more episodes since that time

THE PATIENT
PMH: Macular degeneration, BPH,
anemia, polymyalgia rheumatica
 SH: Retired, non-smoker, no ETOH
 FH: No Meniere’s disease
 ROS: No changes in hearing, vision,
speech; no fall, head injury, weakness/
paralysis of extremities, LOC, or recent
URI

THE PATIENT

Medications:
– Prednisone
– Terazosin
– Ferrous sulfate
– TMP-Sulfa DS
– Ocuvite
DIZZINESS IN THE ELDERLY

Cannot place dizziness into one category
– Disequilibrium can accompany other types of
dizziness when intact compensatory systems
are absent
– Need to distinguish between primary
symptom and secondary causes
– Need to distinguish acute from chronic
dizziness-no consensus
Sloane et. Al., (2001)
CATEGORIZING DIZZINESS
 Pre-syncope
 Syncope
 Disequilibrium
 Psychogenic
 Vertigo
PRESYNCOPE
Sense of impending fainting or LOC
 Episodic diffuse temporary cerebral
ischemia
 Sweating, pallor, telescoping of
peripheral vision

SYNCOPE
Syncope: sudden transient loss of
consciousness with concurrent loss
of postural tone
 Multi-system causation
 Most common causes are vasovagal
episodes or orthostatic hypotension

DISEQUILIBRIUM
Disequilibrium: Perceived postural
instability involving legs and trunk
without head sensation
 Overlap between imbalance and
disequilibrium
 Vertigo not present

PSYCHOGENIC
Dizziness that cannot be readily
classified into previous categories
 No focal or PE findings
 Chronic
 Common Mechanisms
– Hyperventilation
– GAD, Major depressive disorder
– Somatization disorders
– Substance abuse

VERTIGO
Illusion of motion interpreted as self
movement or environmental
movement
 Rotating with spinning sense of falling
or swaying back and forth: Merry-Go
Round Effect

1/2 of patients with dizziness have
vertigo
ETIOLOGY OF VERTIGO
Asymmetry of the vestibular system
due to pathology involving:
– Labyrinth and vestibular
nerve(40%)
– Central vestibular structures in
brainstem (10%)
– Remaining 50% are conditions
noted earlier
VERTIGO

Time course

Provoking factors

Associated symptoms

Prior risk factors
PERIPHERAL VESTIBULAR
DYSFUNCTION
Labyrinthitis (vestibular neuronitis)
 Meniere’s Disease
 Trauma
 Tumors (Acoustic Neuroma)
 Benign Paroxysmal Positional Vertigo

PERIPHERAL VERTIGO

Acute Viral Labyrinthitis /Vestibular
Neuronitis
– Usually preceded by a viral respiratory
or GI infection
– Sudden onset of nausea, vomiting,
severe vertigo worsened by change in
position
– Can last for days to weeks
– Nystagmus may last for months
PERIPHERAL VERTIGO

Meniere’s (Endolymphatic Hydrops)
– Spontaneous onset/recurrent attacks
– Duration of symptoms: min- hrs
– Often preceded by tinnitus, ear
fullness
– Sensori-neuro hearing loss which
varies day to day
– Chronic recurrent
PERIPHERAL VERTIGO
Drugs (www.annuls.org) Appendix
(41-44)
Trauma
Acoustic Neuroma: Vestibular
Schwannoma
– Account for < 1% of patients
– Disequilibrium is more likely
– Gradual rather than acute onset
The Patient
Episodes occurred when he was lying
down and turned over to his left side
 Slightly nauseated-no vomiting
 Reports that the room is spinning
 Last about “10 minutes”
 Getting into an upright position helps

DIZZY HISTORY

Key questions: Describe the first
episode
– Objects spinning/turning around you
– Occur in attacks
– Position change makes you dizzy
– Can you tell when it may start
– Can you stand unsupported
– What will stop the dizziness, make it
better or worse
THE PATIENT
Afebrile, No postural hypotension
 In NAD, cognition appropriate
 HEENT: WNL
 Neck: no carotid bruits
 CV: bradycardia, irregular rhythm
 Lungs: WNL

NEURO EXAM
Neuro: CN 2, 5,7,8-12 intact
 No nystagmus with EOMs
 Romberg/cerebellar tests intact
 DTRs.
 Sensation intact

BENIGN PAROXYSMAL
POSITIONAL VERTIGO
Vertigo with head movements
 Brief episodes lasting < 1 minute;
nausea
 Usually no tinnitus or hearing
impairment
 Spontaneous nystagmus is not present
 Usually self-limited; can persist for
weeks

BPPV
Most common form of positional
vertigo
 No predilection based on gender, race
or age but usually after 4th decade
 Provoked by specific head movements
 Typically have no other neurological
complaint
 May have history of head trauma

CANALITHIASIS
Loose otoconia consisting of calcium
carbonate crystals from the utriculus
 Usually involve the posterior semicircular canal
 Causes inappropriate movement of
endolymph
 Giving an erroneous spinning sensation
with head movement

BPPV ETIOLOGY
CANALITHIASIS
CANALITHIASIS
DIAGNOSTIC CRITERIA
Vertigo w mixed torsional/vertical
nystagmus on Dix Hallpike
 Latency of 1-2 seconds from completion
of test and onset or vertigo/nystagmus
 Paroxysmal provoked vertigo and
nystagmus (increase then decline over
10-20 seconds)
 Fatigability if test repeated


Furman (1999).NEJM: November 18, pp1590-1596
Clinic Testing
Dix Hallpike maneuver
 Sensitivity from 50-88%*
 Purpose is to:
– replicate the symptoms
– elicit positional nystagmus
– to determine whether nystagmus is
fatigable

*Hoffman, RM., et.al.(1999)
DIX HALLPIKE MANEUVER
The patient is positioned in front of
the examiner with their head turned
to the side at 45 degree angle
 The examiner supports the head and
shoulder, then quickly brings patient
to a reclining position with head
rotated to one side and hanging over
the table
 The position is maintained for 30 sec

DIX HALLPIKE MANEUVER
Tell patient not to fixate vision
 Look for nystagmus, noting time of
onset, direction

– Nystagmus upward and torsionally with
upper poles of eyes beating toward the
ground-last ~20-30 seconds
– Once sitting, nystagmus will recur but in the
opposite direction
– Repeat to same side, repetition diminishes
the intensity and duration
DIX HALLPIKE MANEUVER
DIX HALLPIKE
FRENZEL LENSES
THE PATIENT
Nystagmus elicited
 Vertigo elicited-lasted for few
seconds
 Symptoms absent after sitting
upright

ISSUES
Self limiting disorder
 Diagnosed by history-do we need to do
Dix Hall pike
 Dix Hallpike may interfere with
treatment using the Epley test
 When does patient need Canalith
repositioning?

TREATMENT

Epley maneuver:
– Relocate the debris from the posterior
semicircular canal to the vestibule
– 80% success rate after one treatment and
100% after >1 (Epley)
– 89% success rate after one treatment
compared to 23% in untreated group (Lynn)
– Recurrence rate of 30% in 30 month F/u
period; 15% over 4 years (Epley)
Lynn(1995)
CANALITH REPOSITIONING
Home treatments with modified
pocedures
 Modified Semont

– Less effective than modified Epley (95 vs
58%

Brandt-Daroff
– Less effective than modified Epley (64%
vs 23%
THE PATIENT
No further episodes
 Avoids turning to left side while
supine




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References
Froehling, D.A., et.al.,(2000). The canalith repositioning
procedure for the treatment of benign paroxysmal positional
vertigo: a randomized controlled trial. Mayo Clin Proc 75:695
Furman, J.M. et.al(1999). Benign paroxysmal positional vertigo.
NEJM, 341(21), pp.1590-96.
Kroenke, K. et.al., (200). How common are various causes of
dizziness? A critical review. South Med. J.,93: 160-7.
Lynn, S. et.al.,(1995). Randomized trial of canalith repositioning
procedure. Otolaryngol Head Neck Surg. 113:712
Sloane, P.D., et.al.(2001). Dizziness: State of the Science.
Annuls of Internal Medicine 134(9) part 2, pp. 823-31