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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
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