Transcript Falls - traffordcommissioningconsortium.co.uk

‘Dizziness’
David Bourne
Consultant Physician and Geriatrician
UHSM
5th March 2007
Agenda
• Dizziness
• Orthostatic and Postprandial
Hypotension
• Blackouts
• Summary and discussion
Dizziness
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Nonspecific term
Vertigo ~50%
Presyncope
Disequilibrium
– Presyncope and disequilibrium ~25%
• Nonspecific dizziness ~15%
• Psychiatric ~10%
Dizziness
History
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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
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Arrhythmias
PE
Head injury
Psychiatric
– Major depression 25%
– Generalised anxiety 25%
– Somatisation
• Hyperventilation
– Mildly stressful situations
– Purposeful hyperventilation while observing for
nystagmus
Dizziness
Medications
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Antidpressants
Hypnotics
Anticholinergics
Antihypertensives
Lots more
Orthostatic and Postprandial
Hypotension
• Orthostatic hypotension ~20% >65yrs
• Postprandial (15-90mins) ~30% NH residents
• Symptoms
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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
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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
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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
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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
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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
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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
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History
Targeted examination
Undertake simple interventions
Consider appropriate referral
Discussion