Dizziness in the Elderly

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Dizziness in the Elderly

• Steven Zweig, MD
• Family and Community Medicine
• MU School of Medicine

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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.

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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

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Types of Dizziness

• Vertigo - spinning or motion
• Presyncopal lightheadedness - impending faint
• Dysequilibrium - unsteadiness, off balance
• Other dizziness - vague, difficult to describe,
  floating

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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

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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

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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

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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

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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

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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,
  Menieres dx, migraine

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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

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Key Dizziness Syndromes

• Postural dizziness
• Positional vertigo
• Labyrinthitis
• Vestibular neuronitis
• Menieres disease
• Vertebrobasilar TIAs
• Stroke

• Cervical dizziness
• Physical deconditioning
• Drug induced
• Multiple sensory impairments
• Psychological

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Key Factors in the History

• Try to categorize the subtype
• Episodic or continuous
• Onset
• Precipitating or aggravating factors
• Contributing conditions
• Drug history

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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)

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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

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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

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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

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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

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Menieres 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

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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

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Stroke

• Occlusion of vertebral artery (dorsolateral
  medulla) - vertigo, nausea, ipsilateral facial
  numbness, Horners 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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