DIZZY DOS IN THE ELDERLY

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DIZZY DOS IN THE ELDERLY

• Dr Alastair Kerr
• Consultant Geriatrician
• 18/7/07

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DIZZINESS

• Very common
• 30 of community dwelling elderly
• More common in women than men
• Causes often benign and self limiting BUT can be
  life threatening
• Consequences can be serious
• Needs a formal approach to diagnosis Rx

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DIZZINESS

• Can be frustrating due to non specific
  presentation
• Research base is limited
• Most studies done on young patients
• Peripheral vestibular disease and psychological
  disorders predominate
• In elderly much more treatable conditions

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CAUSES OF DIZZINESS

• Broadly divided into four main categories
• 1.Cardiovascular
• 2.Peripheral vestibular disorders
• 3.Central neurological disorders
• 4.Others, including medication
• NB often several overlapping causes

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CARDIOVASCULAR

• Postural Hypotension
• Carotid Sinus Hypersensitivity
• Vasovagal syncope
• Arrythmia
• Mechanical outflow obstruction

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PERIPHERAL VESTIBULAR DISORDERS

• BPPV
• Vestibular neuronitis
• Menieres disease
• Cholesteatoma
• Ramsay Hunt Syndrome

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CENTRAL NEUROLOGICAL DISEASE

• Cerebrovascular Disease
• 1. Subclavian Steal Syndrome
• 2. Wallenbergs Syndrome
• 3. Vasculitides
• Cerebellar disease
• Neurodegenerative eg PD
• Vertebrobasilar insufficiency does NOT exist

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OTHER CAUSES

• Medication
• Haematological disorders
• Metabolic conditions
• Infections
• Trauma
• Visual impairment
• Psychiatric disease

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DRUGS CAUSING DIZZINESS

• Alcohol
• Antidepressants
• Anticonvulsants
• Analgesics
• Antianginals / antiarrythmics
• Antibacterials
• Antipsychotics
• Stemetil / Betahistine

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Why is dizziness such a problem in the elderly?

• Balance depends on interactions between sensory
  and motor input and CNS integration
• Dysfunction of any of these components leads to
  dizziness
• Ageing is associated with changes in vision,
  proprioception, vestibular function and neuronal
  loss in key areas

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ASSESSMENT

• What do you mean by dizzy ?
• Classically there are four subtypes
• 1.Vertigo
• 2.Presyncope
• 3.Dysequilibrium
• 4.Other dizziness

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VERTIGO

• Clear description of subjective or objective
  motion
• Peripheral vestibular disorders produce acute,
  unprecipitated short lived episodes with nausea
  and vomiting
• CNS disorders are usually insidious and
  progressive
• Cranial nerve involvement suggests brain stem
  origin

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Menieres disease

• Tinnitus, deafness, vertigo, n v
• 2/1000 people M F
• Feeling of fullness/pressure in ear
• Dilatation of endolymph system ? cause
• Lasts several hours
• Can occur in clusters
• Can be years between attacks
• No cure
• Rx Betahistine/Stemetil for acute attacks

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Benign paroxysmal positional vertigo (BPPV)

• Commonest causes of vertigo
• Due to otoconial debris in semicircular canals
• Increases with age femalegtmale
• Brief episodes (lt1 min) vertigo (/- imbalance)
  with specific head positions-turning in
  bed,sitting up,looking up
• Episodic lasting few days months
• Asymptomatic intervals months - yrs

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Frequency of complaints in BPPV

• Imbalance 57
• Vertigo 53
• Trouble walking 48
• Light headed 42
• Nausea 35
• Sense of tilt 24
• Sense of floating 22
• Blurred vision 15
• Jumping vision 13

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Causes of BPPV

• Idiopathic (60)
• Advanced age
• Post head trauma(20)
• Vestibular neuritis(9)
• Others (11) mastoiditis, post surgery,
  ototoxicity)
• Examination - normal

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Dix-Hallpike manoeuvre

• Produces symptoms and torsional nystagmus
• Latent period
• Lasts 10-20 secs

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Epley manoeuvre

• Repositioning treatment
• Complete recovery 70 after one session
• 90 after second treatment
• Self management Brandt- Daroff exercises

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PRESYNCOPE

• Usually implies diffuse temporary cerebral
  hypoperfusion
• Usually cardiac
• Patients describe a feeling of an impending faint
  
• Ask whether syncope has ever occurred
• Do the symptoms only occur when upright?
• Are there any associated symptoms?
• Any relation to drugs, meals, baths, elimination?

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DYSEQUILIBRIUM(Multi-sensory deficit syndrome)

• Imbalance
• Usually in pts with multiple medical problems
  (commonly periph neuropathy, poor vision
  hearing)
• Usually felt in the lower limbs or trunk
• No head symptoms
• Most prominent when walking or standing
• Reduced by lying or sitting
• Usually of neuromuscular origin
• Additional effect in many of psychosomatic
  overlay.
• Fear of falling reduced activity worse balance

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OTHER DIZZINESS

• Ask about anxiety or hyperventilation symptoms
• Any relationship with vision
• Remember that several forms of dizziness may
  present together

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PHYSICAL EXAMINATION

• Full general examination including vision and
  hearing
• Are they anaemic?
• Lying and standing BP
• Slow or irregular pulse
• Heart murmurs
• Evidence of heart failure or infection

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NEUROLOGICAL EXAM

• Any evidence of cerebrovascular disease?
• Cerebellar signs?
• Do they have Parkinsonism?
• Any signs of peripheral neuropathy?
• Dix-Hallpike manoeuvre

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INVESTIGATIONS

• Urinalysis
• Full blood count / viscosity
• Electrolytes
• Glucose
• Thyroid function
• B12 / Folate
• ECG

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FURTHER INVESTIGATIONS

• 24hr / 7 day recording
• Tilt testing
• Carotid sinus massage
• Echocardiography
• CT/MRI brain

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MANAGEMENT

• Medication review
• Try to make a diagnosis
• Identify other risk factors and contributing
  conditions
• Correct visual impairment
• Improve muscle strength
• Optimise Calcium and vitamin D stores

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MANAGEMENT

• Optimise medication regimes
• Consider gait mobility aids
• Identify and treat psychological co-morbidities
• Vestibular exercises where appropriate
• (Cooksey-Cawthorne exercises)

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TAKE HOME MESSAGES

• Always try to make a diagnosis
• Medication review
• Causes often multifactorial
• Not all vertigo is Menieres disease
• Management orientated approach often produces
  significant results