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Dizziness in the Elderly

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38% of elderly with dizziness have anxiety, depression, or adjustment disorders ... 261 of 1087 (24%) community living elderly (71 years) had chronic dizziness ... – PowerPoint PPT presentation

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Title: Dizziness in the Elderly


1
Dizziness in the Elderly
  • Steven Zweig, MD
  • Family and Community Medicine
  • MU School of Medicine

2
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.

3
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

4
Types of Dizziness
  • Vertigo - spinning or motion
  • Presyncopal lightheadedness - impending faint
  • Dysequilibrium - unsteadiness, off balance
  • Other dizziness - vague, difficult to describe,
    floating

5
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

6
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

7
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

8
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

9
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

10
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

11
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

12
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

13
Key Factors in the History
  • Try to categorize the subtype
  • Episodic or continuous
  • Onset
  • Precipitating or aggravating factors
  • Contributing conditions
  • Drug history

14
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)

15
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

16
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

17
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

18
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

19
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

20
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

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
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

32
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

33
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

34
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
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