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dizziness

Defined as a disturbed state of spatial awareness. Etiology: 1) multisensory dizziness a) common in elderly, especially diabetics [6] - often multifactorial involving vestibular, somatosensory, &/or visual systems [9] - risk factors (in elderly) [4] - anxiety - depression - impaired hearing [6] - impaired balance - orthostasis - past myocardial infarction - > 4 medications b) may be some overlap with disequilibrium 2) disequilibrium (5%, more common in elderly) {perhaps most common [5]}) a) CNS lesions (stroke)* 1] basal ganglia 2] frontal lobes 3] white matter b) vertebrobasilar ischemia c) cerebellar dysfunction d) acoustic neuroma [3] e) hydrocephalus f) parkinsonism [9] g) peripheral neuropathy [9] - diabetes mellitus, vitamin B12 deficiency, idiopathic, etc b) spondylitis, spondylosis 3) vestibular disorders a) vertigo (50%) 1] peripheral vertigo - saccular & semicircular canal dysfunction common with aging 2] central vertigo is a medical emergency [10] b) Meniere's disease c) vestibular neuronitis [3] d) labyrinthitis e) Herpes zoster oticus f) cervicogenic vertigo 4) presyncopal lightheadedness (25%) a) orthostatic hypotension b) vasovagal attacks c) impaired cardiac output (heart failure) d) hyperventilation 5) psychophysiologic dizziness a) acute or chronic anxiety b) agoraphobia c) depression d) somatoform disorder 6) ocular dizziness a) high magnification & lens implant b) imbalance in extraocular muscles c) oscillopsia 7) physiologic dizziness a) motion sickness b) space sickness c) chronic mountain sickness d) height vertigo 8) migraine 9) transient ischemic attack, stroke (very uncommon) [16] 10) idiopathic dizziness (20%) 12) pharmaceutical agents a) use of 4 or more medications b) antidepressants: SSRI c) cholinesterase inhibitors d) antihypertensive agents - vasodilators e) bronchdilators [9] f) CNS depressants - anticonvulsants - sedatives - anxiolytics - opiates - others g) parasympatholytics [9] - muscle relaxants h) laxatives - milk of magnesia, magnesium citrate [9] 13) dehydration in the elderly (GRS9) [9] - voluntary fluid restriction due to urinary urgency/urge incontinence - diuretics may contribute to dehydration * dizziness is most common symptom linked to a missed diagnosis of stroke presenting to the emergency department [3] Epidemiology: 1) 0.8% of outpatient visits 2) more prevalent in the elderly - 29% of individuals > 72 years of age Physical examination: 1) examine for orthostasis (orthostatic hypotension) 2) cardiac ascultation 3) examine for nystagmus a) head shaking nystagmus 1] close eyes 2] shake head horizontally for 10 seconds 3] open eyes b) vertical nystagmus or torsional nystagmus associated with a single episode of protracted dizziness suggests a central condition [7] 4) Rhomberg test may be positive Clinical manifestations: 1) disturbed spatial awareness - symptoms depend on etiology - symptoms of orthostatic hypotension - symptoms of vertigo - other 2) may persist for 6 months or longer 3) fear of falling, especially elderly Laboratory: 1) complete blood count (CBC) 2) serum electrolytes 3) serum creatinine 4) serum glucose 5) serum thyroid-stimulating hormone (serum TSH) 6) specific tests for specific etiologies Special laboratory: - not often needed [9] - electronystagmography - electrocochleography - rotational chair testing - posturography - electrocardiogram - HOLTER - PACs & a few short runs of supraventricular tachycardia not an indication for cardiology consult [28,29,30] Radiology: - not often needed [9] - CT angiography if TIA suspected (vertigo + neurologic sign) - magnetic resonance imaging (MRI) - generally imaging modality of choice [12] - not indicated in the absence of focal neurologic deficits [28,29,30] - despite dizziness being the most common symptom linked to a missed diagnosis of stroke presenting to the emergency department [3] - less useful than physical therapy (see management) - computed tomography (CT) not useful unless intracranial hemorrhage suspected [12] Complications: 1) increased risk of falls 2) social isolation 3) functional disability 4) depression or anxiety associated with 75% of chronic dizziness [3,9] 5) diminished quality of life 6) risk of vascular event after presenting with an episode of dizziness is low (stroke within 1 month < 1 in 500) [8] Management: 1) fall precautions (also see falls in the elderly) 2) treat modifiable factors [18] a) polypharmacy b) anxiety & depression c) functional mobility 3) physical therapy useful in general [3,28,29,30] 4) vestibular rehabilitation - even simple exercises challenging the vestibular system of benefit [5] - most useful for benign positional vertigo [3] - an internet intervention may help reduce symptoms of chronic dizziness among older adults [25] 5) SSRI for chronic dizziness [3] - depression or anxiety associated with 75% of chronic dizziness [3] 6) see specific etiology 7) prognosis: - dizziness in the elderly NOT associated with increased mortality or risk of hospitalization

Related

falls in the elderly

Specific

disequilibrium in the elderly light-headedness presyncope; near-syncope vertigo

General

sign/symptom

References

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  5. Journal Watch 24(24):188, 2004 - Yardley L, Donovan-Hall M, Smith HE et al Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness. Ann Intern Med. 2004 Oct 19;141(8):598-605. PMID: 15492339 - Zapanta PE and Meyers AD Medscape: eMedicine: Vestibular Rehabilitation http://emedicine.medscape.com/article/883878
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