"dizzy turns" in the elderly

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DIZZY DO’S” IN DIZZY DO’S” IN THE THE ELDERLY ELDERLY Dr Alastair Kerr Dr Alastair Kerr Consultant Geriatrician Consultant Geriatrician 18/7/07 18/7/07

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Page 1: "Dizzy turns" in the elderly

““DIZZY DO’S” IN THEDIZZY DO’S” IN THE ELDERLYELDERLY

Dr Alastair KerrDr Alastair Kerr

Consultant GeriatricianConsultant Geriatrician

18/7/0718/7/07

Page 2: "Dizzy turns" in the elderly

DIZZINESSDIZZINESS

• Very commonVery common

• 30% of community dwelling elderly30% of community dwelling elderly

• More common in women than menMore common in women than men

• Causes often benign and self limiting Causes often benign and self limiting BUT can be life threateningBUT can be life threatening

• Consequences can be seriousConsequences can be serious

• Needs a formal approach to diagnosis & Needs a formal approach to diagnosis & RxRx

Page 3: "Dizzy turns" in the elderly

DIZZINESS DIZZINESS

• Can be frustrating due to non specific Can be frustrating due to non specific presentationpresentation

• Research base is limitedResearch base is limited

• Most studies done on young patientsMost studies done on young patients– Peripheral vestibular disease and Peripheral vestibular disease and

psychological disorders predominatepsychological disorders predominate

• In elderly much more treatable In elderly much more treatable conditionsconditions

Page 4: "Dizzy turns" in the elderly

CAUSES OF DIZZINESSCAUSES OF DIZZINESS

• Broadly divided into four main Broadly divided into four main categoriescategories– 1.Cardiovascular1.Cardiovascular– 2.Peripheral vestibular disorders2.Peripheral vestibular disorders– 3.Central neurological disorders3.Central neurological disorders– 4.Others, including medication4.Others, including medication

• NB often several overlapping causesNB often several overlapping causes

Page 5: "Dizzy turns" in the elderly

CARDIOVASCULARCARDIOVASCULAR

• Postural HypotensionPostural Hypotension

• Carotid Sinus HypersensitivityCarotid Sinus Hypersensitivity

• Vasovagal syncopeVasovagal syncope

• ArrythmiaArrythmia

• Mechanical outflow obstructionMechanical outflow obstruction

Page 6: "Dizzy turns" in the elderly

PERIPHERAL VESTIBULAR PERIPHERAL VESTIBULAR DISORDERSDISORDERS

• BPPVBPPV

• Vestibular neuronitisVestibular neuronitis

• Menieres diseaseMenieres disease

• CholesteatomaCholesteatoma

• Ramsay Hunt SyndromeRamsay Hunt Syndrome

Page 7: "Dizzy turns" in the elderly

CENTRAL NEUROLOGICAL CENTRAL NEUROLOGICAL DISEASEDISEASE

• Cerebrovascular DiseaseCerebrovascular Disease– 1. Subclavian Steal Syndrome1. Subclavian Steal Syndrome– 2. Wallenbergs Syndrome2. Wallenbergs Syndrome– 3. Vasculitides3. Vasculitides

• Cerebellar diseaseCerebellar disease

• Neurodegenerative eg PDNeurodegenerative eg PD

• [Vertebrobasilar insufficiency does NOT [Vertebrobasilar insufficiency does NOT exist]exist]

Page 8: "Dizzy turns" in the elderly

OTHER CAUSESOTHER CAUSES

• MedicationMedication

• Haematological disordersHaematological disorders

• Metabolic conditionsMetabolic conditions

• InfectionsInfections

• TraumaTrauma

• Visual impairmentVisual impairment

• Psychiatric diseasePsychiatric disease

Page 9: "Dizzy turns" in the elderly

DRUGS CAUSING DIZZINESSDRUGS CAUSING DIZZINESS

• AlcoholAlcohol

• AntidepressantsAntidepressants

• AnticonvulsantsAnticonvulsants

• AnalgesicsAnalgesics

• Antianginals / antiarrythmicsAntianginals / antiarrythmics

• AntibacterialsAntibacterials

• AntipsychoticsAntipsychotics

• Stemetil / BetahistineStemetil / Betahistine

Page 10: "Dizzy turns" in the elderly

Why is dizziness such a Why is dizziness such a problem in the elderly?problem in the elderly?

• Balance depends on interactions Balance depends on interactions between sensory and motor input and between sensory and motor input and CNS integrationCNS integration

• Dysfunction of any of these Dysfunction of any of these components leads to dizzinesscomponents leads to dizziness

• Ageing is associated with changes in Ageing is associated with changes in vision, proprioception, vestibular vision, proprioception, vestibular function and neuronal loss in key areasfunction and neuronal loss in key areas

Page 11: "Dizzy turns" in the elderly

ASSESSMENTASSESSMENT

• ““What do you mean by dizzy ? “What do you mean by dizzy ? “

• Classically there are four subtypesClassically there are four subtypes– 1.Vertigo1.Vertigo– 2.Presyncope2.Presyncope– 3.Dysequilibrium3.Dysequilibrium– 4.Other dizziness4.Other dizziness

Page 12: "Dizzy turns" in the elderly

VERTIGOVERTIGO

• Clear description of subjective or objective Clear description of subjective or objective motionmotion

• Peripheral vestibular disorders produce Peripheral vestibular disorders produce acute, unprecipitated short lived episodes acute, unprecipitated short lived episodes with nausea and vomitingwith nausea and vomiting

• CNS disorders are usually insidious and CNS disorders are usually insidious and progressiveprogressive

• Cranial nerve involvement suggests brain Cranial nerve involvement suggests brain stem originstem origin

Page 13: "Dizzy turns" in the elderly

Meniere’s diseaseMeniere’s disease

• Tinnitus, deafness, vertigo, n & vTinnitus, deafness, vertigo, n & v• 2/1000 people ; M = F2/1000 people ; M = F• Feeling of fullness/pressure in earFeeling of fullness/pressure in ear• Dilatation of endolymph system ? causeDilatation of endolymph system ? cause• Lasts several hoursLasts several hours• Can occur in clustersCan occur in clusters• Can be years between attacksCan be years between attacks• No cureNo cure• Rx: Betahistine/Stemetil for acute attacksRx: Betahistine/Stemetil for acute attacks

Page 14: "Dizzy turns" in the elderly

Benign paroxysmal positional Benign paroxysmal positional vertigo (BPPV)vertigo (BPPV)

• Commonest causes of vertigoCommonest causes of vertigo

• Due to otoconial debris in semicircular Due to otoconial debris in semicircular canalscanals

• Increases with age ; female>maleIncreases with age ; female>male

• Brief episodes (<1 min) vertigo (+/- Brief episodes (<1 min) vertigo (+/- imbalance) with specific head positions-imbalance) with specific head positions-turning in bed,sitting up,looking upturning in bed,sitting up,looking up

• Episodic lasting few days – monthsEpisodic lasting few days – months

• Asymptomatic intervals months - yrsAsymptomatic intervals months - yrs

Page 15: "Dizzy turns" in the elderly

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

Page 16: "Dizzy turns" in the elderly

Causes of BPPVCauses of BPPV

• Idiopathic (60%)Idiopathic (60%)– Advanced ageAdvanced age

• Post head trauma(20%)Post head trauma(20%)• Vestibular neuritis(9%)Vestibular neuritis(9%)• Others (11%) – mastoiditis, post surgery, Others (11%) – mastoiditis, post surgery,

ototoxicity)ototoxicity)

• Examination - normalExamination - normal

Page 17: "Dizzy turns" in the elderly

Dix-Hallpike manoeuvreDix-Hallpike manoeuvre

• Produces symptoms and torsional Produces symptoms and torsional nystagmusnystagmus

• Latent periodLatent period

• Lasts 10-20 secsLasts 10-20 secs

Page 18: "Dizzy turns" in the elderly

Epley manoeuvreEpley manoeuvre

• Repositioning treatmentRepositioning treatment

• Complete recovery 70 % after one Complete recovery 70 % after one sessionsession

• 90% after second treatment90% after second treatment

• [Self management :Brandt- Daroff [Self management :Brandt- Daroff exercises]exercises]

Page 19: "Dizzy turns" in the elderly

PRESYNCOPEPRESYNCOPE

• Usually implies diffuse temporary cerebral Usually implies diffuse temporary cerebral hypoperfusionhypoperfusion

• Usually cardiacUsually cardiac

• Patients describe a feeling of an impending faint Patients describe a feeling of an impending faint

• Ask whether syncope has ever occurredAsk whether syncope has ever occurred

• Do the symptoms only occur when upright?Do the symptoms only occur when upright?

• Are there any associated symptoms?Are there any associated symptoms?

• Any relation to drugs, meals, baths, elimination?Any relation to drugs, meals, baths, elimination?

Page 20: "Dizzy turns" in the elderly

DYSEQUILIBRIUMDYSEQUILIBRIUM(Multi-sensory deficit (Multi-sensory deficit syndrome)syndrome)• ImbalanceImbalance• Usually in pts with multiple medical Usually in pts with multiple medical

problems (commonly periph neuropathy, problems (commonly periph neuropathy, poor vision & hearing)poor vision & hearing)

• Usually felt in the lower limbs or trunkUsually felt in the lower limbs or trunk• No head symptomsNo head symptoms• Most prominent when walking or standingMost prominent when walking or standing• Reduced by lying or sittingReduced by lying or sitting• Usually of neuromuscular originUsually of neuromuscular origin• Additional effect in many of “psychosomatic Additional effect in many of “psychosomatic

overlay”. overlay”. • Fear of falling– reduced activity – worse Fear of falling– reduced activity – worse

balancebalance

Page 21: "Dizzy turns" in the elderly

OTHER DIZZINESSOTHER DIZZINESS

• Ask about anxiety or hyperventilation Ask about anxiety or hyperventilation symptomssymptoms

• Any relationship with visionAny relationship with vision

• Remember that several forms of Remember that several forms of dizziness may present togetherdizziness may present together

Page 22: "Dizzy turns" in the elderly

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

• Full general examination including Full general examination including vision and hearingvision and hearing

• Are they anaemic?Are they anaemic?

• Lying and standing BPLying and standing BP

• Slow or irregular pulseSlow or irregular pulse

• Heart murmursHeart murmurs

• Evidence of heart failure or infectionEvidence of heart failure or infection

Page 23: "Dizzy turns" in the elderly

NEUROLOGICAL EXAMNEUROLOGICAL EXAM

• Any evidence of cerebrovascular Any evidence of cerebrovascular disease?disease?

• Cerebellar signs?Cerebellar signs?

• Do they have Parkinsonism?Do they have Parkinsonism?

• Any signs of peripheral neuropathy?Any signs of peripheral neuropathy?

• Dix-Hallpike manoeuvreDix-Hallpike manoeuvre

Page 24: "Dizzy turns" in the elderly

INVESTIGATIONSINVESTIGATIONS

• UrinalysisUrinalysis

• Full blood count / viscosityFull blood count / viscosity

• ElectrolytesElectrolytes

• GlucoseGlucose

• Thyroid functionThyroid function

• B12 / FolateB12 / Folate

• ECGECG

Page 25: "Dizzy turns" in the elderly

FURTHER INVESTIGATIONSFURTHER INVESTIGATIONS

• 24hr / 7 day recording24hr / 7 day recording

• Tilt testingTilt testing

• Carotid sinus massageCarotid sinus massage

• EchocardiographyEchocardiography

• CT/MRI brainCT/MRI brain

Page 26: "Dizzy turns" in the elderly

MANAGEMENTMANAGEMENT

• Medication reviewMedication review

• Try to make a diagnosisTry to make a diagnosis

• Identify other risk factors and Identify other risk factors and contributing conditionscontributing conditions

• Correct visual impairmentCorrect visual impairment

• Improve muscle strengthImprove muscle strength

• Optimise Calcium and vitamin D storesOptimise Calcium and vitamin D stores

Page 27: "Dizzy turns" in the elderly

MANAGEMENTMANAGEMENT

• Optimise medication regimesOptimise medication regimes

• Consider gait mobility aidsConsider gait mobility aids

• Identify and treat psychological co-Identify and treat psychological co-morbiditiesmorbidities

• Vestibular exercises where Vestibular exercises where appropriateappropriate

(Cooksey-Cawthorne exercises)(Cooksey-Cawthorne exercises)

Page 28: "Dizzy turns" in the elderly

TAKE HOME MESSAGESTAKE HOME MESSAGES

• Always try to make a diagnosisAlways try to make a diagnosis

• Medication reviewMedication review

• Causes often multifactorialCauses often multifactorial

• Not all vertigo is Meniere’s diseaseNot all vertigo is Meniere’s disease

• Management orientated approach Management orientated approach often produces significant resultsoften produces significant results