Dizziness in Older Adults Flashcards
Dizziness occurs in up to ____ of older adults
1/3
Prevalence of dizziness increases ___% for every 5 years of age
10
___% of cases of dizziness have multiple causes
> 50
Classification by symptoms: vertigo
Rotational “spinning” sensation
Classification by symptoms: presyncope
Sensation of impending faint
Classification by symptoms: disequilibrium
Feeling of imbalance on standing or walking
Most common types of dizziness presents with…..
Mixed symptoms
What is BPPV?
Episodic, inner ear disorder
What event precipitates BPPV?
Changes in position (e.g. turning, rolling over)
How long do episodes of BPPV last?
5-15 seconds
Pathophysiology of BPPV
Changes in endolymphatic pressure during head movements resulting from dislodged otoconia in semilunar canal
What is meniere disease?
Idiopathic inner ear disorder
Clinical presentation of meniere disease:
Repeated episode of tinnitus
Functional hearing loss w/ sensation of fullness in ears
Severe vertigo
Progressive SNHL
Brain tumors are found in __% of dizzy patients
<1
Most common tumor associated with dizziness
Acoustic neuroma
Symptoms of acoustic neuroma
Unilateral tinnitus & HL predominate (not dizziness)
Bilateral cochlear symptoms (tinnitus, hearing loss) in older persons usually represents
Presbycusis
What is presyncope?
Sensation of near-fainting
Cardiac causes of presyncope
Electrical -> tachy or bradyarrythmias
Structural -> aortic outflow obstruction
Vascular causes of presyncope
Orthostatic hypotension
Vagal stimulation
Postural causes of presyncope
+/- orthostatic hypotension
What is disequilibrium?
Sensation of being unsteady when standing or walking
Factors that contribute to disequilibrium
- Propioceptive disorder
- Visual problems
- MSK disorders
- Gait disorders
The term ___________ is reserved for patients who do not experience vertigo, presyncope or disequilibrium
Lightheadedness
Two most prominent considerations in the context of lightheadedness
Psychiatric causes (depression, anxiety, somatoform disorders) Idiopathic
Use of >___ medications = dizziness risk factor
3
Certain drugs frequently implicated in dizziness
- Those that cause orthostasis or CNS effects
- CV or anti-HTN drugs
- Psychotropic medicaitons
- AGs
- NSAIDs
Characteristics of dizziness in older adults
- Resolves in days to several months
- Chronic or recurrent
- Multifactorial common
4 important history elements
- If dizziness is characterized by spinning, fainting, falling
- If posture affects sx
- If there are other sx ass. w/ dizziness (esp. focal neurological)
- Medications
Components of PE
- Check orthostatics
- Check hearing (gross first)
- Perform provocative test of vestibular system (Head-thrust, Fukuda stepping, Dix-Hallpike)
- Cardiac exam
- Observe balance & gait (Get up & go)
Head-thrust test
Pt. fixates on examiners nose, examiner rotates head rapidly about degrees to left or right
(-) = pt. eyes remain fixated on nose
(+) = pt. eyes move away from target along with head
Fukuda stepping test
Pt. stands in circle on floor, asked to walk when blindfolded w/ outstretched arms, assessor determine s body sway
(+) = >30 degree sway to one side = unilateral vestibular lesion or acoustic neuroma
Diagnostic evaluation of dizziness
- Labs: HCT, CMP, vitamin B12, folic acid, TSH
- Audiometry (esp. if cochlear sx present)
- Vestibular testing (refer to ENT)
- Neuroimaging (CT, MRI)
- ECG - if cardiac cause suspected
- Tilt-table test in select pt. w/ postural hypotension or syncope
BPPV treatment
Epley’s maneuver
Meniere disease treatment
Salt restriction, caffeine restriction, diuretics
Vestibular suppressants during acute attacks (e.g. Meclizine)
Treatment of ototoxicity d/t medication
D/C med, substitute meds, reduce dosage
Treatment of presyncope w/ cardiac cause
Treat CAUSE
- Proper hydration
- Slow rising from sitting/laying
- PT/OT
- Pharm therapy for orthostatic hypotension, autonomic dysfunction
What med treats orthostatic hypotension?
Fludrocortisone
What med treats autonomic dysfunction?
Midodrine
Treatment of posprandial hypotension
- Frequent small meals
- Avoid exertion after meals
- Slow rising from sitting position
- Avoid anti-HTN @ or near mealtime
Treatment of vertebrobasilar ischemia and/or cerebellar infarcts/hemorrhages
Low dose ASA, clopidogrel or ER dypyridamole; rehabilitation
Treatment of acoustic neuroma
Surgery
Treatment of PD
Drug therapy, rehab
Treatment of peripheral neuropathy
Treat underlying disease
Treatment of cervical spine degenerative arthritis, spondylosis
Cervical or vestibular rehabilitation; C collar; +/- surgery
What is orthostatic hypotension?
Decrease is systolic BP of 20mmHG or decrease in diastolic BP of 10mmHG within 3 minutes of standing c/t sitting or supine
It is normal for both systolic & diastolic BP to decrease __mmHG upon standing
~10
Causes of orthostatic hypotension
- Inadequate intravascular volume
- ANS dysfunction
- Decreased venous return
- Inability to increase CO In response to postural changes
Clinical presentation of orthostatic hypotension
- Acute or chronic
- Lightheadedness
- Blurred vision
- Dizziness
- Weakness/fatigue
- Syncope
Indications for tilt table test
- High probability of orthostatic hypotension despite an initial negative evaluation
- Patients with motor impairment that can’t have vital signs taken while standing
- Monitor course of autonomic disorder & its response to therapy
Acute treatment of orthostatic hypotension
TX UNDERLYING CAUSE
e.g. transfuse, hydrate, D/C offending meds
Chronic nonpharm treatment of orthostatic hypotension
EDUCATE, SET GOALS
- Remove offending meds or take @ bedtime
- Avoid large carb meals
- Limit alcohol
- Ensure adequate hydration, give water bolus if symptomatic
- Supplement sodium (in those who can tolerate it)
- LE compression stockings
- Exercise & therapy
Chronic pharm treatment of orthostatic hypotension
Fludrocortisone (1st line)
Midodrine
Pyridostigmine
