“ DIZZY DO’S” IN THE   ELDERLY Dr Alastair Kerr Consultant Geriatrician 18/7/07
DIZZINESS <ul><li>Very common </li></ul><ul><li>30% of community dwelling elderly </li></ul><ul><li>More common in women t...
DIZZINESS  <ul><li>Can be frustrating due to non specific presentation </li></ul><ul><li>Research base is limited </li></u...
CAUSES OF DIZZINESS <ul><li>Broadly divided into four main categories </li></ul><ul><ul><li>1.Cardiovascular </li></ul></u...
CARDIOVASCULAR <ul><li>Postural Hypotension </li></ul><ul><li>Carotid Sinus Hypersensitivity </li></ul><ul><li>Vasovagal s...
PERIPHERAL VESTIBULAR DISORDERS <ul><li>BPPV </li></ul><ul><li>Vestibular neuronitis </li></ul><ul><li>Menieres disease </...
CENTRAL NEUROLOGICAL DISEASE <ul><li>Cerebrovascular Disease </li></ul><ul><ul><li>1. Subclavian Steal Syndrome </li></ul>...
OTHER CAUSES <ul><li>Medication </li></ul><ul><li>Haematological disorders </li></ul><ul><li>Metabolic conditions </li></u...
DRUGS CAUSING DIZZINESS <ul><li>Alcohol </li></ul><ul><li>Antidepressants </li></ul><ul><li>Anticonvulsants </li></ul><ul>...
Why is dizziness such a problem in the elderly? <ul><li>Balance depends on interactions between sensory and motor input an...
ASSESSMENT <ul><li>“What do you mean by dizzy ? “ </li></ul><ul><li>Classically there are four subtypes </li></ul><ul><ul>...
VERTIGO <ul><li>Clear description of subjective or objective motion </li></ul><ul><li>Peripheral vestibular disorders prod...
Meniere’s disease <ul><li>Tinnitus, deafness, vertigo, n & v </li></ul><ul><li>2/1000 people ; M = F </li></ul><ul><li>Fee...
Benign paroxysmal positional vertigo (BPPV) <ul><li>Commonest causes of vertigo </li></ul><ul><li>Due to otoconial debris ...
Frequency of complaints in BPPV <ul><li>Imbalance 57% </li></ul><ul><li>Vertigo 53% </li></ul><ul><li>Trouble walking 48% ...
Causes of BPPV <ul><li>Idiopathic (60%) </li></ul><ul><ul><li>Advanced age </li></ul></ul><ul><li>Post head trauma(20%) </...
Dix-Hallpike manoeuvre <ul><li>Produces symptoms and torsional nystagmus </li></ul><ul><li>Latent period </li></ul><ul><li...
Epley manoeuvre <ul><li>Repositioning treatment </li></ul><ul><li>Complete recovery 70 % after one session </li></ul><ul><...
PRESYNCOPE <ul><li>Usually implies diffuse temporary cerebral hypoperfusion </li></ul><ul><li>Usually cardiac </li></ul><u...
DYSEQUILIBRIUM (Multi-sensory deficit syndrome) <ul><li>Imbalance </li></ul><ul><li>Usually in pts with multiple medical p...
OTHER DIZZINESS <ul><li>Ask about anxiety or hyperventilation symptoms </li></ul><ul><li>Any relationship with vision </li...
PHYSICAL EXAMINATION <ul><li>Full general examination including vision and hearing </li></ul><ul><li>Are they anaemic? </l...
NEUROLOGICAL EXAM <ul><li>Any evidence of cerebrovascular disease? </li></ul><ul><li>Cerebellar signs? </li></ul><ul><li>D...
INVESTIGATIONS <ul><li>Urinalysis </li></ul><ul><li>Full blood count / viscosity </li></ul><ul><li>Electrolytes </li></ul>...
FURTHER INVESTIGATIONS <ul><li>24hr / 7 day recording </li></ul><ul><li>Tilt testing </li></ul><ul><li>Carotid sinus massa...
MANAGEMENT <ul><li>Medication review </li></ul><ul><li>Try to make a diagnosis </li></ul><ul><li>Identify other risk facto...
MANAGEMENT <ul><li>Optimise medication regimes </li></ul><ul><li>Consider gait mobility aids </li></ul><ul><li>Identify an...
TAKE HOME MESSAGES <ul><li>Always try to make a diagnosis </li></ul><ul><li>Medication review </li></ul><ul><li>Causes oft...
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"Dizzy turns" in the elderly

  1. 1. “ DIZZY DO’S” IN THE ELDERLY Dr Alastair Kerr Consultant Geriatrician 18/7/07
  2. 2. DIZZINESS <ul><li>Very common </li></ul><ul><li>30% of community dwelling elderly </li></ul><ul><li>More common in women than men </li></ul><ul><li>Causes often benign and self limiting BUT can be life threatening </li></ul><ul><li>Consequences can be serious </li></ul><ul><li>Needs a formal approach to diagnosis & Rx </li></ul>
  3. 3. DIZZINESS <ul><li>Can be frustrating due to non specific presentation </li></ul><ul><li>Research base is limited </li></ul><ul><li>Most studies done on young patients </li></ul><ul><ul><li>Peripheral vestibular disease and psychological disorders predominate </li></ul></ul><ul><li>In elderly much more treatable conditions </li></ul>
  4. 4. CAUSES OF DIZZINESS <ul><li>Broadly divided into four main categories </li></ul><ul><ul><li>1.Cardiovascular </li></ul></ul><ul><ul><li>2.Peripheral vestibular disorders </li></ul></ul><ul><ul><li>3.Central neurological disorders </li></ul></ul><ul><ul><li>4.Others, including medication </li></ul></ul><ul><li>NB often several overlapping causes </li></ul>
  5. 5. CARDIOVASCULAR <ul><li>Postural Hypotension </li></ul><ul><li>Carotid Sinus Hypersensitivity </li></ul><ul><li>Vasovagal syncope </li></ul><ul><li>Arrythmia </li></ul><ul><li>Mechanical outflow obstruction </li></ul>
  6. 6. PERIPHERAL VESTIBULAR DISORDERS <ul><li>BPPV </li></ul><ul><li>Vestibular neuronitis </li></ul><ul><li>Menieres disease </li></ul><ul><li>Cholesteatoma </li></ul><ul><li>Ramsay Hunt Syndrome </li></ul>
  7. 7. CENTRAL NEUROLOGICAL DISEASE <ul><li>Cerebrovascular Disease </li></ul><ul><ul><li>1. Subclavian Steal Syndrome </li></ul></ul><ul><ul><li>2. Wallenbergs Syndrome </li></ul></ul><ul><ul><li>3. Vasculitides </li></ul></ul><ul><li>Cerebellar disease </li></ul><ul><li>Neurodegenerative eg PD </li></ul><ul><li>[Vertebrobasilar insufficiency does NOT exist] </li></ul>
  8. 8. OTHER CAUSES <ul><li>Medication </li></ul><ul><li>Haematological disorders </li></ul><ul><li>Metabolic conditions </li></ul><ul><li>Infections </li></ul><ul><li>Trauma </li></ul><ul><li>Visual impairment </li></ul><ul><li>Psychiatric disease </li></ul>
  9. 9. DRUGS CAUSING DIZZINESS <ul><li>Alcohol </li></ul><ul><li>Antidepressants </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>Analgesics </li></ul><ul><li>Antianginals / antiarrythmics </li></ul><ul><li>Antibacterials </li></ul><ul><li>Antipsychotics </li></ul><ul><li>Stemetil / Betahistine </li></ul>
  10. 10. Why is dizziness such a problem in the elderly? <ul><li>Balance depends on interactions between sensory and motor input and CNS integration </li></ul><ul><li>Dysfunction of any of these components leads to dizziness </li></ul><ul><li>Ageing is associated with changes in vision, proprioception, vestibular function and neuronal loss in key areas </li></ul>
  11. 11. ASSESSMENT <ul><li>“What do you mean by dizzy ? “ </li></ul><ul><li>Classically there are four subtypes </li></ul><ul><ul><li>1.Vertigo </li></ul></ul><ul><ul><li>2.Presyncope </li></ul></ul><ul><ul><li>3.Dysequilibrium </li></ul></ul><ul><ul><li>4.Other dizziness </li></ul></ul>
  12. 12. VERTIGO <ul><li>Clear description of subjective or objective motion </li></ul><ul><li>Peripheral vestibular disorders produce acute, unprecipitated short lived episodes with nausea and vomiting </li></ul><ul><li>CNS disorders are usually insidious and progressive </li></ul><ul><li>Cranial nerve involvement suggests brain stem origin </li></ul>
  13. 13. Meniere’s disease <ul><li>Tinnitus, deafness, vertigo, n & v </li></ul><ul><li>2/1000 people ; M = F </li></ul><ul><li>Feeling of fullness/pressure in ear </li></ul><ul><li>Dilatation of endolymph system ? cause </li></ul><ul><li>Lasts several hours </li></ul><ul><li>Can occur in clusters </li></ul><ul><li>Can be years between attacks </li></ul><ul><li>No cure </li></ul><ul><li>Rx: Betahistine/Stemetil for acute attacks </li></ul>
  14. 14. Benign paroxysmal positional vertigo (BPPV) <ul><li>Commonest causes of vertigo </li></ul><ul><li>Due to otoconial debris in semicircular canals </li></ul><ul><li>Increases with age ; female>male </li></ul><ul><li>Brief episodes (<1 min) vertigo (+/- imbalance) with specific head positions-turning in bed,sitting up,looking up </li></ul><ul><li>Episodic lasting few days – months </li></ul><ul><li>Asymptomatic intervals months - yrs </li></ul>
  15. 15. Frequency of complaints in BPPV <ul><li>Imbalance 57% </li></ul><ul><li>Vertigo 53% </li></ul><ul><li>Trouble walking 48% </li></ul><ul><li>Light headed 42% </li></ul><ul><li>Nausea 35% </li></ul><ul><li>Sense of tilt 24% </li></ul><ul><li>Sense of floating 22% </li></ul><ul><li>Blurred vision 15% </li></ul><ul><li>Jumping vision 13% </li></ul>
  16. 16. Causes of BPPV <ul><li>Idiopathic (60%) </li></ul><ul><ul><li>Advanced age </li></ul></ul><ul><li>Post head trauma(20%) </li></ul><ul><li>Vestibular neuritis(9%) </li></ul><ul><li>Others (11%) – mastoiditis, post surgery, ototoxicity) </li></ul><ul><li>Examination - normal </li></ul>
  17. 17. Dix-Hallpike manoeuvre <ul><li>Produces symptoms and torsional nystagmus </li></ul><ul><li>Latent period </li></ul><ul><li>Lasts 10-20 secs </li></ul>
  18. 18. Epley manoeuvre <ul><li>Repositioning treatment </li></ul><ul><li>Complete recovery 70 % after one session </li></ul><ul><li>90% after second treatment </li></ul><ul><li>[Self management :Brandt- Daroff exercises] </li></ul>
  19. 19. PRESYNCOPE <ul><li>Usually implies diffuse temporary cerebral hypoperfusion </li></ul><ul><li>Usually cardiac </li></ul><ul><li>Patients describe a feeling of an impending faint </li></ul><ul><li>Ask whether syncope has ever occurred </li></ul><ul><li>Do the symptoms only occur when upright? </li></ul><ul><li>Are there any associated symptoms? </li></ul><ul><li>Any relation to drugs, meals, baths, elimination? </li></ul>
  20. 20. DYSEQUILIBRIUM (Multi-sensory deficit syndrome) <ul><li>Imbalance </li></ul><ul><li>Usually in pts with multiple medical problems (commonly periph neuropathy, poor vision & hearing) </li></ul><ul><li>Usually felt in the lower limbs or trunk </li></ul><ul><li>No head symptoms </li></ul><ul><li>Most prominent when walking or standing </li></ul><ul><li>Reduced by lying or sitting </li></ul><ul><li>Usually of neuromuscular origin </li></ul><ul><li>Additional effect in many of “psychosomatic overlay”. </li></ul><ul><li>Fear of falling– reduced activity – worse balance </li></ul>
  21. 21. OTHER DIZZINESS <ul><li>Ask about anxiety or hyperventilation symptoms </li></ul><ul><li>Any relationship with vision </li></ul><ul><li>Remember that several forms of dizziness may present together </li></ul>
  22. 22. PHYSICAL EXAMINATION <ul><li>Full general examination including vision and hearing </li></ul><ul><li>Are they anaemic? </li></ul><ul><li>Lying and standing BP </li></ul><ul><li>Slow or irregular pulse </li></ul><ul><li>Heart murmurs </li></ul><ul><li>Evidence of heart failure or infection </li></ul>
  23. 23. NEUROLOGICAL EXAM <ul><li>Any evidence of cerebrovascular disease? </li></ul><ul><li>Cerebellar signs? </li></ul><ul><li>Do they have Parkinsonism? </li></ul><ul><li>Any signs of peripheral neuropathy? </li></ul><ul><li>Dix-Hallpike manoeuvre </li></ul>
  24. 24. INVESTIGATIONS <ul><li>Urinalysis </li></ul><ul><li>Full blood count / viscosity </li></ul><ul><li>Electrolytes </li></ul><ul><li>Glucose </li></ul><ul><li>Thyroid function </li></ul><ul><li>B12 / Folate </li></ul><ul><li>ECG </li></ul>
  25. 25. FURTHER INVESTIGATIONS <ul><li>24hr / 7 day recording </li></ul><ul><li>Tilt testing </li></ul><ul><li>Carotid sinus massage </li></ul><ul><li>Echocardiography </li></ul><ul><li>CT/MRI brain </li></ul>
  26. 26. MANAGEMENT <ul><li>Medication review </li></ul><ul><li>Try to make a diagnosis </li></ul><ul><li>Identify other risk factors and contributing conditions </li></ul><ul><li>Correct visual impairment </li></ul><ul><li>Improve muscle strength </li></ul><ul><li>Optimise Calcium and vitamin D stores </li></ul>
  27. 27. MANAGEMENT <ul><li>Optimise medication regimes </li></ul><ul><li>Consider gait mobility aids </li></ul><ul><li>Identify and treat psychological co-morbidities </li></ul><ul><li>Vestibular exercises where appropriate </li></ul><ul><li>(Cooksey-Cawthorne exercises) </li></ul>
  28. 28. TAKE HOME MESSAGES <ul><li>Always try to make a diagnosis </li></ul><ul><li>Medication review </li></ul><ul><li>Causes often multifactorial </li></ul><ul><li>Not all vertigo is Meniere’s disease </li></ul><ul><li>Management orientated approach often produces significant results </li></ul>
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