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					Dizziness: Diagnostics
Background


     1.   ICD-9 Code(s)
     2.   Definition
               o     Difficult to define due to its nonspecific and variable symptoms
               o     Various abnormal sensations relating to perception of the body's relationship to space
     3.   General information
               o     Broad differential diagnosis
               o     Etiology is often multifactorial 7,10,11
               o     Algorithmic methods less helpful due to complexity of presentation and descriptions of dizziness quality inconsistent
                     and unreliable2, 27


Pathophysiology


     1.   Pathology of disease
               o     Dizziness is a symptom of several underlying conditions 3,6,17, 23,25, 28
               o     Mechanism of causation unknown10,11
     2.   Incidence, prevalence
               o     Most common complaint experienced by older adults1,9,23
               o     >8 million outpatient visits per year
               o      15-30% of elderly patients seek medical evaluation for dizziness at some point
     3.   Risk factors
               o     Multi factorial etiology (see Table 1), possibly a geriatric syndrome5, 6, 8
               o     Recent studies suggest cardiovascular disease, peripheral vestibular disease and adverse drug effect to be major
                     contributory cause of dizziness in the elderly.24
     4.   Morbidity, mortality
               o     May lead to falls and injuries19
                                Hip fractures
               o     Pre-syncopal and syncopal conditions suggest underlying cardiac cause


Diagnostics


     1.   History
               o     Practical "symptom or complaint-oriented" approach
               o     It is useful to divide dizziness into ‘episodic’ or ‘chronic persistent’
               o     4 subcategories:
                                Vertigo
                                Presyncope
                                Disequilibrium disorder
                                Lightheadedness
               o     Common causes listed in Table 1
               o     Open ended complaint-specific questions:
                                What type of dizziness does the patient have?
                                How old is the patient?
                                          Elderly patients have multifactorial dizziness
                                What is the relation of dizziness to position or motion?
                                Is dizziness recurrent?
                                What is the course of dizziness?
                                          Abrupt vs. gradual onset
                                          Duration of symptoms
                                          Exacerbating and relieving factors
                                          Situations provoking psychiatric disorders
                                                    Anxiety
                                                    Panic
                                                    Phobias
                                          Associated features
                                          Falls & injuries
                                What are the past medical problems?
                                          Particularly orthostasis
                                          Coronary ischemic events
                                          Hypoglycemia
                                          Transient ischemic attacks
                                What are the current medications?
          o     Dizziness sub-categories:
                         Vertigo
                                    False sense of motion, as if body or environment is moving
                                    Usually spinning in one direction
                         Presyncope
                                    Used to describe experience of near-fainting
                                    May be heralded by dimming of vision or sounds in the ears
                         Disequilibrium
                                    Signifies loss of balance or a sense of unsteadiness
                                    Primarily involving the lower extremities
                         Lightheadedness
                                    Psychogenic
                                    Vague group of symptoms
                                    Sensations often associated with other somatic Sx (headache)
                         Multiple factor / mixed dizziness of elderly
                                    Could be the cause of some non-specific Sx
                                    Possible factor studies are:
                                             Anxiety trait
                                             Depressive Sx
                                             Impaired balance
                                             History of myocardial infarction
                                             Postural hypotension
                                             Taking five or more medications
                                             Impaired hearing
2.   Physical exam
          o     Vision
          o     Hearing
          o     Pulses
          o     Orthostatic hypotension
          o     Affect
          o     Cardiac examination for evaluation of arrhythmias and murmurs
          o     Important tests:
                         Dix-Hallpike maneuver
                         Seated head turn
                                    For qualitative vestibular function
                                    Performed by moving the head rapidly by 45°
                                             In brief, small-amplitude
                                             Thrust head to one side
                                             Patient's eyes focus on examiner's nose
                                    Evaluates integrity of vestibular-ocular control
          o     Neurological exam
                         May reveal signs of particular condition
                         May also eliminate a condition from the DDx
                         Romberg test
                                    Stand with heels together with eyes open and then closed
                                    Helps to evaluate individuals with vestibular and/or spinal proprioceptive problems
                         Timed Get Up and Go test
                                    Another useful test to assess gait and balance disorder
                                    Also for reproducibility of Sx of dizziness during the test (Table 3)
3.   Diagnostic tests
          o     Lab evaluation:
                         Helps in diagnosing about 3% of dizziness cases in a primary care setting
                         Complete blood count
                         Chest x-rays
          o     Diagnostic imaging
                         CNS imaging including brain and neck
                         CT or MRI scans for:
                                             Ischemic disease
                                             Neuro-degenerative changes
                                             Space occupying lesions
                                    EEG
                                    Brainstem Auditory Evoked Response
                                             For suspected seizure disorder
                                             May help if clinically indicated
                                        Evidence suggests that these tests show abnormalities
                                                  Only in patients already suspected of having CNS disease process on physical exam
               o     Other studies
                              Otolaryngology investigations are rarely diagnostic in the elderly
                                        Though frequently used
                              Audiometry is recommended for patients with dizziness and hearing complaints
                              Utility of Electronystagmography (ENG)
                                        Unknown in dizzy patients without vertigo or nystagmus
               o     Cardiovascular tests:
                              EKG
                                        In a primary care study showed no changes
                                        In emergency rooms revealed attacks of:
                                                  SVT
                                                  Paroxysmal AF
                              Echocardiogram- if there is a new heart murmur, syncope or evidence of structural organic heart disease   15


                              Carotid doppler
                                        May have low diagnostic yield; has not been evaluated for dizziness15
                              Head up tilt testing
                                        May be helpful in investigating selected cases of neuro-cardiogenic pre-syncopal episodes
               o     Psychiatric screening
                              For anxiety and depression
                              Alcohol use may be evident in patients with:
                                        Multiple physical complaints
                                        Apparent lack of a physical etiology
                              Hyperventilation tests are usually not done in the elderly
                                        May be useful in the young for:
                                                  Eliciting symptoms
                                                  Therapeutic role
               o     Other scales used for research or to establish Dx
                              Dizziness Handicap Inventory12,14 (Table 4)
                              Others:
                                        Vertigo-Dizziness-Imbalance Questionnaire16
                                        UCLA Dizziness Questionnaire


Differential Diagnosis


      1.   Dizziness and syncope
               o     Good history will help you distinguish the two
               o     Usually underlying cardiovascular dz in syncope
               o     May be multifactorial:
                              Syncope or "passing-out"
                                        Carries a higher mortality compared to patients with dizziness
                              Dizziness i.e., "fainting" episodes
      2.   Extensive DDx
               o     Vertigo
                                        Commonly due to vestibular disorders (but may be a manifestation of cardiovascular disease 27 ):
                                                           Peripheral
                                                           Central
                              Peripheral disorders
                                        40-50% involving the inner ear or eighth cranial nerve
                                        Result in dizziness (Table 2)
                                        Common peripheral vestibular disorders:
                                                  Benign positional vertigo
                                                  Vestibular neuronitis
                                                  Labyrinthitis
                                                  Meniere's disease
                              Central vestibular disorders
                                        10-20% result in vertical nystagmus and the myriad of symptoms associated with:
                                                  Cerebrovascular dz
                                                  Tumors
                                                  Demyelinating dz
                                                  Migraines
                                                  Seizures
                                                    Multiple sclerosis
                                                    Other CNS dz
                             Psychological disorders
                                         15%
                                         Disorders in which patients commonly experience a sensation of:
                                                    Lightheadedness
                                                    Anxiety
                                                    Somatization
                                                    Depression
                                         Panic disorder and psychogenic hyperventilation are also commonly associated with:
                                                    Chronic
                                                    Recurrent episodes of dizziness
               o     Presyncope
                             25%
                             Number of etiologies
                                         Metabolic and cardiovascular disorders
                                                    Such as diabetes
                                         History of ischemic heart disease
                                         Postural hypotension
                                         Seizures
                             Usually related to global brain deficiency of blood or nutrients
                                         Rather than a focal event suggesting cerebral circulatory disturbances as the predominant cause
                                         If presyncopal event abrupt (regardless of position), consider cardiovascular origin
                                                    Arrhythmia or ischemic event
               o     Disequilibrium disorder
                             Refers to gait and balance difficulties
                             A feeling of unsteadiness with a clear head
                             May cause chronic dizziness from disequilibrium order:
                                         Presbystasis
                                                    Interplay of dizziness with age related physiologic changes
                                         Accumulated impairments of musculoskeletal disorders
                                         Cervical spondylosis
                                         Peripheral neuropathy
                                         Parkinson's disease states
                                         Visual impairments
                                         Role of polypharmacy




Dizziness: Therapeutics
Acute Treatment


     1.   First address possible underlying conditions, then
               o    Focus on maximizing function
     2.   General measures:
               o     Complete medication review
               o     Optimize hydration
               o     Ensure adequate sleep
               o     Encourage physical activity4
                             "Out of bed and eyes open" dictum
     3.   Specific measures
               o     Benign Positional Vertigo
                             Immensely helpful are the vestibular rehabilitation program or canalith repositioning maneuver18, 26,27, 29
                                         On the basis of habituation for resolution of symptoms
                             Epley's and other particle repositioning maneuvers
                                         May provide prompt relief of symptoms
               o     Vestibulocochlear disorders
                             Require examination and removal of cerumen
                             Symptomatic management of Meniere's disease
                             Use of diuretics
               o     Orthostatic hypotension
                             Responds to the use of TED compression stockings
                       Increase in salt intake
                       Cardiovascular medication reduction or
                       Dosage adjustment
                       Reconditioning exercises
                       Slow and careful rising
                       Use of medications:
                                   Fludrocortisone
                                   Midodrine
         o     Postprandial hypotension
                       May respond to:
                                   Consumption of small meals
                                   Use of caffeine
                                   Increased fluids with meals
                                   Physical activity after meals
         o     Cardiac dysfunction
                       Particularly arrhythmias
                       Should be treated with antiarrhythmics
         o     Vertebrobasilar insufficiency
                       Improved by controlling hypertension
                       Use of anticoagulants
                       Aspirin
         o     Cervical spondylosis
                       Symptoms may be improved by use of collar
                       Exercises
                       Physical therapy
         o     Psychogenic dizziness
                       May be due to depression
                       Anxiety
                       Panic attacks
                       Situational factors
                       Other forms of psychiatric disorders
                       Antidepressant treatment
                                   Risks and benefit of use should be assessed
                                   Both may cause dizziness:
                                              TCAs
                                              SSRIs
                       SSRI
                                   Preferred meds for depression in elderly
                                   While evaluating clinical response to Tx of psychiatric disorders
                                   Good dictum to follow in older patients is by:
                                              "Starting low and going slow"
         o     Disequilibrium and balance disorder
                       Requires assessment of many sensorimotor deficits
                                   Consider discontinuation of medications
                                              Alcohol
                                   Evaluation of visual deficits
                                              Cataract
                                   Use of hearing aid
                                   Footwear
                                              Assistive devices
                                   Environmental modification
                       Home balance and gait training or head and neck exercises
                                   Shown to be effective
                                   Supervised by physical therapist
         o     Medications for vestibular suppression may reduce nausea
                       Meclizine
                       Promethazine
         o     Severe vertigo may be helped by the use of
                       Lorazepam 0.5mg oral bid or tid
                       If needed diazepam 1mg oral bid
         o     Scopolamine and other agents are also sometimes used for symptomatic control
                     Not recommended for use in elderly due to anticholinergic side-effects
4.   Further management (24 hrs)
         o     May include critical complications to watch for
                 o     Medications for vestibular suppression
                                 Delay central vestibular compensation and reprocessing
                                 Therefore only short-term (72-hours) use of these agents is recommended
                                 Indicated in extreme cases of dizziness associated with:
                                          Vertigo
                                          Nausea
                                          Balance problems
      5.    Long-term management
                 o     In 10% no apparent cause on initial presentation
                 o     Careful follow-up should be considered
                 o     Note for appearance of new neurological signs and cardiac symptoms


Follow-Up


      1.    Return to office
                 o     Time frame for return visit: depends on the impact on social and physical functioning
                 o     Recurrent dizziness usually has less serious underlying causes
                 o     Earlier follow-up for new onset dizziness
                                 Where the cause of dizziness is not readily apparent after clinical examination and laboratory tests
      2.    Refer to specialist
                 o     Dizziness associated with vertigo
                 o     Neurological signs and cardiac symptoms


Admit to Hospital


             For first episode of dizziness with syncope and if:


                 o     Fever and other underlying infections
                 o     Presence of neurological signs and symptoms or cardiac symptoms
                 o     History of exposure to poisons or toxins, for example, carbon monoxide poisoning
                 o     Gastrointestinal bleeding


Prognosis


      1.    Chronic recurrent non-specific dizziness has a good prognosis and no increase in mortality if the first episode is investigated to
              rule out any critical illness13
      2.    In many cases non-specific dizziness symptoms improve with:
                 o     General exercise
                 o     Maintenance of hydration and nutrition
                 o     Sleep
                 o     Minimizing CNS medications



Dizziness: Tables
Diagnostics
Therapeutics
See also Dizziness & Vertigo


           Table 1 - Usual Causes of Dizziness and Their 'Symptom-Presentation'
                                                                                             17


           Table 2 - Causes and Features of Nystagmus
           Table 3 - Timed 'Get Up and Go' Test for Functional Assessment in Older Adults             20, 21


           Table 4 - Dizziness Handicap Inventory
                                                          12, 14




Table 1 - Usual Causes of Dizziness and Their 'Symptom-Presentation'


      1.    Vertigo
                 o     Peripheral vestibulopathy in 50% cases
                 o     Benign positional vertigo (BPPV)
                 o     Meniere's Disease
                 o     Labyrinthitis
                 o     Vestibular Neuronitis
                 o     Central cause
                                 Tumor
                                   Subdural
                                   Demyelination
                                   Neurodegenerative
      2.   Pre-syncope
                o       Orthostatic hypotension
                o       Neurocardiogenic syncope
                o       Situational
                o       Organic heart disease
                o       Arrhythmias
                o       Carotid sinus disease
                o       Seizures
                o       Hypoglycemia
                o      Transient ischemic attacks
      3.   Disequilibrium
                o       Balance & gait disorder
                o       Sensorimotor dysfunction
                o       Neurodegenerative disorders of CNS
                o       Mixed CNS diseases
                                   Ischemic
                                   Degenerative
                o    Presbystasis
      4.   Psychogenic
                o       Anxiety
                o       Depression
                o       Panic disorder
                o       Hyperventilation
                o      Agoraphobia
      5.   Multiple factors etiology or combination in the elderly of
                o       Anxiety trait
                o       Depressive symptoms
                o       Impaired balance
                o       History of myocardial infarction
                o       Postural hypotension
                o       Use of five or more medications
                o       Impaired hearing


Table 2 - Causes and Features of Nystagmus


      1.   Central
                o       Multidirectional
                o       Gaze-dependent
                o       Vertical component
                o       Not suppressed by visual fixation
                o       Non- fatigable
      2.   Peripheral
                o       Unidirectional
                o       Gaze-independent
                o       No vertical component
                o       Suppressed by visual fixation
                o       Fatigable


Table 3 - Timed 'Get Up and Go' Test for Functional Assessment in Older Adults


      1.   Simple test of observing a person stand up from a chair
                o       Walk 10 feet
                o       Turn around
                o       Walk back
                o       Sit down again
                                   Correlates with activities of daily living (ADLs)
                                   Normal person takes < 10 seconds to complete the task
                                   Note:
                                              Use of hands
                                              Staggering
                                              Unsteadiness
                                   Gives quantitative and qualitative information
Table 4 - Dizziness Handicap Inventory


      1.    25 items to assess functional, emotional and physical impact
      2.    The scale is self-administered
      3.    To each item, the following scores can be assigned:
                 o     0 - No
                 o     2 - Sometimes
                 o     4 - Yes
                 o     Patient is asked to answer each question as it pertains to dizziness or unsteadiness problems only
                 o     F,P, or E labels are assigned:
                                Functional (F)
                                Physical (P)
                                Emotional (E) aspects of dizziness, respectively
                 o     In the DHlsf, items are scored:
                                0 = yes and no
                 o     Higher score is assigned to a better feeling or functioning.
                 o    Patients are requested to provide answer by considering their condition during the last month
      4.    Questionnaire:
                1.    Does looking up increase your problem? (P)
                2.    Because of your problem, do you feel frustrated? (E)
                3.    Because of your problem, do you restrict your travel for business or recreation? (F)
                4.    Does walking down the aisle of a supermarket increase your problem? (P)
                5.    Because of your problem, do you have difficulty getting into or out of bed? (E)
                6.    Does your problem significantly restrict your participation in social activities (F)
                                Such as going out to dinner
                                Going to the movies
                                Dancing
                               Going to parties?
                 7.    Because of your problem, do you have difficulty reading? (F)
                 8.    Does performing more ambitious activities increase your problems? Such as: (P)
                                Sports
                                Dancing
                                Household chores
                                         Sweeping or putting dishes away
                 9.    Because of your problem, are you afraid to leave your home without having someone accompany you? (E)
                 10.   Because of your problem, have you been embarrassed in front of others? (E)
                 11.   Do quick movements of your head increase your problem? (P)
                 12.   Because of your problem, do you avoid heights? (F)
                 13.   Does turning over in bed increase your problem? (P)
                 14.   Because of your problem, is it difficult for you to do strenuous homework or yardwork? (F)
                 15.   Because of your problem, are you afraid people may think you are intoxicated? (E)
                 16.   Because of your problem, is it difficult for you to go for a walk by yourself? (F)
                 17.   Does walking down a sidewalk increase your problem? (P)
                 18.   Because of your problem, is it difficult for you to concentrate? (E)
                 19.   Because of your problem, is it difficult for you to walk around your house in the dark? (F)
                 20.   Because of your problem, are you afraid to stay home alone? (E)
                 21.   Because of your problem, do you feel handicapped? (E)
                 22.   Has your problem placed stress on your relationships with members of your family or friends? (E)
                 23.   Because of your problem, are you depressed? (E)
                 24.   Does your problem interfere with your job or household responsibilities? (F)
                 25.   Does bending over increase your problem? (P)


References


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      2.     Coatesworth AP. Assessment and treatment of dizziness. J Neurol Neurosurg Psychiatry. 2000 Nov, 69(5) 706
      3.     Plum F, Mac-Gowan D. The causes and treatment of Dizziness. Primary Care Report1995, vol 1(10), 76-86
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             primary care. British Journal of General Practice, 1998, 48, 1136-1140
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             47:12-17,1999
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Author: Arvind Modawal, MD, MPH Department of Family Medicine, University of
Cincinnati

Editor: Melissa M. Stiles, MD University of Wisconsin-Madison, Madison, WI

				
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