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)
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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