Dizziness

Introduction
 Most common reason for elderly >75 years of age visits
 Not a diagnosis, but is a complain
 Differential diagnosis of dizziness is challenging:
Cause is unexplained in 40-80% of cases
Manifestation of life-threatening diseases to normal basic physiologic responses
No diagnostic confirmatory tools available

Epidemiology
 Affect 20-30% of the generation population:
Average age: mid 40’s
2-3x more common in women
 High incidence of psychiatric comorbidities

Classification

History and physical examination

 History:
Onset, duration, number of episodes, triggers, associated auditory and neurologic signs
TiTrATE: Timing, Trigger, And Target Examination
 If not due to vertigo, investigate other medical conditions (e.g., arrhythmia, diabetes)
 Physical examination:
Ocular examination
Otologic examination
Blood Pressure
Neurologic examination
Benign Paroxysmal Positional Vertigo (BPPV)
Optional: CBC, CMP, ECG, CT, MRI
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Important notes during examination:

 “Dizziness” is such an ambiguous term to start with by the patient- “Doctor, I am so dizzy!”
 The patients should be encouraged to describe their symptoms without using the word “dizziness”.
 Doctors should try to understand and record the symptoms according to patient’s description and
again avoid the word dizziness.
General Classification and Treatment
 Vertigo
Introduction
 Spinning sensation
 Social history: Alcohol, nicotine, caffeine, sexual histories

Classification of Vertigo
 Peripheral vertigo: Problem in the part of the inner ear that controls balance.
 Central vertigo: Problem in the vestibular structures in the central nervous system.

Social history: Alcohol, nicotine,

caffeine, sexual histories

Drug Induced Causes

Treatment
 Treating underlying causes
(e.g., anemia, hypotension, thyroid dysfunction, glucose levels, pregnancy, migraine, anxiety)

 Orthostatic hypotension (+ blood pressure monitoring)

1. Midodrine
Not taken within 4 hours of bedtime or when lying down
Adverse reactions: Urinary frequencies, urinary retention, and skin rash
2. Fludrocortisone
Monitor potassium level and heart failure symptoms
Adverse reactions: Edema, hyperglycemia, muscle weakness

 Psychogenic dizziness
Associate with nausea, SOB, chest tightness, paresthesia
Benzodiazepines as short-term treatment

 Vestibular system suppressants (<1 week, ideally <48 hours)

o Anticholinergics – Diphenhydramine, betahistine
o Benzodiazepines
o Antiemetics – Promethazine, metoclopramide

 Physical therapy, vestibular exercises

A&E Clinical Guideline No. 19 - Guideline on Approach & Management of Patient with Dizziness