DIZZINESS IN AN OLDER ADULT

10/12/05

MARY JO WILLIS MS, APRN, BC

CLINICAL PROFESSOR
NURSE PRACTITIONER
 I have no financial interest to
report
 OBJECTIVES
 Review common causes of
dizziness/vertigo
 Describe clinical pearls of vertigo
testing/treatment
 Discuss the issues of vertigo testing
 THE CASE

 79 year old with Hx postural

hypotension
 Sudden onset of dizziness 2 weeks
ago
 Two more episodes since that time
 THE PATIENT
 PMH: Macular degeneration, BPH,
anemia, polymyalgia rheumatica
 SH: Retired, non-smoker, no ETOH
 FH: No Meniere’s disease
 ROS: No changes in hearing, vision,
speech; no fall, head injury, weakness/
paralysis of extremities, LOC, or recent
URI
 THE PATIENT
 Medications:
– Prednisone
– Terazosin
– Ferrous sulfate
– TMP-Sulfa DS
– Ocuvite
 DIZZINESS IN THE ELDERLY

 Cannot place dizziness into one category

– Disequilibrium can accompany other types of
dizziness when intact compensatory systems
are absent
– Need to distinguish between primary
symptom and secondary causes
– Need to distinguish acute from chronic
dizziness-no consensus
Sloane et. Al., (2001)
CATEGORIZING DIZZINESS
 Pre-syncope
 Syncope
 Disequilibrium
 Psychogenic
 Vertigo
 PRESYNCOPE

 Sense of impending fainting or LOC

 Episodic diffuse temporary cerebral
ischemia
 Sweating, pallor, telescoping of
peripheral vision
 SYNCOPE
 Syncope: sudden transient loss of
consciousness with concurrent loss
of postural tone
 Multi-system causation
 Most common causes are vasovagal
episodes or orthostatic hypotension
 DISEQUILIBRIUM
 Disequilibrium: Perceived postural
instability involving legs and trunk
without head sensation
 Overlap between imbalance and
disequilibrium
 Vertigo not present
 PSYCHOGENIC
 Dizziness that cannot be readily
classified into previous categories
 No focal or PE findings
 Chronic
 Common Mechanisms
– Hyperventilation
– GAD, Major depressive disorder
– Somatization disorders
– Substance abuse
 VERTIGO

 Illusion of motion interpreted as self

movement or environmental
movement
 Rotating with spinning sense of falling
or swaying back and forth: Merry-Go-
Round Effect
 1/2 of patients with dizziness have
vertigo
ETIOLOGY OF VERTIGO
Asymmetry of the vestibular system
due to pathology involving:
– Labyrinth and vestibular
nerve(40%)
– Central vestibular structures in
brainstem (10%)
– Remaining 50% are conditions
noted earlier
 VERTIGO

 Time course

 Provoking factors

 Associated symptoms

 Prior risk factors

PERIPHERAL VESTIBULAR
DYSFUNCTION
 Labyrinthitis (vestibular neuronitis)
 Meniere’s Disease
 Trauma
 Tumors (Acoustic Neuroma)
 Benign Paroxysmal Positional Vertigo
 PERIPHERAL VERTIGO
 Acute Viral Labyrinthitis /Vestibular
Neuronitis
– Usually preceded by a viral respiratory
or GI infection
– Sudden onset of nausea, vomiting,
severe vertigo worsened by change in
position
– Can last for days to weeks
– Nystagmus may last for months
 PERIPHERAL VERTIGO

 Meniere’s (Endolymphatic Hydrops)

– Spontaneous onset/recurrent attacks
– Duration of symptoms: min- hrs
– Often preceded by tinnitus, ear
fullness
– Sensori-neuro hearing loss which
varies day to day
– Chronic recurrent
PERIPHERAL VERTIGO

Drugs (www.annuls.org) Appendix

(41-44)
Trauma
Acoustic Neuroma: Vestibular
Schwannoma
– Account for < 1% of patients
– Disequilibrium is more likely
– Gradual rather than acute onset
 The Patient
 Episodes occurred when he was lying
down and turned over to his left side
 Slightly nauseated-no vomiting
 Reports that the room is spinning
 Last about “10 minutes”
 Getting into an upright position helps
 DIZZY HISTORY
 Key questions: Describe the first
episode
– Objects spinning/turning around you
– Occur in attacks
– Position change makes you dizzy
– Can you tell when it may start
– Can you stand unsupported
– What will stop the dizziness, make it
better or worse
 THE PATIENT
 Afebrile, No postural hypotension
 In NAD, cognition appropriate
 HEENT: WNL
 Neck: no carotid bruits
 CV: bradycardia, irregular rhythm
 Lungs: WNL
 NEURO EXAM

 Neuro: CN 2, 5,7,8-12 intact

 No nystagmus with EOMs
 Romberg/cerebellar tests intact
 DTRs.
 Sensation intact
 BENIGN PAROXYSMAL
POSITIONAL VERTIGO
 Vertigo with head movements
 Brief episodes lasting < 1 minute;
nausea
 Usually no tinnitus or hearing
impairment
 Spontaneous nystagmus is not present
 Usually self-limited; can persist for
weeks
 BPPV

 Most common form of positional

vertigo
 No predilection based on gender, race
or age but usually after 4th decade
 Provoked by specific head movements
 Typically have no other neurological
complaint
 May have history of head trauma
 CANALITHIASIS
 Loose otoconia consisting of calcium
carbonate crystals from the utriculus
 Usually involve the posterior semi-
circular canal
 Causes inappropriate movement of
endolymph
 Giving an erroneous spinning sensation
with head movement
BPPV ETIOLOGY
CANALITHIASIS
CANALITHIASIS
 DIAGNOSTIC CRITERIA
 Vertigo w mixed torsional/vertical
nystagmus on Dix Hallpike
 Latency of 1-2 seconds from completion
of test and onset or vertigo/nystagmus
 Paroxysmal provoked vertigo and
nystagmus (increase then decline over
10-20 seconds)
 Fatigability if test repeated

 Furman (1999).NEJM: November 18, pp1590-1596

 Clinic Testing

 Dix Hallpike maneuver

 Sensitivity from 50-88%*
 Purpose is to:
– replicate the symptoms
– elicit positional nystagmus
– to determine whether nystagmus is
fatigable

*Hoffman, RM., et.al.(1999)

 DIX HALLPIKE MANEUVER

 The patient is positioned in front of

the examiner with their head turned
to the side at 45 degree angle
 The examiner supports the head and
shoulder, then quickly brings patient
to a reclining position with head
rotated to one side and hanging over
the table
 The position is maintained for 30 sec
DIX HALLPIKE MANEUVER

 Tell patient not to fixate vision

 Look for nystagmus, noting time of
onset, direction
– Nystagmus upward and torsionally with
upper poles of eyes beating toward the
ground-last ~20-30 seconds
– Once sitting, nystagmus will recur but in the
opposite direction
– Repeat to same side, repetition diminishes
the intensity and duration
DIX HALLPIKE MANEUVER
DIX HALLPIKE
FRENZEL LENSES
 THE PATIENT

 Nystagmus elicited
 Vertigo elicited-lasted for few
seconds
 Symptoms absent after sitting
upright
 ISSUES

 Self limiting disorder

 Diagnosed by history-do we need to do
Dix Hall pike
 Dix Hallpike may interfere with
treatment using the Epley test
 When does patient need Canalith
repositioning?
 TREATMENT
 Epley maneuver:
– Relocate the debris from the posterior
semicircular canal to the vestibule
– 80% success rate after one treatment and
100% after >1 (Epley)
– 89% success rate after one treatment
compared to 23% in untreated group (Lynn)
– Recurrence rate of 30% in 30 month F/u
period; 15% over 4 years (Epley)
Lynn(1995)
CANALITH REPOSITIONING

 Home treatments with modified

pocedures
 Modified Semont
– Less effective than modified Epley (95 vs
58%
 Brandt-Daroff
– Less effective than modified Epley (64%
vs 23%
 THE PATIENT
 No further episodes
 Avoids turning to left side while
supine
 References

 Froehling, D.A., et.al.,(2000). The canalith repositioning

procedure for the treatment of benign paroxysmal positional
vertigo: a randomized controlled trial. Mayo Clin Proc 75:695
 Furman, J.M. et.al(1999). Benign paroxysmal positional vertigo.
NEJM, 341(21), pp.1590-96.
 Kroenke, K. et.al., (200). How common are various causes of
dizziness? A critical review. South Med. J.,93: 160-7.
 Lynn, S. et.al.,(1995). Randomized trial of canalith repositioning
procedure. Otolaryngol Head Neck Surg. 113:712
 Sloane, P.D., et.al.(2001). Dizziness: State of the Science.
Annuls of Internal Medicine 134(9) part 2, pp. 823-31