1. ‘Dizziness’ David Bourne Consultant Physician and Geriatrician UHSM 5 th March 2007

2. Agenda Dizziness Orthostatic and Postprandial Hypotension Blackouts Summary and discussion

3. Dizziness Nonspecific term Vertigo ~50% Presyncope Disequilibrium –Presyncope and disequilibrium ~25% Nonspecific dizziness ~15% Psychiatric ~10%

4. Dizziness History Open ended questions Positional changes in symptoms Rx Presyncome –Prodrome to fainting –Lasts seconds to minutes History most most sensitive: –Vertigo 87% –Presyncope 74% –Psychiatric 55% –Disequilibrium 33%

5. Dizziness Vertigo Acute asymmetry of the vestibular system –Illusion of motion –Whirling –Tilting –Moving –Imbalance –Panic attacks –Agoraphobia / Fear of falling

6. Dizziness Examination Confirms the diagnosis Most useful components –Orthostatic BP –Pulse changes –Systolic murmur ?AS –Gait observation –Eye movements –Romberg’s Test Peripheral neuropathy Hallpike’s Test Psychological testing No patient volunteered a psychiatric explanation

7. Dizziness in the elderly ~1/3 elderly Multiple pathology –Geriatric syndrome (5 th Geriatric Giant) Associations –Postural hypotension –5 or more medications –Hearing impaired –Impaired balance –Anxiety / depression –Previous MI

8. Disequilibrium Sense of imbalance/ unsteadiness Often multifactorial –Peripheral neuropathy –Visual impairment –Muscular skeletal –Gait –Vestibular –Do they cause dizziness? Vertebrobasilar insufficiency Cervical spondylosis

9. Nonspecific dizziness Arrhythmias PE Head injury Psychiatric –Major depression 25% –Generalised anxiety 25% –Somatisation Hyperventilation –Mildly stressful situations –Purposeful hyperventilation while observing for nystagmus

10. Dizziness Medications Antidpressants Hypnotics Anticholinergics Antihypertensives Lots more

11. Orthostatic and Postprandial Hypotension Orthostatic hypotension ~20% >65yrs Postprandial (15-90mins) ~30% NH residents Symptoms –Light-headed –Generalised weakness –Blurred vision –Legs buckling –Neck pain / headaches –Stroke –Angina

12. Orthostatic and Postprandial Hypotension BP on standing and at 2 and 5mins Fall in BP + symptoms –Systolic 20mmHg –Diastolic 10mmHg Many will have systolic hypertension Assosciations –Anti hypertensives –Oral hypoglycaemics –Antidepresants –Opiates –Alcohol

13. Orthostatic and Postprandial Hypotension Normal response to orthostatic stress Normal response to standing 500-1000ml pool in lower extremities and splanchnic (most) circulation  VR  –SBP  5-10mmHg –DBP  5-10mmHg –HR  10-25/min Baroreceptor reflex  SNS  + PSNS  PR   VR   CO  ADH 

14. Orthostatic and Postprandial Hypotension Mechanism of autonomic failure Autonomic failure –NA  Na  in prox renal tubule   Na excretion  new steady state plasma vol –Absent HR  (except POTS young  tilt)

15. Orthostatic and Postprandial Hypotension Causes of autonomic failure Autonomic failure –Neurological conditions Impaired baroreceptor response in the elderly Postprandial hypotension PD MSA DM Paraneoplastic syndromes –Neurogenic syncope / CSH –Micturition / defaecation syncope –Rx antidpressants often overlooked

16. Orthostatic and Postprandial Hypotension Cause of volume depletion Volume depletion –Hyperglycamia –Haemorrhage –D+V –Rx Diuretics

17. Orthostatic and Postprandial Hypotension Treatment Nonpharmacological Pharmacological

18. Orthostatic and Postprandial Hypotension Treatment - Nonpharmacological Volume replacement Rx review –  blockers –Antidepressants Education and physical manoeuvres –Standing –Weather –Meal times Salt Water with a meal Small meals Low carbohydrate Alcohol Avoid standing quickly and exercise

19. Orthostatic and Postprandial Hypotension Treatment - Nonpharmacological Education and physical manoeuvres –Leg crossing   CO ~15% –Clench fists –Squatting –Straining Rx chronic cough –Tilt bed  renin system   nocturnal diuresis –Compression stockings to lower abdomen –Exercise Cardiac reconditioning

20. Orthostatic and Postprandial Hypotension Treatment - pharmacological Fludrocortisone –Long t½ –  Blood volume –  vessel sensitivity to catecholamines –?  NA release –50ug titrated weekly  max 500ug –SE oedema / supine HT / K  / CCF

21. Orthostatic and Postprandial Hypotension Treatment - pharmacological Sympathomimetics Midodrine –Doesn’t cross BBB avoiding some SE –  agonist 2.5mg od  10mg tds –SE supine HT / GI / urinary retention Caffeine NSAIDS Desmopressin  blockers eg pindolol DA antagonists Erythropoitin in context of anaemia

22. Blackouts Abrupt loss of consciousness and loss of postural tone Rapid and complete recovery ~ 3% A+E attendances ~1% hospital admissions Cardiac syncope  risk of sudden death Lifetime risk 30% Framingham rise >70yrs

23. Blackouts Risk factors IHD CVD HT Low body mass index Alcohol DM

24. Blackouts Cause Vasovagal Cardiac Unknown 30%

25. Blackouts Cardiovascular Arrhythmia –Cf vasovagal without warning Well tolerated –Persistent arrhythmia –Bradycardias

26. Blackouts Cardiovascular Blood flow obstruction –AS –HOCM –PS –PE

27. Blackouts Noncardiac Neurocardiogenic Orthostatic hypotension CSH –Relatively benign nb injuries Seizures Metabolic CVD

28. Blackouts Noncardiac Seizures –5-15% syncope –Post ictal Metabolic –Hypoglycaemia CVD

29. Summary and discussion History Targeted examination Undertake simple interventions Consider appropriate referral Discussion