DIZZINESS Module # 1 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512 Welcome to the “Dizziness” module. Over the next many slides we will attempt to review the issue of dizziness in the elderly in Module 1. We hope that you will enjoy this module as much as we had fun making it.

PROCESS Series of 3 modules and questions on 1) Etiologies, 2) Evaluation, 3) Management Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break Our process will be for you to complete 3 a series of 3 modules and questions on the following topics1) Etiologies, 2) Evaluation, 3) Management These modules will utilize Power point with voice overlay. This will be followed by 1-3 case based questions with answers to explain the right and wrong answers. Then you will have the option to continue with the next module or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed on main page minifellowship to indicate your completion.

Objectives Upon completion of the module the learner will be able to: 1) Describe the four main classifications 2) Classify dizziness symptoms into one of four main groups 3) List the most common causes of each classification of dizziness Describe the prognosis of dizziness What we would like you to get out of this is to help you to classify dizziness into four main areas that, diagnostically, will assist you to care for your patient. The most common causes will be listed for each of the classifications that you try to clarify your patients’ symptoms into and, lastly, we will try to describe the initial evaluation in subsequent modules.

Incidence &Prevalence 7 million clinic visits year the most common symptoms for referral to neurology and otolaryngology practices. Prevalence: 13% to 38% of elders. This is a disease that affects many people, plagues neurologists and otolaryngologists, and has a prevalence in elders up to 38%. Hence, it is of great importance to have some skill in geriatric care to efficiently and effectively evaluate this problem.

Challenges to evaluation and management Precise classification often difficult. Patients and clinicians alike may inappropriately worry about a serious cardiac or neurologic cause. Specific therapy is not available for many patients with dizziness. Dizziness will have multiple potentially causative factors at least half of the time. Precise classification of the cause is often difficult. Patients and clinicians alike may inappropriately worry about a serious cardiac or neurologic causes. Specific therapy is not available for many patients with dizziness. Dizziness will have multiple potentially causative factors at least half of the time. Don’t’ despair We’re going to assist you to try and differentiate the important and treatable causes from the unimportant. As you will learn we often don’t have specific therapy for dizziness to “turn it off” and, as usual, in elder care it often has multiple potential causative factors.

CLASSIFICATION Symptom-oriented approach: (Drachman)[i] Classify as Vertigo (rotational sensation), “spinning” Presyncope (impending faint), “fainting” Disequilibrium (loss of balance without vertigo or presyncope sensation), “falling” Lightheadedness (ill-defined, not otherwise classifiable). [i] Drachman DA, A 69 year old man with chronic dizziness JAMA 1998;280:2111-2118 What is recommended on initial evaluation, which I have found extremely helpful, is to try to classify the patient’s symptom into one of four areas: Vertigo, Presyncope, Disequilibrium or Lightheadedness. Vertigo can often be described as a spinning sensation. You can ask the patient if either the room is spinning around them or if they are spinning in the room. Presyncope can be likened to passing out or near fainting. Disequilibrium is more of a loss of balance without either vertigo or presyncope, or what we might call “head” sensations: a feeling of falling, a feeling of imbalance can all be used to describe this. Lastly, lightheadedness is often the most ill-defined. Often we use this term when none of the other three above (vertigo, presyncope, or disequilibrium) fits the category. The Bad news (Although some sensations correspond more often than not to at least a general etiologic category (eg, vertigo suggests vestibular dysfunction at least 80% to 90% of the time), these four sensations remain nonspecific, occurring with many different disorders.

Vertigo Three most common specific peripheral vestibular disorders: ( 35%-55% all causes dizziness) [i] Benign positional vertigo Labyrinthitis Meniere's disease. [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478 Vertigo is one of the most common of the peripheral vestibular disorders made up mostly by benign positional vertigo or BPV, labyrinthitis and Meniere’s disease. We’ll explore each one of these individually.

Vertigo Benign positional vertigo (BPV) Symptoms: spinning sensation of patient moving or room moving episodic aggravated or brought on by changes in position, spells are often brief (5 to 15 seconds) milder than the severe vertiginous attacks spinning sensation of patient moving or room moving, episodic aggravated or brought on by changes in position, such as turning, rolling over or getting in and out of bed, or bending over. spells are often brief (5 to 15 seconds) milder than the severe vertiginous attacks seen with disorders such as labyrinthitis and Meniere's disease.

Vertigo Labyrinthitis (sometimes called vestibular neuronitis) Symptoms: Spinning sensation Acute, lasts for several days, and resolves spontaneously Often associated with viral infection Labyrinthitis, or vestibular neuronitis, is described as much more severe in its vertiginous symptoms, can last for several days in a row, resolves spontaneously, and is often associated with a viral type infection.

Vertigo Meniere's disease Symptoms: -Tinnitus -Fluctuating hearing loss, -Severe vertigo + progressive sensorineural hearing loss. -Vertigo may improve as hearing impairment worsens. Meniere’s disease has symptoms of: repeated episodes of tinnitus, fluctuating hearing loss, severe vertigo accompanied eventually by a progressive sensorineural hearing loss. The frequency and severity of vertigo may improve as hearing impairment worsens

Vertigo Other: Central vestibular disorders minority of cases of vertigo ( ~ < 6 % of causes of dizziness) etiologies: Cerebrovascular disease Brain tumors Multiple sclerosis Rare central causes. As in many diseases, there are the “others.” In this case, it represents the central vestibular disorders. Note previously what we have described were peripheral vestibular disorders. These are in the minority - < 6% of all causes. Some of the main factors here include CNS disease, brain tumors and, more rarely, multiple sclerosis and then getting into a bunch of very rare neuropathic causes.

Other: Central vestibular disorders Cerebrovascular disease ( 5% of all causes dizziness) [i] Symptoms: dizziness presenting symptom < 20% of the time. more commonly, it is preceded or accompanied by other neurologic deficits in the distribution of the posterior circulation. [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478 Cerebrovascular disease: < 5% of all cause dizziness. If you’re having cerebrovascular insufficiency, it will present with dizziness first < 20% of the time. More commonly, dizziness is preceded by posterior circulation neurologic deficits. Here we are talking about balance, gait disorders, hypotension, loss of consciousness.

Other: Central vestibular disorders Cerebrovascular disease Diagnosis Note: verifying vertigo due to transient ischemic attack can be difficult in the absence of other neurologic deficits, Tests: Ultrasound can show flow, MRA demonstrates anatomy but not flow Verifying that vertigo is due to a TIA of posterior circulation can be very difficult in the absence of associated neurologic deficits. Ultrsound can show flow when evaluating the posterior circulation, or an MRA can demonstrate anatomy but not as accurately show flow, neither of which are truly predictive of whether the symptoms your patient is having (vertigo) is due to posterior circulatory disease. But, if one does have associated neurologic deficits, then your confidence should grow stronger that the dizziness is cerebrovascular in etiology.

Other: Central vestibular disorders Brain tumors; Incidence: (< 1 % of all causes dizziness) [i] Acoustic neuroma: -most common tumor -associated with cochlear symptoms (tinnitus and hearing loss) -unilateral cochlear symptoms [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478 Acoustic neuroma Incidence; < 1 % of all dizziness but (slightly more prevalent (2% to 3%) in older patients referred to neurologists.) Still it is the most common brain tumor cause of dizziness is acoustic neuroma. It will often have cochlear symptoms, such as tinnitus and hearing loss associated with this. It is usually unilateral, whereas bilateral symptoms described as hearing loss, dizziness and tinnitus are more representative of presbyacusis than tumor.

2) Nonvertiginous Dizziness (Presyncope) Symptoms: sensation of near fainting. Etiologies: Diminished cerebral perfusion. ( for further information see syncope module) P-A-S-S O-U-T (mnemonic) P ressure (hypotensive causes) O utput (cardiac)/O2 (hypoxia) A rrhythmias U nusual causes S eizures T ransient Ischemic Attacks S ugar (hypo/hyperglycemia) & Strokes, CNS dz’s The next major cause of nonvertiginal dizziness is presyncope. It’s a sensation of near fainting, like you are going to pass out. Of course, its etiology is: diminished cerebral perfusion. This topic will be covered more intensely in the syncope module, but just to help you with some of the causes is a mnemonic that we favor called the “P-A-S-S O-U-T mnemonic.” Some of the main etiologies are pressure related problems, such as orthostatic hypotension and vasovagal disorders, that make up perhaps 30% of true syncope, arrhythmias (tachyarrhythmias, bradyarrhythmias) or seizures, oftentimes atypical and more rare, sugar related problems such as hypo or, more rarely, hyperglycemias through dehydration causing the symptomatology. Cardiac output symptoms influenced by valvular lesions or heart failure or hypoxia driven etiologies such as pulmonary or cardiac insufficiency type syndromes. The unusual causes can include most often psychiatric, such as depression or anxiety. Note, this is an infrequent cause in elders, and if you believe that is the diagnosis to be very confident that you’ve eliminated other causes. And, lastly, of course, the TIA or transient ischemic attacks that we’ve previously discussed.

THE PROBLEM in DIAGNOSING PRESYNCOPE Most presyncopal patients presenting with dizziness ( without true syncope) have symptoms attributable to postural change (with or without orthostatic hypotension) rather than more serious cardiac causes. Postural symptoms without orthostatic blood-pressure changes are particularly common in elderly persons. Likewise, orthostatic blood-pressure changes in the absence of symptoms are also quite common. The problem, of course, is that many elders presenting with presyncope type symptoms will have their symptoms related to postural change, such as we’ve seen in BPV, etc., and may not have a cardiac cause. Also, many will have the postural symptoms without any orthostatic blood pressure symptoms that confirm your theory of possible hypotension. Contrarily, they can also have orthostatic blood pressure change and have no symptoms at all. Hence, the diagnosis of presyncope takes a careful history observing symptoms, physical exam and an effort to rule out more easily excluded causes to narrow your diagnoses.

3) Disequilibrium (loss of balance without “head” sensations) Symptoms: unsteady when standing or walking. Etiologies: chronic vestibulopathics, visual problems musculoskeletal disorders weaknesses) somatosensory or gait deficits Note: Balance depends on: vestibular system, visual and somatosensory systems. Therefore multi-factorials causes are common. The third major classification is disequilibrium. This is the loss of balance without the “head” sensations of vertigo or presyncope type symptoms. The individual usually has their symptomatology of disequilibrium only when standing or walking. We know that our balance system is highly dependent upon the vestibular, visual and somatosensory systems. Therefore, we can often have multiple causes of this. Some of the prominent ones are the chronic vestibular diseases,( BPV or Labrynthitis). visual problems (eg, errors of refraction, cataract, loss of binocular vision, macular degen­eration), musculoskeletal disorders (eg, arthritis, muscle weaknesses) and somatosensory or gait deficits (eg, neuropathies, previous strokes, cerebellar disease, Parkinson's disease, dementia).that are added to this problem.

4)Lightheadedness (ill-defined, not otherwise classifiable) Symptoms: vague sensation best described as “none of the other symptoms described in vertigo, presyncope, or disequilibrium, ie NOT:"spinning," "fainting," or "falling." The final classification is lightheadedness. Truly, this is probably the “garbage bag” diagnosis. Often a clinician will have worked their way through history and some physical exam and eliminated the vertigo symptoms, the “presyncope” classification, and the “disequilibrium” classification and end up with the lightheaded classification.

4)Lightheadedness Etiologies: The two most prominent considerations; ( 1/3 of all cases of dizziness.) a. Psychiatric (10% - 25% all causes of dizziness) b. Idiopathic causes ( most common) Additional etiologies c, Prescription drug toxicity d. Other causes; -cervical arthritis* -visual disorders* -carotid sinus hyper-sensitivity* *(these factors as the actual cause are difficult to substantiate) Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478 Lightheadedness can make up a third of all dizziness. Here we see a bigger proportion of psychiatric causes and depression, anxiety, somatoform disorders really lead the list. Then we have the non-helpful but common idiopathic causes, that is any cause of dizziness and, perhaps more helpful, prescription drug toxicity. It is known that greater than five medications are risk factors. Some of the dominant medications here area cardiovascular, anti-hypertensives, the psychotropic medications, diuretics, all that can perhaps mitigate orthostatic hypotension. Lastly, other causes: cervical arthritis, visual disorders and carotid sinus hyper-sensitivity. These are all quite real in the elderly and can be a factor, although sometimes proving that these are the exact etiologies. Our efforts as clinicians to reduce dizziness will be to maximize the elders’ visual disorder, screen carefully and try to avoid hypotension and carotid sinus stimulation, and improve range of motion and activity of cervical spine so that these factors will minimized as much as possible.

PROGNOSIS ~ 75% resolve within days to several months ~25% experience chronic or recurrent symptoms. By this time you should be quite depressed in thinking that this is a disease that has multiple factors that I’m going to have a hard time pinning down the exact etiologies. However, time is on our side in allowing us to time to figure out the diagnoses and, for the most part, the disease is self limited and relatively benign.

PROGNOSIS Associated with increased risk of: falls syncope psychological distress diminished social activities Not associated with change in: mortality hospitalization severe disability We do know that dizziness is associated with in creased risk of; falls, syncope, emotional distress, and diminished social activities. But what can encourage us that it’s not associated with increased risk of mortality, hospitalization or severe disability. Disability was measured by activities of daily living or nursing home placement. What do we know? One study looked at over 102 patients. What they found in this prospective one year study was that psychiatric disorders, disequilibrium or vestibular diseases other than benign BPV or labyrinthitis were more likely to persist. An additional study looked at over 1,000 community dwelling elders, and 24% of individuals with dizziness of a month or more were more likely to have anxiety or depressive symptoms, hearing loss, balance disorders, postural hypotension, previous MI with five or more medications. This helps to guide us to perhaps the areas that we can create an impact in our chronic dizzy patients by carefully screening them for psychiatric disorders, working on postural hypotension, cardiac diseases, trimming their medication list to the lowest possible number. [i] Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165 [ii] Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165

The End of Module One on Evaluation of Dizziness Credits: Adapted with permission from; Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165 This completes our module on etiologies. To proceed to the question close this window, advance to page two in this learning unit and click on “module 1 question”. Then, if you have enough energy, proceed to module #2 which talks about evaluation.