1. DIZZINESS Suggestions for Lecturer -1-hour lecture
-Use GNRS slides alone or to supplement your own teaching materials.
-Refer to GNRS for further content and for strength of evidence (SOE) levels.
-Refer to Geriatrics at Your Fingertips for updated information.
-The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2. OBJECTIVES
Know and understand:
The factors that may lead to dizziness in older adults
The elements of evaluation (history, physical examination, testing) of older adults with dizziness and syncope
The treatment options for dizziness

3. TOPICS COVERED Classification and Causes of Dizziness
Prognosis for Older Adults with Dizziness
Evaluation and Management of Dizziness

4. IMPORTANCE AND COMPLEXITY OF DIZZINESS
Dizziness is a common symptom in older adults
Prevalence in older adults of 4%–30%
Prevalence increases with age
Challenges for clinicians
Precise classification is difficult
Worry about serious causes
Specific therapy not available for many
50% of cases have multiple causes

5. DIZZINESS: CLASSIFICATION BY SYMPTOMS
Vertigo — Rotational sensation
Presyncope — Sensation of impending faint
Disequilibrium — Feeling of imbalance on standing or walking
Other — Lightheadedness, not as specific symptoms
Mixed — Most common type

6. CAUSES OF VERTIGO Vestibular disorders
Benign paroxysmal positional vertigo (BPPV)
Ménière disease
Ototoxic medications (eg, aminoglycosides, diuretics, NSAIDs)
Acoustic neuroma
Cerebrovascular disease

7. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)
Episodic inner ear disorder
Aggravated or brought on by changes in position (eg, turning, rolling over, bending over)
Spells are often brief (5–15 sec)
Probably results from changes in endolymphatic pressure during head movements resulting from dislodged otoconia in semicircular canal

8. MÉNIÈRE DISEASE Idiopathic inner ear disorder
Repeated episodes of tinnitus
Fluctuating hearing loss with sensation of fullness in ears
Severe vertigo
Eventual progressive sensorineural hearing loss

9. PRESYNCOPE Sensation of near-fainting
Sign of decreased cerebral perfusion
Cardiac causes
Electrical: tachy- or bradyarrhythmias
Structural, esp. aortic outflow obstruction
Vascular causes (eg, orthostatic hypotension, vagal stimulation, dehydration)
Postural change (with or without orthostatic hypotension)
Postprandial hypotension
Presyncope, a feeling of faintness or lightheadedness, usually results from a cardiovascular problem causing brain hypoperfusion through postural hypotension. There is no specific definition of postural hypotension in older adults, but it is commonly defined as a drop in systolic arterial blood pressure of at least 20 mmHg and/or a drop in diastolic blood pressure of 10 mmHg after standing up from a supine position. However, older adults commonly describe dizziness on standing from a supine position without any orthostatic changes in blood pressure.
Another common condition, postprandial hypotension, is defined as a decrease in systolic blood pressure of ≥20 mmHg in a sitting or standing posture within 1–2 hours of eating a meal.

10. DISEQUILIBRIUM
Sensation of being unsteady when standing or, in particular, walking
Many factors can contribute to imbalance:
Vascular disorders
Tumors
Proprioceptive disorders
Visual problems
Musculoskeletal disorders
Gait disorders
Disequilibrium, a feeling of imbalance or unsteadiness on standing or walking, usually results from visual or proprioceptive system abnormalities, with or without vestibular system involvement. Common contributing conditions include vision problems (eg, refractory errors, cataract, macular degeneration), musculoskeletal disorders (eg, arthritis, muscle weakness, deconditioning after prolonged illness), proprioceptive disorders (eg, neuropathies), and gait disorders (eg, cerebrovascular stroke, Parkinson disease, cerebellar disorders). Vascular disorders such as vertebrobasilar ischemia and/or cerebellar infarcts/hemorrhage or cerebellopontine tumors (eg acoustic neuromas) are also in the differential diagnosis.

11. OTHER FORMS OF DIZZINESS
Best reserved as a description for patients who do not experience vertigo, presyncope, or disequilibrium
Patient may describe “lightheadedness,” “wooziness,” or other nonspecific sensations
The most prominent consideration is a psychiatric cause (depression, anxiety, somatoform disorders)

12. MEDICATIONS AND DIZZINESS
In older adults, prescription drug toxicity is an important contributor to dizziness
Certain drugs are more frequently implicated:
Those that cause orthostasis or CNS effects
Cardiovascular or antihypertensive drugs
Psychotropic medications
Aminoglycosides
NSAIDs
Antihistamines and anticholinergics

13. CHARACTERISTICS OF DIZZINESS IN OLDER PERSONS
Usually resolves within days to several months
Chronic or recurrent symptoms
Multifactorial etiology common
Commonly associated with postural hypotension, anxiety and depression, use of 5 or more medications, impaired gait and balance
View as geriatric syndrome requiring multifactorial assessment and intervention strategy

14. EVALUATION OF DIZZINESS: HISTORY
Elicit the patient’s own description of the event without prompting
Learn:
Whether the dizziness is characterized by any of 3 sensations: spinning, fainting, or falling
Whether there is a positional effect on symptoms
Frequency and duration of symptoms
What other symptoms are associated with dizziness (specifically ask about hearing loss and focal neurological symptoms)
What medications the patient is taking
The clinical history begins with helping patients to describe their symptoms as precisely as possible, which is potentially daunting for those with multiple sensations. Patients should be encouraged to use their own words and to try distilling the symptoms into specific sensations such as spinning, imbalance or unsteadiness, or fainting.
It is also important to document the frequency and duration of dizziness, and whether changing head position exacerbates the dizziness. It is useful to establish whether symptoms peak at any specific time of day, such as after meals or first thing in the morning. Patients should be asked about associated symptoms such as hearing loss, ear fullness, diplopia, dysarthria, and tinnitus. It is also important to elicit the impact on the patient’s quality of life.
Patients with Ménière disease complain of recurrent dizziness associated with ear fullness and/or tinnitus along with fluctuating hearing loss. Patients with acoustic neuroma complain of hearing loss and tinnitus but not of ear fullness. Patients with Ménière disease, CNS diseases, or BPPV complain of recurrent dizziness, while patients with psychogenic and central dizziness usually complain of continual dizziness.
Inquiring about precipitating factors such as after eating meals (postprandial hypotension), looking down or rolling over in bed (vestibular conditions), or standing from supine position (orthostatic hypotension) can suggest interventions, as well as corroborate timing of symptoms. Any evaluation must include a critical review of medications, including over-the-counter medications.

15. EVALUATION OF DIZZINESS: PHYSICAL EXAMINATION
Take blood pressure and pulse while patient is supine and after standing for 12 min
Perform a provocative test of vestibular system:
Head-thrust test
Fukuda stepping test
Dix-Hallpike maneuver
Perform cardiac examination, test hearing and vision and observe for nystagmus
Observe for balance and gait difficulties
The physical examination should begin with measurements of orthostatic changes in blood pressure. Nystagmus should be evaluated; horizontal or rotatory nystagmus usually indicates a peripheral vestibular lesion, while vertical nystagmus is seen in central lesions. Hearing and vision tests should be done, and the cranial nerves examined if vertebrobasilar ischemia or infarction is suspected. The Timed Up and Go test can be performed to look for gait and balance problems. Provocative tests of the vestibular system can be done at the bedside:
Head-thrust test: Ask the patient to fixate on the examiner’s nose. The examiner then rotates the head rapidly about 10 degrees to the left or right. In patients with a vestibular deficit, the eyes move away from the target along with the head, followed by a corrective saccade back to the target, while normal eyes remain fixed on the target without a saccade.
Fukuda stepping test: Draw a circle on the floor, and ask the patient to stand in the center. Blindfold the patient and ask him or her to take a few steps forward as if walking on a straight line with outstretched arms. The examiner notes the patient’s body sway as the patient takes the steps. In a unilateral vestibular lesion or acoustic neuroma, the patient’s body will sway by >30 degrees toward the affected side.
Dix-Hallpike maneuver: This is a useful test for the diagnosis of BPPV. Ask the patient to sit on the examination table with the head rotated 30–45 degrees to one side. Instruct the patient to fix his or her vision on the examiner’s forehead. The examiner holds the patient’s head firmly in the same position, and moves the patient from a seated to a supine position with the head hanging below the edge of the table and the chin pointing slightly upward. The examiner notes the direction, latency, and duration of the nystagmus, if present. The diagnostic criteria for BPPV include 1) paroxysmal vertigo along with a rotatory nystagmus, 2) latency for 1–2 seconds between the completion of the maneuver and the onset of vertigo and nystagmus, and 3) fatigability (decrease in the intensity of the vertigo and nystagmus with repeated testing).

16. EVALUATION OF DIZZINESS: DIAGNOSTIC TESTING (1 of 2)
Laboratory
In patients with chronic dizziness, check hematocrit, glucose, electrolytes, renal function, vitamin B12, folic acid, thyrotropin
Audiometry
May help if cochlear symptoms are present (tinnitus, asymmetric hearing loss)
Abnormal results may indicate Ménière disease or, rarely, a tumor

17. EVALUATION OF DIZZINESS: DIAGNOSTIC TESTING (2 of 2)
Vestibular testing
Electronystagmography
Rotatory chair
Dynamic posturography
Neuroimaging (CT, MRI) occasionally warranted
ECG if cardiac cause suspected
Tilt-table testing only in select patients with postural hypotension or syncope
MRI provides better resolution than CT for posterior fossa lesions. However, in a community-based study of adults ≥65 years old, the similar prevalence of MRI abnormalities in the dizzy and nondizzy group led to the conclusion that routine MRI will not identify a specific cause of dizziness in most patients.

18. MANAGEMENT OF DIZZINESS: VERTIGO
Common causes or coexisting conditions
Treatment
Benign paroxysmal positional vertigo
Epley’s maneuver is treatment of choice
Ménière disease
Salt restriction, diuretics; vestibular suppressants may be helpful during acute attacks; in severe cases, may need surgery, including endolymphatic decompression, vestibular nerve resection, and labyrinthectomy
Ototoxic medications, eg, aminoglycosides, diuretics, NSAIDs
Discontinue, substitute, or reduce the dosage of offending medication
Topic
Slide 18

19. MANAGEMENT OF DIZZINESS: PRESYNCOPE
Common causes or coexisting conditions
Treatment
Cerebral ischemia secondary to orthostatic hypotension, cardiac causes, dehydration, medications, vasovagal attack, autonomic dysfunction secondary to diabetes, parkinsonism
Treatment of specific cause (eg, proper hydration); slow rising from sitting or lying down position; graduated support stockings; PT and/or OT; medications (eg, fludrocortisone, midodrine) as needed
Postprandial hypotension
Frequent small meals; avoid exertion after meals; slow rising from sitting position; avoid antihypertensive drugs at or near meal time
Topic
Slide 19

20. MANAGEMENT OF DIZZINESS: DISEQUILIBRIUM
Common causes or coexisting conditions
Treatment
Vertebrobasilar ischemia and/or cerebellar infarcts/hemorrhages
Low-dose aspirin, clopidogrel, or extended-release dipyridamole; rehabilitation
Cerebellopontine angle tumor, eg, acoustic neuroma
Surgery
Parkinson disease
Drug therapy, rehab
Peripheral neuropathy secondary to diabetes; vitamin B12 deficiency; idiopathic, etc.
Treatment of the underlying disease
Cervical spine degenerative arthritis, spondylosis
Cervical or vestibular rehabilitation; cervical collar; surgery if needed
Topic
Slide 20

21. MANAGEMENT OF DIZZINESS: MIXED
Common causes or coexisting conditions
Treatment
Medications: antianxiety drugs, antidepressants, anticonvulsants, antipsychotics, antihypertensives, anticholinergics
Discontinue, substitute, or reduce the dosage of offending medication
Combination of any of the above causes
Multifactorial intervention
Topic
Slide 21

22. EPLEY’S MANEUVER Self-treatment of BPPV using Epley’s maneuver
Perform the maneuver 3 times a day until free of BPPV for 24 hours. Use the positions shown here when the right ear is affected. Reverse all positions (left instead of right) when the left ear is affected. The affected ear is the ear that when turned downward during the Dix-Hallpike test triggers vertigo or nystagmus, or both.
Each maneuver consists of the following steps (numbered to match the illustrations):
1. Sit on the bed with a pillow far enough behind you to be under your shoulders when you lie back. Turn your head 45 degrees to the left.
2. Holding your head in the turned position, lie back quickly so that your shoulders are supported on the pillow and your head is reclined on the bed. Hold this position for 30 seconds.
3. Remain prone on the bed and turn your head 90 degrees to the right. Hold this position for 30 seconds.
4. Turn your head and body another 90 degrees to the right; you should now be looking down at the bed. Hold this position for 30 seconds.
5. Sit up, facing to the right.

23. SUMMARY
Precise classification of dizziness into vertigo, presyncope, disequilibrium, and lightheadedness is often difficult, and multiple causes of the same symptoms are common
Most dizziness resolves within days to several months
Key physical exam steps include checking for orthostatic hypotension, performing the head-hanging (Dix-Hallpike) test, and observing gait
Treatment of dizziness focuses on treating the underlying disorder

24. CASE 1 (1 of 3)
A 75-year-old woman comes to the office because she has had a gradually increasing sense of imbalance over the past few months.
She resides in an independent-living facility.

25. CASE 1 (2 of 3)
Which of the following is least likely to be identified as the underlying cause?
Visual deficit
Vestibular disorder
Peripheral sensory impairment
Musculoskeletal weakness
Stroke

26. Peripheral sensory impairment Musculoskeletal weakness Stroke
CASE 1 (3 of 3)
Which of the following is least likely to be identified as the underlying cause?
Visual deficit
Vestibular disorder
Peripheral sensory impairment
Musculoskeletal weakness
Stroke
ANSWER: E
The insidious nature of this patient’s symptom points to an ongoing process rather than an acute development such as stroke. Furthermore, in patients presenting with dizziness, vertigo, or imbalance, the proportion of cases attributable to stroke is very low.
The sense of equilibrium is mediated by central integration of multiple inputs from vestibular, visual, and proprioceptive systems. Disequilibrium is believed to be multifactorial—a variety of disorders can contribute to a subjective sensation of imbalance. For example, the number of vestibular hair cells decreases as people age; although it is unclear what degree of loss yields functional deficits, vestibular hair cell loss is a possible source of this patient’s sense of imbalance.
Age-related ocular conditions, such as glaucoma, cataracts, and macular degeneration, may contribute to imbalance. Other possible age-related contributors include disorders of peripheral sensory organs, as found in peripheral vascular disease and diabetes mellitus, and musculoskeletal conditions such as arthritic changes in the cervical spine, knees, and hips.

27. CASE 2 (1 of 3)
A 77-year-old woman comes to the office because she has episodes of severe dizziness.
Evaluation suggests a vestibular problem, and vestibular suppressant treatments are prescribed.
At follow-up 1 week later, she reports that the episodes are now mild, but she still has a feeling of imbalance. Vestibular rehabilitation is considered as a possible next management step. 27

28. CASE 2 (2 of 3)
Which of the following is true regarding vestibular rehabilitation and long-term functional recovery?
Vestibular rehabilitation is ineffective in long-term studies.
Combining vestibular rehabilitation with physical repositioning maneuvers improves functional recovery.
Vestibular rehabilitation is effective only for managing vestibular neuritis or Ménière disease.
In patients with benign positional vertigo, vestibular rehabilitation reduces dizziness in short-term rather than long-term studies. 28

29. CASE 2 (3 of 3)
Which of the following is true regarding vestibular rehabilitation and long-term functional recovery?
Vestibular rehabilitation is ineffective in long-term studies.
Combining vestibular rehabilitation with physical repositioning maneuvers improves functional recovery.
Vestibular rehabilitation is effective only for managing vestibular neuritis or Ménière disease.
In patients with benign positional vertigo, vestibular rehabilitation reduces dizziness in short-term rather than long-term studies.
ANSWER: B
Vestibular rehabilitation is an effective means of managing unilateral peripheral vestibular disorders, such as vestibular neuritis, labyrinthitis, Ménière disease, and loss of vestibular function due to ablative surgery (eg, excision of acoustic neuroma) or trauma (eg, temporal bone fracture involving the labyrinth). Rehabilitation involves movement-based training exercises to desensitize the vestibular system and limit associated symptoms. Patients learn to coordinate eye and head movements, to improve balance and walking skills, and to cope with or become more active despite the condition.
A Cochrane review of 27 randomized clinical trials showed that vestibular rehabilitation was effective in reducing subjective dizziness and improved participation in life roles and activities of daily living. The exception to these findings was for the group with BPPV. For this group of patients, comparisons of vestibular rehabilitation with specific physical repositioning maneuvers (eg, Epley maneuver) showed that the repositioning maneuvers more effectively reduced dizziness symptoms, particularly in the short term. Combining the maneuvers with vestibular rehabilitation was effective in improving functional recovery in the longer term. There were no reports of adverse effects after vestibular rehabilitation, and positive effects were maintained in studies with follow-up assessment at 3–12 months. 29

30. CASE 3 (1 of 3)
An 85-year-old woman comes to the office because she recently had episodes of dizziness.
The episodes lasted a few hours and consisted of a sensation of the room spinning around her. During the episodes, her right ear felt blocked and she had a roaring sensation.
The symptoms gradually improved, and she now is back at her baseline sense of well-being.

31. CASE 3 (2 of 3)
Which of the following is the most likely diagnosis?
Benign paroxysmal positional vertigo
Acute labyrinthitis
Arrhythmia
Ménière disease
Migraine-associated vertigo

32. Which of the following is the most likely diagnosis?
CASE 3 (3 of 3)
Which of the following is the most likely diagnosis?
Benign paroxysmal positional vertigo
Acute labyrinthitis
Arrhythmia
Ménière disease
Migraine-associated vertigo
ANSWER: D
The features that facilitate diagnosis are its duration and the presence of hearing symptoms. The following table is a proposed diagnostic algorithm based on these characteristics.
True vertigo is the perception of rotational movement of self or surroundings (eg, spinning or floating). Ménière disease and benign paroxysmal positional vertigo are episodic true vertigos. This patient’s description of her dizziness correlates with Ménière disease.
Patients with symptoms lasting >1–2 days are likely to have either vestibular neuritis or labyrinthitis. The distinguishing characteristic between these 2 otogenic sources of true vertigo is hearing loss. Because labyrinthitis involves inflammation of the inner labyrinthine structures where cochlear and vestibular apparatuses are in continuity, both hearing loss and vertigo are expected. In contrast, vestibular neuritis is believed to be associated with inflammation of the vestibular nerve, thus sparing any cochlear symptoms.
In this case, the presence of true vertigo excludes a diagnosis of arrhythmia. Similarly, the absence of headache excludes migraine-associated vertigo. Migraine is increasingly recognized as a cause of recurrent vertigo. Migraine symptoms such as headache, visual aura, photophobia, or phonophobia during or preceding the vertiginous episode are key diagnostic features.
Episodic true vertigo (symptoms last minutes to hours)
Prolonged true vertigo (symptoms last ˃1–2 days)
No hearing loss
Benign paroxysmal positional vertigo
Vestibular neuritis
Hearing loss
Ménière disease
Labyrinthitis

33. Copyright © 2014 American Geriatrics Society
GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Aman Nanda, MD and questions by Kourosh Parham, MD, PhD Managing Editor: Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society