Most Common Cause Of Dizziness In Elderly

Most Common Cause Of Dizziness In Elderly – Diagnosing the cause of dizziness can be difficult because symptoms are often nonspecific and the differential diagnosis is wide. However, some simple questions and a physical examination can help narrow down the possible diagnoses. It is estimated that more than half of all patients with dizziness are treated by primary care physicians.

Dizziness is a presenting symptom in approximately 3% of primary care visits and nearly 3% of emergency department visits in patients 25 years and older.

Most Common Cause Of Dizziness In Elderly

Most Common Cause Of Dizziness In Elderly

Dizziness can be divided into four main types: vertigo, imbalance, presyncope, or lightheadedness. Although a proper history and physical examination can usually make the diagnosis, the ultimate cause of dizziness cannot be determined in up to one in five patients.

What’s Making You Dizzy? If You’re Older, There Could Be Lots Of Reasons

Because they are usually not diagnostically helpful, laboratory tests and radiographic studies are not routinely performed in the workup of patients with dizziness when no other neurologic abnormalities are present.

Therefore, the history should first focus on the types of sensations the patient is feeling. Table 1 includes descriptions of the main categories of dizziness.

It is worth noting that some causes of dizziness may be associated with more than one set of descriptors.

Medication history should be obtained as dizziness (especially orthostatic hypotension) is a well-known adverse effect of many medications

Dizziness And Vertigo Shawn Stepp, Pa C Central Maine Medical Center Emergency Department We Have All Had The Vague Dizzy Patient In The Office Or The.

Head trauma and whiplash can cause a variety of dizziness symptoms, from vertigo to lightheadedness. The incidence of dizziness after a head injury or initial vertigo after a sprain has been reported to be as high as 78% to 80%.

Paroxysmal vertigo with migraine symptoms and photophobia, phonophobia, or aura symptoms during at least two episodes of vertigo

Blood pressure drops during body position changes, resulting in reduced blood flow to the brain, a side effect of many medications (see Table 2)

Most Common Cause Of Dizziness In Elderly

A decrease in systolic blood pressure of 20 mmHg, a decrease in diastolic blood pressure of 10 mmHg, or an increase in pulse rate of 30 beats per minute

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Diminished tactile response while walking causes patients to be unaware when their feet touch the ground, leading to imbalance and falls

These include benign paroxysmal positional vertigo (BPPV), vestibular neuritis (a viral infection of the vestibular nerve), labyrinthitis (an infection of the labyrinth organs), and Meniere’s disease (an increase in lymphatic fluid in the inner ear).

Hearing loss and symptom duration can help further narrow the differential diagnosis in patients with vertigo. Vertigo with hearing loss is usually caused by Meniere’s disease or labyrinthitis, while vertigo without hearing loss is more likely to be caused by BPPV or vestibular neuritis.

Paroxysmal vertigo is often caused by BPPV or Meniere’s disease, while persistent vertigo may be caused by vestibular neuritis or labyrinthitis.

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Migrainetic vertigo, or vestibular migraine, is another underlying cause of vertigo, affecting about 3% of the general population and about 10% of migraineurs.

This diagnosis should be considered after other causes of vertigo have been ruled out. Migrainetic vertigo is diagnosed in a patient with a history of episodic vertigo and either a current migraine or a history of migraine and at least two episodes of vertigo with one of the following symptoms: migraine, photophobia, phonophobia, or aura.

Several cardiovascular medications increase the risk of orthostatic hypotension in older adults, including reserpine (at doses greater than 0.25 mg), doxazosin (Cardura), and clonidine (Catapres).

Most Common Cause Of Dizziness In Elderly

There are many underlying conditions that can cause a feeling of imbalance. Stroke is an important and life-threatening cause of dizziness and needs to be ruled out when dizziness is associated with other symptoms of stroke. However, other neurologic findings are often present. In a population-based study of more than 1,600 patients, 3.2% of patients who presented to the emergency department with dizziness were diagnosed with a stroke or transient ischemic attack (TIA), but only 0.7% had dizziness alone. Patients present with a diagnosis of stroke or TIA.

What’s Causing My Dizziness?

Causing a fall. Doctors should ask for a history of other problems that may cause imbalance, such as Parkinson’s disease, peripheral neuropathy, and any musculoskeletal disorders that may affect gait.

Psychiatric causes of dizziness are common, especially anxiety. Therefore, questions about anxiety and depression should be included in the patient’s history. In one study, about 28 percent of people with dizziness reported at least one symptom of an anxiety disorder.

A study of patients with chronic dizziness found that those with panic disorder were more likely to experience neurological symptoms than those without panic disorder.

It has been reported that up to 60% of patients with chronic subjective dizziness suffer from anxiety disorders.

When To Seek Treatment For Dizziness

Hyperventilation syndrome is an important cause of dizziness. Although this condition may be associated with anxiety disorders, many patients without anxiety disorders hyperventilate. Hyperventilation is defined as breathing in excess of metabolic demands, resulting in respiratory alkalosis and dizziness. Patients may sigh repeatedly and may experience associated symptoms such as chest pain, paresthesias, abdominal distension, and epigastric pain.

The primary goal of the physical exam is to reproduce the patient’s dizziness symptoms in the office. There are some simple physical exams that can be done to help achieve this goal.

Blood pressure should be measured first with the patient in the supine position and again at least one minute after the patient is standing. A decrease in systolic blood pressure of 20 mmHg, a decrease in diastolic blood pressure of 10 mmHg, or an increase in pulse rate of 30 beats per minute indicates orthostatic hypotension.

Most Common Cause Of Dizziness In Elderly

) can diagnose BPPV if positive, but cannot rule out BPPV if negative. The procedure is performed on a flat examination table. When the patient is in a sitting position, the doctor turns the patient’s head 45 degrees to one side, then quickly places the patient in a supine position with the head hanging about 20 degrees from the end of the table, and observes the patient’s eyes for about 30 seconds. Repeat this movement, turning your head to the other side. Nystagmus is the diagnosis of vestibular fragments in the ear facing downward, closest to the examination table. Patients usually experience nystagmus with a latency period of several seconds and a feeling of dizziness that can last up to a minute.

Vertigo —

Damage to the labyrinth and cranial nerve VIII (vestibulocochlear nerve) often produces spontaneous nystagmus. The saccadic eye movements associated with the patient’s smooth pursuit of the physician’s finger as it moves slowly left, right, up, and down may be related to central causes, such as brainstem or cerebellar disease. The head pulse test involves asking the patient to stay focused on a target while the doctor quickly moves the patient’s head back and forth. Sideways movement of the eye accompanied by refixation saccades (rapid oscillatory eye movements that occur when the eye is fixed on an object) indicates the presence of a lesion on the side of the eye movement. Bilateral reimmobilization movements often occur with ototoxicity. Another test that can induce nystagmus is for the patient to lean forward 30 degrees while the doctor vigorously rocks the patient’s head back and forth for 20 seconds. The presence of nystagmus suggests a peripheral cause in the ipsilateral direction of the nystagmus.

Other physical tests include the Romberg test and gait observation. Swinging to one side on the Romberg test indicates ipsilateral vestibular dysfunction. In addition, the patient’s gait will tend to favor the side of the vestibular lesion. Ataxia indicates cerebellar dysfunction, and the patient’s gait is often slow, broad-based, and irregular.

In the early stages of Parkinson’s disease, the gait is often slower, with smaller stride lengths and reduced arm swing, and later in the disease, freezing and hesitation develop.

If hyperventilation syndrome is suspected, the diagnosis can be confirmed by asking the person to take 20 rapid deep breaths in and out to try to reproduce symptoms.

Dizziness: Approach To Evaluation And Management

All patients with dizziness should undergo a thorough cardiovascular examination. However, tests such as ECG, Holter monitoring, and carotid Doppler testing should only be performed if an underlying cardiac cause is suspected based on other test results or known cardiac disease.

In general, laboratory tests and radiographic studies are not helpful in the workup of patients with dizziness when no other neurologic abnormalities are present.

Laboratory studies, including complete blood counts, metabolic panels, and thyroid function tests, are very ineffective at diagnosing the cause of dizziness. In a meta-analysis, only 26 of 4 538 patients (0.6%) had laboratory abnormalities that could explain their dizziness symptoms.

Most Common Cause Of Dizziness In Elderly

Electronystagmography tests vestibular function by using electrodes to detect nystagmus. The test has been reported to have a sensitivity of 69% to 74% and a specificity of 81% to 83% for peripheral vestibular disease. Sensitivity as high as 81% and specificity as high as 93% have been reported for central vestibular disorders.

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After obtaining the patient’s history, the doctor can tailor the physical exam to best suit the differential diagnosis. Figure 2 describes one approach to the initial assessment of a patient with dizziness.

The initial medical history can help place the diagnosis into one of four major categories of dizziness. Questions specific to that category can then further narrow down the possible diagnoses. A thorough neurological and cardiovascular examination should be performed on all patients, with a targeted physical examination based on suspicion

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