DIZZINESS Module # 3 Management 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 #3 on Management. Over the next many slides we will attempt to review the Management of dizziness in the elderly. If you have not reviewed module 1 and 2 on dizziness please do so at this time and then return to module 3. We hope that you will enjoy this module more than we did making it. Recall that at the end of the last module on evaluation we reviewed some basic principles on approach to diagnosis and initial treatment. We will not repeat those in this module, rather we will concentrate on treatment of some specific etiologies of dizziness.

PROCESS Series of modules and questions 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 to review management of dizziness with using a PowerPoint module with voice overlay. This will be followed by 2 case based questions with answers to explain the right and wrong response. This will then complete the series on dizziness. Then you will have the option to continue with additional modules on other topics 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: Describe the management of the most common causes of dizziness Describe the Epley maneuver List the physiology blood pressure maintenance and the changes with aging At the completion of this module we hope that you will know how to handle most of the common causes of dizziness. Also we hope you have a good idea of how to perform the Epley maneuver and perhaps teach your patients how to do this at home. Lastly that you understand the elderly’s unique blood pressure problems that predispose them to othostasis.

MANAGEMENT “Tincture of time” spontaneously resolution in > 50% or substantially improves within 2 weeks. Often associate with viral or other self-limited illnesses 50 % or more will be MULTIFACTORAL “Tincture of time” In up to half of the patients, dizziness will spontaneously resolves or substantially improve within weeks. Often it is associated with a viral infection or other self-limited illnesses, dehydration or a medication adverse effect. The two most common (labrynthitis and BPV ) typically resolve within days or weeks respectively Finally, when managing a patient with dizziness, it is important to remember that approximately half of patients may have two or more potential causes

MANAGEMENT Acute vertigo attacks Treatment occur with peripheral vestibular disorders such as labyrinthitis Meniere's disease SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9 Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003. Vol 58, No 4, 46-52 Treatment First choice avoid medications, hydrate Second choice trial of “Epley Maneuvers If fails may benefit from meclizine or Prednisone if needed, a benzodiazepine. Often “trade” vertigo for increased fall risk, sedation and anticholinegic effects Meclizine overprescribed for chronic vestibulopathies and non-vertiginous dizziness. Acute vertigo attacks occur with peripheral vestibular disorders such as labyrinthitis and Meniere's disease. The first move is try to make sure the patient is well hydrated and can rest as much as possible. We must make sure that the elder has a support person readily available if they do not require hospitalization. Second choice is a trial of “Epley Maneuvers” if the patient is not too severely vertiginous at the time ( we will cover this later) For persistent and severe symptoms, the patient may benefit from meclizine or if needed, a benzodiazepine. This is not without some risk since meclizine introduces anticholinergic side effects that include sedation, confusion, constipation and increased fall risk. Benzodiazepines give the same risk factors minus the constipation. If one must use a benzodiazepine the best choice is lorazepam or oxazepam. I want to remind you that this is for acute vertigo because certainly meclizine is overprescribed for chronic vestibulopathies and non-vertiginous dizziness. For acute severe labrynthitis , prednisone at 1 mg/kd/day for 5 days then taper over 2 weeks has been used.

MANAGEMENT Benign positional vertigo usually can be treated with simple reassurance For severe or persistent symptoms: the canalolith repositioning procedure (Epley's maneuver) home habituation exercises SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9 Benign positional vertigo This problem can usually be treated with simple reassurance, since symptoms are typically mild and usually improve within weeks to several months. For severe or persistent symptoms, the canalolith repositioning procedure (Epley's maneuver) may be performed in the office and then the patient may be educated about home habituation exercises to reduce symptoms. These will be shown and discussed in the next slides

The Epley Maneuver, or Canalith Repositioning Maneuver, is much like the Dix-Hallpike Maneuver with the additional modifications that we will describe. Again, the patient here is sitting on the end of the exam table or bed. If their right ear is affected, they turn their head 45o to the left and lie down quickly with shoulders on the pillow and head reclining. They wait about 30 seconds then turn their head 90o onto their right ear. Wait again 30 seconds or at least as long as they can stand it. This is usually when their vertiginous symptoms start to occur. Then they turn their body onto their right side, wait another 30 seconds, then swing their legs over the side of the bed and push themselves up with their arms keeping their head and shoulders in the same alignment as when they were on the bed. When performed in the clinic, repeat this until the symptoms have declined. While performing this, we should be simultaneously training our patients to be able to do this at home.

Left ear is symptomatic; This is the same maneuver as previously reported but reversed.

MANAGEMENT Meniere's disease If attacks are frequent or disabling may benefit from prophylactic treatment with salt restriction or diuretic therapy or both. Occasional require referral to otolaryngology for consideration of surgery SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9 Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003. Vol 58, No 4, 46-52 Meniere's disease in which attacks are frequent or disabling may benefit from prophylactic treatment with salt restriction or diuretic therapy with Hydrochlorothiazide 12.5mg to 25 mg per day or sometimes both. Occasional patients may require referral to otolaryngology for consideration of surgery

Orthostatic hypotension Correct reversible causes of Syncope Etiologies: P-A-S-S O-U-T (mnemonic) P ressure (hypotensive causes) A rrhytmias S eizures S ugar (hypo/hyperglycemia) O utput (cardiac) /O2 (hypoxia) U nusual causes T ransient Ischemic Attacks & Strokes Orthostatic hypotension is perhaps one of the areas where we have the most potential to benefit our patients. First, we must look for correctable causes. The mnemonic here gives you a differential for syncope, of which orthostatic hypotension is a major cause. You can review more on syncope in the Syncope module. The next slides will review the topic of orthostatic hypotension.

P ressure (Hypotensive induced causes) Why elderly are predisposed to hypotension problems I want to pause over the next few slides to discuss elders and why they are predisposed to orthostatic hypotension. This is important knowledge to have to prepare us to reduce this problem in the elderly.

Mechanisms of compensation for gravitational effects of standing Autonomic Endocrine Carotid/aortic baroreceptors  renin release  angiotensin II  aldosterone sympathetic tone To maintain blood pressure, whether we are elders or not, we need an intact autonomic nervous system that is driven by our carotid/aortic baroreceptors. When they sense decline in pressures, they send stimuli to the brain to increase sympathetic tone, which then causes increased peripheral vasoconstriction and heart rate. On the other side, our endocrine system must release renin that increases angiotensin II and aldosterone leading to vasoconstriction and sodium retention, respectively. Another thing that we ask our endocrine system to do is to reduce atrial natriurectic factor which reduces vasodilatation and increases the renin-angiotensin system. vasoconstriction  sodium retention peripheral vasoconstriction & heart rate Atrial Natriurectic factor  vasodilator  renin-angiotensin

Aging, Physiology and Blood Pressure Physiology of Pressure maintenance Aging Physiologic changes Baroreceptors sensitivity Decreased sensitivity Volume (fluid) Decreased reserve Vascular tone Decreased tone B-receptor responsiveness Decreased B-receptor responsiveness Muscle tone and therefore venous return What happens to this system as we age? Our baroreceptors become less sensitive and are less quick to respond to dropping blood pressure. We keep less fluid reserve in our bodies due to reduced muscle mass and, hence, have less margin of error when we do start to drop in our fluid intake or with increased fluid loss. Our vascular tone decreases and, perhaps most important, our beta responsiveness in cardiac output declines and we cannot reach the same maximum heart rate or cardiac output we might have had as younger people. Lastly, muscle tone is decreased and, therefore, our venous return is decreased. All of these set the stage for an increased incidence of hypotensive events.

Disease changes that predispose Incidence increased Physiology of Pressure maintenance Aging Physiologic changes Disease changes that predispose Incidence Autonomic Nervous System dysfunction (e.g.DM) increased Cerebrovascular auto-regulatory dysfunction (HTN)* Medications *(20-30% of HTN pop. Age > 65 can have orthostatic hypotension (O.H.)) ( 7% of Normotensive pop. age > 65 can have orthostatic hypotension ) Then along come diseases that affect the system even more profoundly. Diseases that affect the autonomic nervous system, such as in diabetic neuropathy or cerebrovascular auto regulatory changes, such as in chronic hypertension. As noted here, up to 30% of our patients with hypertension over age 65 will demonstrate orthostatic changes of significance, whereas only 7% of the normotensive population will do the same. Lastly, medications, (that we will repeatedly remind nag about), are a significant factor in the incidence of orthostatic hypotension.

General Causes of P ressure Problems: 1)Vasovagal 1-29 % of all causes syncope. 2) Orthostatic Hypotension 5-29 % of all causes syncope General causes of pressure problems overall also include vasovagal. If we were talking about syncope it would cover up to 29%, whereas orthostatic hypotension covers approximately another 29%.

Orthostatic Hypotension CAUSES The List of causes: a) Volume loss b) Medications c) Situational d) Primary Autonomic Disease e) Secondary Autonomic Disease f) Adrenal Insuffiency a)Volume Loss blood loss fluid loss (diarrhea, sweating, diuresis, dehydration) b) Medications; antihypertensives B-blockers alcohol anticholinergics antianginals vasodilators antiparkinsonian The list of orthostatic causes is quite long. However, the clinician can quickly sort through these. Certainly volume loss is often quite apparent. Medications, which we’ve covered before, are the same list of common offenders that would either affect blood pressure through direct vasodilatation or impaired cardiac output.

Orthostatic Hypotension CAUSES continued c)Situational (many of these involve the Vasovagal mechanism) micturition postprandial* cough carotid sinus sensitivity defecation laughing Situational causes, mostly mediated through vasovagal mechanisms will include micturition, postprandial, cough, carotid sinus sensitivity, defecation, and laughing. Note that up to 30-40% of elderly nursing home population will show orthostatic blood pressure changes after meals, but only 2% are symptomatic from it.

Orthostatic Hypotension CAUSES continued d) Primary Autonomic Disease Idiopathic Multi-System Atrophy (e.g.Shy-Dragger) Parkinson’s disease e) Secondary Autonomic disease Neuropathic e.g.DM, amyloid, alcoholism, auto-immune Cancer, B12 def., porphyria CNS e.g. CVA’S, MS, Tumors, Wernickes, spinal cord lesions Renal failure Additional causes include both the primary autonomic diseases, foremost of which is Parkinson’s disease, and the secondary autonomic diseases, which are quite common. Among those, probably the most common are diabetic neuropathies, alcoholic neuropathies, renal failure, and various autonomic disease.

MANAGEMENT Vision Improve MSK Re-strengthening Disequilibrium: Vision Improve MSK Re-strengthening Gait evaluation and therapy Balance training Assistive device evaluation and use Chronic vestibulopathy: Vestibular rehabilitation? SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9. Disequilibrium: For the elderly patient with chronic disequilibrium, this is often multi-factorial, so here the pursuit and the correction or improvement in as many factors as possible is key. ( See module 2 for discussion). Here we should maximize their vision, improve musculoskeletal problems, improve strength, gait or balance with physical therapy, take measures to prevent falls, including the use of a cane, walker, or other assistive device, Chronic vestibulopathy: Vestibular rehabilitation (a type of physical therapy exercise program) may be beneficial in persons with persistent dizziness.

MANAGEMENT Lightheadness Psychiatric issues depression, anxiety & somatoform disorders Antidepressants? Counseling? Prescription drug toxicity usually cardiovascular, antihypertensive, psycho-tropic and diuretics. For lightheadedness the two most common offenders are psychiatric problems and medication toxicity Psychiatric issues Depression, anxiety are the most treatable disorders. Here the clinician could consider a trial of antidepressants. Newer antidepressants (eg, selective serotonin-reuptake inhibitors, mirtazapine, bupropion) are preferable to tricyclic antidepressants, which sometimes cause orthostatic hypotension, sedation, and constipation. Prescription drug toxicity This usually involves the cardiovascular, antihypertensive, psycho-tropic or diuretics medications.

MANAGEMENT Lightheadness Other causes Treatment cervical arthritis: pain control, ROM visual disorders: maximize vision carotid sinus hyper-sensitivity: Avoid neck pressure, Medication review If improvement or correction of the psychiatric or medication conditions does not change symptoms then pursuit of these common “other causes” is likely to benefit, these are cervical arthritis, visual disorders and carotid sinus hyper-sensitivity. For cervical arthritis, controlling pain and improving range of motion would be key in this area. Often we will need to add the care of a physical therapist in order to maximize the benefits and to train them to do the exercise correctly. Obviously, visual disorders would be an ophthalmologic evaluation to maximize this aspect of their lightheadedness. Lastly, carotid sinus hypersensitivity within the elderly, as previously discussed, is felt to not be a common problem. One would need to avoid neck pressure, perform careful medication reviews and, if persists, may need to have a cardiology evaluation for tilt table or electrophysiologic evaluations.

Practical Approach to Evaluating the Dizzy Patient History ( start with Brief, focused evaluation and simple follow-up) Step #1; Describe symptoms Step #2: Pass out? ( syncope often requires early cardiac w/u) Step # 3: Classify* into 3 key sensations: (spinning, fainting, or falling?) Step #4: Positional effect on symptoms? worsen with head movements? (eg, benign positional vertigo), standing up (eg, orthostatic hypotension) associated with ambulating (eg, disequilibrium) Step # 5; Associated symptoms? syncope ( needs syncope eval.) nausea or vomiting, ( vertigo) hearing, ear symptoms ( Meniere's disease, acoustic neuroma) ataxia or focal neurologic deficits (central neurological cause) multiple somatic complaints (depression, anxiety, somatoform disorder) Step #6: Medications review: (especially new around the time of onset ) *CLASSIFICATION Symptom-oriented approach--- Classify as: Vertigo (rotational sensation), …………………….“spinning” Presyncope (impending faint),…………………… “fainting” Disequilibrium (loss of balance without head sensation)“falling” Lightheadedness (ill-defined, not otherwise classifiable). Let’s review the approach. The following is a summary of a diagnostic approach to the dizzy patient. Remember: to start with this brief focused evaluation and early follow up. First: in history get them to describe their symptoms. In step #2 try to get them to clarify whether they did have a syncopal event. Then in step #3, assist them in classifying the symptoms into the three key sensations that will guide you to “spinning”, “fainting” or “falling”. Determine in step #4 the positional effect on the symptoms. In step #5 look for associated symptoms that might guide you. Lastly, review the medications. At the bottom of this slide is a review of the classifying symptoms and what they relate to.

Practical Approach to Evaluating the Dizzy Patient Physical examination Orthostatic blood pressure and pulse Nystagmus exam: 1st: Primary position. 2nd: Gaze-evoked 3rd: Dix-Hallpike test, 4th Head-shaking. Cardiovascular exam Neurologic (cerebellar, propioceptive, motor, sensory) ( include “Up and go test”) Vision & Hearing Diagnosis & Treatment Assume multi-factorial Classify Symptoms List Factors derived from “ Classification”) and their etiologies Treat multiple factors and the easiest first Time is on your side ( go slow), see patient back often The physical exam should focus on orthostatic blood pressure changes, the nystagmus exam, a short cardiovascular exam, a neurologic exam, and vision-hearing exams. Lastly, diagnosis and treatment should assume from the beginning that there will be multiple factors causing this dizziness. Again, we classify the symptoms, list the factors in this classification and their etiologies, and treat the multiple factors - the easiest ones first. Remember, time is on your side – go slow and see the patient often.

The End of Dizziness Modules Request “Dizzy Pearls” summary card from 402.559.3964 or kfturner@unmc.edu Credits: Adapted with permission from; Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165 This is the end of the dizziness module. If you would like a summary card of the diagnostic evaluation that you have just seen, please contact the number listed below. Please close out this window and complete the question and review the explanations. Then, if you have enough energy, you can proceed to alternative modules or take a break.