1. DIZZINESS Suggestions for Lecturer -1-hour lecture
-Use GNRS slides alone or to supplement 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 on patient evaluation and management.
-Supplement lecture with handouts.
-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 classification and causes of dizziness in older adults
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
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
More common in women than in men
Challenges for clinicians
Precise classification is difficult
Worry about serious causes
Specific therapy not available for many
50% of cases have multiple causes
The various and often nonspecific terms—lightheadedness, giddiness, wooziness, vertigo, spinning, floating, and imbalance—that patients typically use to describe dizziness add to the diagnostic and management challenge.

5. ACUTE VS. CHRONIC DIZZINESS
Acute Dizziness:
Independent of age
Usually results from a disorder of one system
Most common causes include: acute vestibular neuritis, cerebrovascular ischemia, and cardiovascular disorders resulting in hypotension
Chronic Dizziness:
Ongoing for greater than 1–2 months
More common in older adults
Often has multifactorial etiology
Considered a geriatric syndrome and requires a multifactorial assessment and intervention strategy
Chronic dizziness is associated with risk factors such as angina, myocardial infarction, stroke, arthritis, diabetes, syncope, anxiety, depressive symptoms, impaired hearing, and the use of medications in several classes. In a study of a large community sample and in another study in which patients attended a geriatric clinic, the complaint of chronic dizziness was associated with factors such as anxiety, depressive symptoms, postural hypotension, use of ≥5medications, and impaired gait and balance (SOE=B). Complaints of chronic dizziness were more common in patients who had >5 of these risk factors than in those having <2 of these risk factors. Similar to delirium and falls, chronic dizziness can be thought of as a geriatric syndrome that prompts a multifactorial assessment and intervention strategy, which is likely more effective at alleviating symptoms than a standard disease-oriented approach.

6. DIZZINESS: CLASSIFICATION BY SYMPTOMS
Vertigo — Rotational sensation
Presyncope — Sensation of faintness or lightheadedness
Dysequilibrium — Feeling of imbalance on standing or walking
Other — Vague feeling, may be described as “floating”, “lightheadedness”, “wooziness”, or other nonspecific sensations
Mixed — A combination of two or more of the above is the most common type
See Table 27.1 in Chapter 27 – Dizziness, in GNRS5, for more information on the classification of dizziness

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

8. 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

9. 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

10. PRESYNCOPE Sensation of near-fainting
Sign of decreased cerebral perfusion
Postural change – dizziness on standing from a supine position (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.

11. DYSEQUILIBRIUM
Sensation of imbalance or unsteadiness on standing or walking
Many factors can contribute to imbalance:
Vision problems
Proprioceptive disorders
Musculoskeletal disorders
Gait disorders
Dysequilibrium, 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).

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

13. MIXED DIZZINESS A combination of two or more types of dizziness
Most common type reported by older adults
Likely results from combinations of diseases affecting the vestibular, CNS, visual or proprioceptive systems
Systemic disorders (eg, anemia, heart failure, diabetes mellitus, and hypothyroidism) can contribute to instability or dizziness
Consider carotid sinus hypersensitivity or carotid sinus syndrome in the differential

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

15. 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

16. 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, imbalance or unsteadiness, or fainting
Whether there is a positional effect on symptoms
Frequency and duration of symptoms
If symptoms peak at any specific time of day
What other symptoms are associated with dizziness (specifically ask about hearing loss, ear fullness, diplopia, dysarthria, and tinnitus)
What medications the patient is taking, including any OTC medications
How symptoms are affecting the patient’s quality of life
OTC= over the counter
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.

17. 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:
Dix-Hallpike maneuver
Head-thrust test
Fukuda stepping test
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).

18. 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)
Helps differentiate between acoustic neuroma and Meniere disease

19. EVALUATION OF DIZZINESS: DIAGNOSTIC TESTING (2 of 2)
ECG if cardiac cause suspected
Holter and Event monitor only if suspicion of arrhythmia
Tilt-table testing only in select patients with postural hypotension or syncope
Vestibular testing
Electronystagmography
Rotatory chair
Dynamic posturography
Neuroimaging (CT, MRI) occasionally warranted
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. (SOE=B)

20. 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 20

21. 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); dosage adjustment or removal of offending medications; 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
PT= Physical Therapy
OT= Occupational Therapy
Topic
Slide 21

22. MANAGEMENT OF DIZZINESS: DYSEQUILIBRIUM
Common causes or coexisting conditions
Treatment
Vertebrobasilar ischemia and/or cerebellar infarcts/hemorrhages
Low-dose aspirin, clopidogrel, or extended-release dipyridamole/aspirin; rehabilitation
Cerebellopontine angle tumor, eg, acoustic neuroma
Surgery
Parkinson disease
Drug therapy, rehabilitation therapy
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 22

23. MANAGEMENT OF DIZZINESS: PSYCHOGENIC
Common causes or coexisting conditions
Treatment
Anxiety, depression, or psychosomatic disorders
Psychotherapy and/or antidepressant therapy
Topic
Slide 23

24. 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 24

25. 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.

26. SUMMARY
Precise classification of dizziness into vertigo, presyncope, dysequilibrium, and lightheadedness is often difficult, and multiple causes of the same symptoms are common
Most dizziness resolves within days to several months
Important to elicit a detailed history from the patient including a medication history
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

27. CASE 1 (1 of 3)
An 85-year-old woman has had recent episodes of dizziness in which she senses the room spinning around her, feels her right ear is blocked, and hears a roaring sensation.
The symptoms improve gradually until she returns to baseline over a few hours.
She has no associated headaches.
History: diabetes, hypertension

28. CASE 1 (2 of 3)
Which one of the following is the most likely diagnosis?
Benign paroxysmal positional vertigo
Acute labyrinthitis
Arrhythmia
Ménière disease
Migraine-associated vertigo

29. CASE 1 (3 of 3)
Which one of the following is the most likely diagnosis?
Benign paroxysmal positional vertigo
Acute labyrinthitis
Arrhythmia
Ménière disease
Migraine-associated vertigo
ANSWER: D
Several characteristics, including duration of vertigo and presence of hearing symptoms, help establish the diagnosis of Ménière disease in this patient (SOE=B). In patients with Ménière disease, episodes last several hours and include the triad of vertigo, hearing loss (commonly low frequency, which may be subjectively described as blocked ears), and tinnitus (often roaring). The pathophysiology of Ménière disease is believed to be related to pressure from excess endolymphatic fluid leading to inner ear dysfunction.
Benign paroxysmal positional vertigo is the most common cause of vertigo; its underlying pathophysiology is thought to be displacement of canaliths from the utricle into the semicircular canals, primarily the posterior semicircular canal. Patients with this disorder have episodic vertigo lasting no more than a few minutes and no other associated otologic symptoms.
Patients with symptoms lasting >2 days are likely to have either vestibular neuritis or labyrinthitis. The distinguishing characteristic between these otogenic sources of true vertigo is hearing loss. Labyrinthitis involves inflammation of the inner labyrinthine structures where cochlear and vestibular apparatuses are in continuity, causing both hearing loss and vertigo. In contrast, vestibular neuritis is believed to be associated with inflammation of the vestibular nerve, thus sparing the cochlea.
In this case, the presence of true vertigo and the absence of associated headache exclude arrhythmia and migraine-associated vertigo, respectively. Migraine is increasingly recognized as a cause of recurrent vertigo. Key diagnostic features are headache, visual aura, and photophobia or phonophobia during or preceding the vertiginous episode.

30. CASE 2 (1 of 3)
An 81-year-old woman has episodes of dizziness in which the room spins intensely when she tries to get out of bed.
The episodes last ≤1 minute.
At first they were associated with intense nausea.
She feels better when she does not move her head.
She has had no other recent changes in health, and has worn the same glasses for the past year.
She has never had tinnitus or changes in hearing.
History: hypertension, COPD, cholecystectomy (performed 30 years ago)
Physical examination
External auditory canals and tympanic membrane appear normal.
Results of lateralization and conduction examinations using a 512 Hz tuning fork (Weber and Rinne tests) are normal.
Cardiovascular and neurologic findings are unremarkable.

31. CASE 2 (2 of 3)
Which one of the following is most likely to aid in the diagnosis?
Comprehensive vestibular testing
Carotid duplex scans
Positional maneuvers (Dix-Hallpike test)
MRI of the head
Audiometric examination

32. CASE 2 (3 of 3)
Which one of the following is most likely to aid in the diagnosis?
Comprehensive vestibular testing
Carotid duplex scans
Positional maneuvers (Dix-Hallpike test)
MRI of the head
Audiometric examination
ANSWER: C
Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness. It occurs in all age groups, and its prevalence increases with age. BPPV can present with vertigo associated with head movement, but its presentation in older adults may be atypical, thus accounting for a low recognition rate in the primary care setting. Vertiginous episodes of BPPV may occur over a period of weeks or months. BPPV is believed to be associated with displacement of fragments of utricular otoconia into the semicircular canals, with the posterior semicircular canal most commonly affected. Otoconia—minute calcareous particles in the gelatinous membrane in the inner ear—may fragment with trauma, age, or changes in the physiology of endolymph (eg, pH, calcium concentration). Presentation of BPPV is varied because otoconia fragments can be displaced into any of the semicircular canals on either (or both) sides and may be free floating (canalithiasis) or attached to the cupula (cupulolithiasis). Positional maneuvers can be used to diagnose and treat most cases. In rare intractable cases, surgical management may be considered. A strong association with osteoporosis has been reported, which suggests that idiopathic BPPV may have diagnostic and management implications beyond a purely otologic focus.
The Dix-Hallpike test is a standard component in evaluation of dizziness. In this procedure, the examiner stands to one side of the patient and rotates the patient’s head 45 degrees to that side to align the ipsilateral posterior semicircular canal with the sagittal plane of the body. Next, the examiner moves the patient, whose eyes are open, from the seated to the supine test-ear-down position and then extends the patient’s neck slightly so that the chin is pointed slightly upward. The latency, duration, and direction of nystagmus, if present, and the latency and duration of vertigo, if present, are noted. Each position should be maintained at least 30–45 seconds or until nystagmus resolves. If positive, rotary nystagmus toward the test ear is commonly observed. This is induced by the movement of free-floating debris within the affected canal (away from the cupula, inducing deflection of the cupula away from the vestibule). If no nystagmus is observed, or, if present, once it resolves, the patient is seated upright and once again eyes are monitored for nystagmus, which is once again documented as above. The procedure is repeated for the opposite ear.
Although a combination of computerized audiologic and vestibular function tests as well as carotid and cerebral imaging may be required if the Dix-Hallpike test is inconclusive, they are not warranted at this time.

33. GNRS5 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS5 Teaching Slides modified from GRS9 Teaching Slides based on chapter by Aman Nanda, MD and questions by Kourosh Parham, MD, PhD Managing Editor: Andrea N. Sherman, MS Copyright © 2016 American Geriatrics Society