1. DIZZINESS IN AN OLDER ADULT 10/12/05 MARY JO WILLIS MS, APRN, BC CLINICAL PROFESSOR NURSE PRACTITIONER

2. n I have no financial interest to report

3. OBJECTIVES n Review common causes of dizziness/vertigo n Describe clinical pearls of vertigo testing/treatment n Discuss the issues of vertigo testing

4. THE CASE n 79 year old with Hx postural hypotension n Sudden onset of dizziness 2 weeks ago n Two more episodes since that time

5. THE PATIENT n PMH: Macular degeneration, BPH, anemia, polymyalgia rheumatica n SH: Retired, non-smoker, no ETOH n FH: No Meniere’s disease n ROS: No changes in hearing, vision, speech; no fall, head injury, weakness/ paralysis of extremities, LOC, or recent URI

6. THE PATIENT n Medications: –Prednisone –Terazosin –Ferrous sulfate – TMP-Sulfa DS –Ocuvite

7. DIZZINESS IN THE ELDERLY n Cannot place dizziness into one category –Disequilibrium can accompany other types of dizziness when intact compensatory systems are absent –Need to distinguish between primary symptom and secondary causes –Need to distinguish acute from chronic dizziness-no consensus Sloane et. Al., (2001)

8. CATEGORIZING DIZZINESS n Pre-syncope n Syncope n Disequilibrium n Psychogenic n Vertigo

10. PRESYNCOPE n Sense of impending fainting or LOC n Episodic diffuse temporary cerebral ischemia n Sweating, pallor, telescoping of peripheral vision

11. SYNCOPE n Syncope: sudden transient loss of consciousness with concurrent loss of postural tone n Multi-system causation n Most common causes are vasovagal episodes or orthostatic hypotension

12. DISEQUILIBRIUM n Disequilibrium: Perceived postural instability involving legs and trunk without head sensation n Overlap between imbalance and disequilibrium n Vertigo not present

13. PSYCHOGENIC n Dizziness that cannot be readily classified into previous categories n No focal or PE findings n Chronic n Common Mechanisms –Hyperventilation –GAD, Major depressive disorder –Somatization disorders –Substance abuse

14. VERTIGO n Illusion of motion interpreted as self movement or environmental movement n Rotating with spinning sense of falling or swaying back and forth: Merry-Go- Round Effect n 1/2 of patients with dizziness have vertigo

15. ETIOLOGY OF VERTIGO Asymmetry of the vestibular system due to pathology involving: –Labyrinth and vestibular nerve(40%) –Central vestibular structures in brainstem (10%) –Remaining 50% are conditions noted earlier

16. VERTIGO n Time course n Provoking factors n Associated symptoms n Prior risk factors

17. PERIPHERAL VESTIBULAR DYSFUNCTION n Labyrinthitis (vestibular neuronitis) n Meniere’s Disease n Trauma n Tumors (Acoustic Neuroma) n Benign Paroxysmal Positional Vertigo

18. PERIPHERAL VERTIGO n Acute Viral Labyrinthitis /Vestibular Neuronitis –Usually preceded by a viral respiratory or GI infection –Sudden onset of nausea, vomiting, severe vertigo worsened by change in position –Can last for days to weeks –Nystagmus may last for months

19. PERIPHERAL VERTIGO n Meniere’s (Endolymphatic Hydrops) –Spontaneous onset/recurrent attacks –Duration of symptoms: min- hrs –Often preceded by tinnitus, ear fullness –Sensori-neuro hearing loss which varies day to day –Chronic recurrent

20. PERIPHERAL VERTIGO Drugs (www.annuls.org) Appendix (41-44) www.annuls.org Trauma Acoustic Neuroma: Vestibular Schwannoma –Account for < 1% of patients –Disequilibrium is more likely –Gradual rather than acute onset

21. The Patient n Episodes occurred when he was lying down and turned over to his left side n Slightly nauseated-no vomiting n Reports that the room is spinning n Last about “10 minutes” n Getting into an upright position helps

22. DIZZY HISTORY n Key questions: Describe the first episode –Objects spinning/turning around you –Occur in attacks –Position change makes you dizzy –Can you tell when it may start –Can you stand unsupported –What will stop the dizziness, make it better or worse

23. THE PATIENT n Afebrile, No postural hypotension n In NAD, cognition appropriate n HEENT: WNL n Neck: no carotid bruits n CV: bradycardia, irregular rhythm n Lungs: WNL

24. NEURO EXAM n Neuro: CN 2, 5,7,8-12 intact n No nystagmus with EOMs n Romberg/cerebellar tests intact n DTRs. n Sensation intact

25. BENIGN PAROXYSMAL POSITIONAL VERTIGO n Vertigo with head movements n Brief episodes lasting < 1 minute; nausea n Usually no tinnitus or hearing impairment n Spontaneous nystagmus is not present n Usually self-limited; can persist for weeks

26. BPPV n Most common form of positional vertigo n No predilection based on gender, race or age but usually after 4 th decade n Provoked by specific head movements n Typically have no other neurological complaint n May have history of head trauma

27. CANALITHIASIS n Loose otoconia consisting of calcium carbonate crystals from the utriculus n Usually involve the posterior semi- circular canal n Causes inappropriate movement of endolymph n Giving an erroneous spinning sensation with head movement

28. BPPV ETIOLOGY

29. CANALITHIASIS

30. CANALITHIASIS

31. DIAGNOSTIC CRITERIA n Vertigo w mixed torsional/vertical nystagmus on Dix Hallpike n Latency of 1-2 seconds from completion of test and onset or vertigo/nystagmus n Paroxysmal provoked vertigo and nystagmus (increase then decline over 10-20 seconds) n Fatigability if test repeated n Furman (1999).NEJM: November 18, pp1590-1596

32. Clinic Testing n Dix Hallpike maneuver n Sensitivity from 50-88%* n Purpose is to: –replicate the symptoms –elicit positional nystagmus –to determine whether nystagmus is fatigable *Hoffman, RM., et.al.(1999)

33. DIX HALLPIKE MANEUVER n The patient is positioned in front of the examiner with their head turned to the side at 45 degree angle n The examiner supports the head and shoulder, then quickly brings patient to a reclining position with head rotated to one side and hanging over the table n The position is maintained for 30 sec

34. DIX HALLPIKE MANEUVER n Tell patient not to fixate vision n Look for nystagmus, noting time of onset, direction –Nystagmus upward and torsionally with upper poles of eyes beating toward the ground-last ~20-30 seconds –Once sitting, nystagmus will recur but in the opposite direction –Repeat to same side, repetition diminishes the intensity and duration

35. DIX HALLPIKE MANEUVER

36. DIX HALLPIKE

37. FRENZEL LENSES

38. THE PATIENT n Nystagmus elicited n Vertigo elicited-lasted for few seconds n Symptoms absent after sitting upright

39. ISSUES n Self limiting disorder n Diagnosed by history-do we need to do Dix Hall pike n Dix Hallpike may interfere with treatment using the Epley test n When does patient need Canalith repositioning?

40. TREATMENT n Epley maneuver: –Relocate the debris from the posterior semicircular canal to the vestibule –80% success rate after one treatment and 100% after >1 (Epley) –89% success rate after one treatment compared to 23% in untreated group (Lynn) –Recurrence rate of 30% in 30 month F/u period; 15% over 4 years (Epley) Lynn(1995)

42. CANALITH REPOSITIONING n Home treatments with modified pocedures n Modified Semont –Less effective than modified Epley (95 vs 58% n Brandt-Daroff –Less effective than modified Epley (64% vs 23%

44. THE PATIENT n No further episodes n Avoids turning to left side while supine

45. n References n Froehling, D.A., et.al.,(2000). The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 75:695 n Furman, J.M. et.al(1999). Benign paroxysmal positional vertigo. NEJM, 341(21), pp.1590-96. n Kroenke, K. et.al., (200). How common are various causes of dizziness? A critical review. South Med. J.,93: 160-7. n Lynn, S. et.al.,(1995). Randomized trial of canalith repositioning procedure. Otolaryngol Head Neck Surg. 113:712 n Sloane, P.D., et.al.(2001). Dizziness: State of the Science. Annuls of Internal Medicine 134(9) part 2, pp. 823-31