1. DOWNWARD SPIRAL Dizziness in Elders Presented by: Mary Sokolowski, BSN, RN

2. Introduction Definition of Dizziness: Various abnormal sensations Generic term – giddiness, lightheadedness, faintness, vertigo, ataxia Syncope: Loss of consciousness + fall

3. SCOPE OF PROBLEM 90 million Americans seek care each year (Kovar, Jepson, & Jones, 2006) Most common complaint > age 75 1/3 to 1/4 of older adults c/o dizziness (Nettina, 2001) Syncope – a main reason for inpatient care (Wohrle & Kochs, 2003)

4. GERIATRIC SYNDROME? Nonspecific nature – multiple causes Peripheral Vestibular: 4 – 71% Cerebrovascular: 6 – 70% Postural Hypotension: 2 – 15% Psychogenic: 6 – 40% (Kao, Nanda, Williams, & Tinetti, 2001)

5. APPROACH Lack of clear guidelines Suggested approach – Treat as syndrome Rule out treatable causes Assess risk factors for chronic dizziness (Salles, Kressig, & Michel, 2003)

6. PATHOPHYSIOLOGY Several different body systems Disruption of stability – affects balance Balance – coordination of brain + nerve impulses from eyes, ears, neck, limbs, joints

7. REVIEW – Vestibular System SEE HANDOUT Labyrinth – 1) Cochlea (auditory receptors) 2) Vestibule, utricle, saccule 3) Semicircular canals Endolymph Hair cells Otoconia – “ear rocks” (Hain & Ramaswamy, 1999)

8. BALANCE: Head movement → hair cells bent by otoconia or endolymph → signal from inner ear → 8 th cranial nerve → cerebellum Sensory system (eyes, muscles, joints) → input to brain Brain interprets → balance Distortion in any system = Dizziness

9. HEIGHTS

10. MOTION SICKNESS

11. SPINNING

12. SUBTYPES / CATEGORIES Presyncope Vertigo Disequilibrium / Ataxia Psychogenic / Other (Nettina, 2001) ** SEE HANDOUT **

13. Benign Paroxysmal Positional Vertigo # 1 cause of vertigo Accounts for 50% of dizziness in elders Profile: Abrupt dizziness with position changes +/- nausea and vomiting Episodes < 1 minute Accompanied by nystagmus (Kovar, et al., 2003)

14. BPPV: Causes Otoconia in semicircular canals ½ - Idiopathic Other causes: Head Injury Infection Degenerative changes of aging Migraines (Kovar et al. 2003)

15. SYNCOPE Definition A main reason for inpatient treatment Rapid onset with rapid recovery Episode lasts < 20 seconds Misdiagnosis possible (Wohrle & Kochs, 2003)

16. SYNCOPE: Causes Cardiac disease, arrhythmia Reflex syndrome Orthostatic hypotension Carotid Sinus Syndrome Autonomic Failure (Wohrle & Kochs, 2003)

17. DIAGNOSIS: Dizziness **1 st PRIORITY: Recognize treatable conditions History: Structured interview – S/S, PMH Medication History DHI Scale – see HANDOUT (Salles et al., 2003)

18. DIAGNOSIS: Dizziness Physical Exam: Broad Review of systems – Rule out emergent conditions Vision, hearing, otoscopic exam Arthritis, neck pain, neuropathy (Wohrle & Kochs, 2003)

19. DIAGNOSIS: Dizziness Provocative Tests: Orthostatic changes Hyperventilation Rapid head/neck movement Carotid sinus massage (Wohrle, 2003)

20. DIAGNOSIS: Dizziness Provocative tests: Vestibular testing Tilt testing Electrophysiology (EPS) studies Psychological testing Dix-Hallpike Maneuver – HANDOUT (Kovar, et al., 2006)

21. DIAGNOSIS: Dizziness **2nd Priority: Assess Risk Factors for Chronic Dizziness 7 Risk factors: Depressive S/S, cataracts, abnormal balance/gait, postural BP changes, DM, past MI, > 3 medications Multifactoral syndrome (Kao et al. 2001)

22. Management/ Treatment ** Early Recognition of S/S – KEY Treatment of etiologic factors: Cardiac Sensory problems – correction Vasovagal – avoid triggers, salt, water, meds, pacing (Wohrle & Kochs, 2003)

23. Management / Treatment Carotid sinus syndrome – pacing, salt, vasoconstriction Orthostatic hypotension – avoid meds, ETOH, large meals; caution with position changes Cognitive behavioral therapy - ↓ anxiety (Wohrle & Kochs, 2003)

24. Balance / Vestibular Rehab Repeated exposure to causative stimulus Epley’s bedside maneuver – Repositioning therapy Success rate DHI – before and after (Kovar et al., 2006)

25. Antivertigenous Meds Meclizine / Antivert ↓ Labyrinth excitability Most effective – motion sickness, vertigo Diphenidol – nausea + vertigo

26. PATIENT EDUCATION Minimize contributing factors: Rise slowly, support stockings, avoid movements associated with vertigo Balance / Vestibular rehab – Post V.R. – sleep / head position recommendations Balance rehab – muscle strengthening, Tai Chi Antivertigenous meds – side effects, etc

27. SAFETY PLAN Environmental safety proofing – home Driving – discussion Emergency plan

28. CASE STUDY See HANDOUT (Nettina, 2001)

29. THE END ?? QUESTIONS ??