Basic of Geriatrics and Internal Medicine for Physiotherapist by Rasheedy D - HTML preview

DIZZINESS

Dizziness is one of the most common presenting complaints in older persons. The complaint of “dizziness” is subjective, cannot be measured.

Dizziness is reported more common in women than men age 65 years or older; the overall prevalence ranges from 4% to 30%. It is the third most common reason why patients aged 65 and older visit family physicians. The likelihood of reporting dizziness increases by 10% for every 5 years of increasing age.

Dizziness is a word used by different people to describe many different phenomena. It is a nonspecific term that includes vertigo, dysequilibrium, lightheadedness, spinning, giddiness, faintness, floating, feeling woozy, and many other sensations.

Consequences:

Dizziness has been associated with increased fear of falling, and with worsening of depressive symptoms and of self-rated health. Chronic dizziness has a negative effect on quality of life among older persons, and it has been associated with increased risk for falls, orthostatic hypotension, syncope, stroke, and disability.

Dizziness is usually categorized into one of four groups:

Vertigo (sense of rotation or being pushed) Vertigo is considered to result from a disturbance within the vestibular system or its connections

Non vertigo

1. Pre-syncope or impending faint: result from a hypoperfusion of the brain.
2. Imbalance (sensation localized to the body, relieved by sitting or lying down) usually results from Multiple mechanisms; abnormal proprioception, cerebellar, motor vestibulospinal function
3. Ill-defined lightheadedness (cerebral sensation of being woozy, floating, swimming, visual abnormalities)
4. A fifth category, which is common in the elderly, is “mixed dizziness.”

Causes

Clinical clues

Divide the approach to dizziness into two main categories:

1. Vertigo

Patients usually describe “room spinning” or “self-spinning.” If symptoms are neurological, they may be due to peripheral or central pathology.

 (a) Peripheral Causes

These are related to inner ear pathology. The vertigo is episodic, may be induced by or worsened with head movement in any direction, and typically accompanied by nausea or vomiting. Patients may have auditory symptoms of tinnitus, hearing loss, aural pressure, and fullness in the ears. The three main causes are as follows:

1. Benign paroxysmal positional vertigo (BPPV) : The duration of vertigo is seconds to minutes and is usually triggered by head movement. Patients have no auditory symptoms. Vertigo is reproduced by Dix-Hallpike testing.
2. Vestibular neuronitis or viral labyrinthitis : The duration of vertigo is days to weeks. Patients usually have no auditory symptoms with vestibular neuronitis but may have severe nausea and vomiting.
3. Ménière’s disease: The duration of vertigo is minutes to hours. Patients may have hearing loss, tinnitus, and aural pressure which they describe as fullness in the ear.

(b) Central Causes

Patients may give a history of weakness, numbness, dysphagia, dysarthria, visual problems, and bowel or bladder dysfunction. The duration is usually minutes to hours or is intractable. Causes include cerebellar or brainstem infarct, hemorrhage, tumor, abscess, head trauma, vertebrobasilar migraine, and multiple sclerosis, among others.

2. Non-vertigo

There are three main symptoms:

(a) Light-Headedness, Feeling of Passing Out, or Presyncope

The causes include postural hypotension, cardiac arrhythmias, aortic stenosis, dehydration, anemia, antihypertensive medications, and hypoglycemia. Patients might have profuse perspiration, palpitations, nausea, and generalized weakness. Symptoms usually occur when the patient is getting up from a supine position or after meals. Screen for orthostatic hypotension.

(b) Unsteadiness or Disequilibrium

This is the most common type of chronic dizziness. Medications such as sedatives and hypnotics may be responsible. The patient may have impaired vision, peripheral neuropathy, muscle weakness, arthritis, mechanical foot problems, or impaired joint position sense. Patients may complain of numbness, tingling, weakness, or incoordination of limbs which is worsened by walking and relieved by sitting or lying down.

Screen for orthostatic hypotension in these patients as well. Further work-up with electrodiagnostic studies and orthopedics consultation may be required.

(c) Floating Sensation

This is usually associated with anxiety, stress, and other mood disorders. The patients may describe tingling sensations also. Associated symptoms include insomnia, fatigue, headache, and neck pain. The sensation can be exacerbated by hyperventilation or emotional stress.

The most common types in elderly:

Benign positional vertigo, patients experience vertigo with a change in head position. The onset of symptoms often occurs when patients get into or out of bed or when they extend their neck, the top shelf syndrome. The diagnosis can be confirmed by eliciting fatigable nystagmus during the positioning maneuver

Benign positional vertigo is usually caused by otolithiasis of the posterior semicircular canal. They have vertigo when they turn over in bed or when they turn their head from side to side while walking.

Benign positional vertigo can be treated effectively by procedures designed to rotate the freely moving otoliths around the semicircular canal. One of these methods is the canalith repositioning procedure

vertebrobasilar ischemia is usually associated with other neurologic symptoms. However, vertigo can be the only symptom of vertebrobasilar ischemia and should be suspected in a patient who has prominent cerebrovascular risk factors. Ischemia of the vestibular system in the brainstem should be suspected if a patient has unexplained vomiting that seems out of proportion to the symptoms of dizziness. Vertebrobasilar ischemia can cause recurrent attacks of vertigo. Associated symptoms include visual symptoms, unsteadiness, extremity numbness or weakness, dysarthria, confusion, and drop attacks. The most common causes of vertebrobasilar ischemia are embolism, large artery atherosclerosis, penetrating small-artery disease, and arterial dissection. The diagnosis is made on the basis of associated clinical signs and symptoms.

Cervical vertigo arises from irritation of proprioceptive receptors in the facet joints of the cervical spine. Osteoarthritis or muscle spasm is usually responsible. Clinically, vertigo or a more vague lightheadedness is reported, accompanied by an occipital headache and neck stiffness or pain. Management involves treating the underlying arthritis or acute neck problem. Two mechanisms have been proposed to explain cervical dizziness: proprioceptive deficits and vascular abnormalities. Proprioceptive deficits in the cervical spine can cause dizziness secondary to stimulation or proprioceptive receptors in the facet joints of the cervical spine. In older persons, cervical osteoarthritis most likely causes dizziness via this mechanism. The patient usually complains of pain in the neck upon movement, along with a worsening of dizziness. There is often a history of arthritis or whiplash injury. Further examination may reveal a decreased range of motion of the neck or signs of radiculopathy or mylopathy and/or spastic gait.

A vascular mechanism causing cervical dizziness is thought to result from obstruction of the vertebral arteries. One theory is that when there is extensive blockage of one vertebral artery, rotation of the head can cause sufficient obstruction of the other vertebral artery to cause brainstem ischemia. Another theory is that when a person turns his/her head or neck, an osteoarthritic spur may press on the nearby vertebral artery, causing a transient disruption of the blood flow.

Imbalance or disequilibrium (usually due to multisensory affection): questions should focus on vision (glaucoma or refractive error), hearing, arthritis of the neck or extremities, alcohol use, and symptoms of peripheral neuropathy. The effect of support while walking (holding the elbow or carrying a cane) is important because a marked improvement in stability with only minimal support is characteristic of multiple sensory deficit. The possibility of Parkinson's disease should be considered. Dilated cerebral ventricles or a midline cerebellar tumor can also produce these symptoms without other specific neurologic findings.

Pre-syncope: Presyncope is the sensation that one is about to pass out It is described as a feeling of severe light-headedness and may be associated with unsteadiness or falling. The sensation arises because of temporarily decreased blood flow to the cerebral cortex leading to hypoxia. Most adults experience transient pres