dizziness
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Introduction
Defined as a disturbed state of spatial awareness.
Etiology
- multisensory dizziness
- common in elderly, especially diabetics[6]
- often multifactorial involving vestibular, somatosensory, &/or visual systems[9]
- risk factors (in elderly)[4]
- anxiety
- depression
- impaired hearing[6]
- impaired balance
- orthostasis
- past myocardial infarction
- > 4 medications
- may be some overlap with disequilibrium
- common in elderly, especially diabetics[6]
- disequilibrium (5%, more common in elderly) {perhaps most common[5]})
- vestibular disorders
- vertigo (50%)
- peripheral vertigo
- saccular & semicircular canal dysfunction common with aging
- central vertigo is a medical emergency[10]
- peripheral vertigo
- Meniere's disease
- vestibular neuronitis[3]
- labyrinthitis
- Herpes zoster oticus
- cervicogenic vertigo
- vertigo (50%)
- presyncopal lightheadedness (25%)
- psychophysiologic dizziness
- acute or chronic anxiety
- agoraphobia
- depression
- somatoform disorder
- ocular dizziness
- high magnification & lens implant
- imbalance in extraocular muscles
- oscillopsia
- physiologic dizziness
- motion sickness
- space sickness
- chronic mountain sickness
- height vertigo
- migraine
- transient ischemic attack, stroke (very uncommon)[16]
- idiopathic dizziness (20%)
- pharmaceutical agents
- use of 4 or more medications
- antidepressants: SSRI
- cholinesterase inhibitors
- antihypertensive agents
- bronchdilators[9]
- CNS depressants
- parasympatholytics[9]
- laxatives
- dehydration in the elderly (GRS9)[9]
- voluntary fluid restriction due to urinary urgency/urge incontinence
- diuretics may contribute to dehydration
* dizziness is most common symptom linked to a missed diagnosis of stroke presenting to the emergency department[3]
Epidemiology
- 0.8% of outpatient visits
- more prevalent in the elderly
- 29% of individuals > 72 years of age
Physical examination
- examine for orthostasis (orthostatic hypotension)
- cardiac ascultation
- examine for nystagmus
- Rhomberg test may be positive
Clinical manifestations
- disturbed spatial awareness
- symptoms depend on etiology
- symptoms of orthostatic hypotension
- symptoms of vertigo
- other
- symptoms depend on etiology
- may persist for 6 months or longer
- fear of falling, especially elderly
Laboratory
- complete blood count (CBC)
- serum electrolytes
- serum creatinine
- serum glucose
- serum thyroid-stimulating hormone (serum TSH)
- specific tests for specific etiologies
Diagnostic procedures
- not often needed[9]
- electronystagmography
- electrocochleography
- rotational chair testing
- posturography
- electrocardiogram
- HOLTER
- PACs & a few short runs of supraventricular tachycardia not an indication for cardiology consult[28][29][30]
- HOLTER
Radiology
- not often needed[9]
- CT angiography if TIA suspected (vertigo + neurologic sign)
- magnetic resonance imaging (MRI)
- generally imaging modality of choice[12]
- not indicated in the absence of focal neurologic deficits[28][29][30]
- despite dizziness being the most common symptom linked to a missed diagnosis of stroke presenting to the emergency department[3]
- less useful than physical therapy (see management)
- computed tomography (CT) not useful unless intracranial hemorrhage suspected[12]
Complications
- increased risk of falls
- social isolation
- functional disability
- depression or anxiety associated with 75% of chronic dizziness[3][9]
- diminished quality of life
- risk of vascular event after presenting with an episode of dizziness is low (stroke within 1 month < 1 in 500)[8]
Management
- fall precautions (also see falls in the elderly)
- treat modifiable factors[18]
- polypharmacy
- anxiety & depression
- functional mobility
- physical therapy useful in general[3][28][29][30]
- vestibular rehabilitation
- even simple exercises challenging the vestibular system of benefit[5]
- most useful for benign positional vertigo[3]
- an internet intervention may help reduce symptoms of chronic dizziness among older adults[25]
- SSRI for chronic dizziness[3]
- depression or anxiety associated with 75% of chronic dizziness[3]
- see specific etiology
- prognosis:
- dizziness in the elderly NOT associated with increased mortality or risk of hospitalization
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013-15
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 649
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012 2015, 2018, 2022.
- ↑ 4.0 4.1 Journal Watch 20(7):56, 2000
Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Inten Med 132:337, 2000 PMID: https://www.ncbi.nlm.nih.gov/pubmed/10691583
Drachman DA Occam's razor, geriatric syndromes, and the dizzy patient. Ann Intern Med 132:403, 2000 PMID: https://www.ncbi.nlm.nih.gov/pubmed/10691591 - ↑ 5.0 5.1 5.2 Journal Watch 24(24):188, 2004
Yardley L, Donovan-Hall M, Smith HE et al Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness. Ann Intern Med. 2004 Oct 19;141(8):598-605. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15492339
Zapanta PE and Meyers AD Medscape: eMedicine: Vestibular Rehabilitation http://emedicine.medscape.com/article/883878 - ↑ 6.0 6.1 6.2 Uneri A, Polat S. Vertigo, dizziness and imbalance in the elderly. J Laryngol Otol. 2008 May;122(5):466-9. Epub 2007 Sep 13. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17850686
- ↑ 7.0 7.1 Stanton VA et al, Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007, 82:1319 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17976351
- ↑ 8.0 8.1 Kim AS et al. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med 2011 Jan; 57:34 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20855127
- ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
Geriatric Review Syllabus, 10th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 10.0 10.1 Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010 Aug 15;82(4):361-8, 369. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20704166
- ↑ Zapanta PE and Meyers AD Medscape: eMedicine: Vestibular Rehabilitation http://emedicine.medscape.com/article/883878
- ↑ 12.0 12.1 12.2 Lawhn-Heath C et al. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emerg Radiol 2013 Jan; 20:45. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22940762
- ↑ Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern Med. 2001 May 1;134(9 Pt 2):823-32. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11346317
- ↑ Alrwaily M, Whitney SL Vestibular rehabilitation of older adults with dizziness. Otolaryngol Clin North Am. 2011 Apr;44(2):473-96 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21474018
- ↑ Barin K, Dodson EE. Dizziness in the elderly. Otolaryngol Clin North Am. 2011 Apr;44(2):437-54 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21474016
- ↑ 16.0 16.1 Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006 Oct;37(10):2484-7. Epub 2006 Aug 31. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16946161
- ↑ Wetmore SJ, Eibling DE, Goebel JA et al Challenges and opportunities in managing the dizzy older adult. Otolaryngol Head Neck Surg. 2011 May;144(5):651-6 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21493351
- ↑ 18.0 18.1 Dros J, Maarsingh OR, Beem L, et al. Functional prognosis of dizziness in older adults in primary care: a prospective cohort study. J Am Geriatr Soc. 2012;60:2263-2269. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23231549
- ↑ Cianfrone G, Pentangelo D, Cianfrone E et al Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: a reasoned and updated guide. Eur Rev Med Pharmacol Sci. 2011 Jun;15(6):601-36. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21796866
- ↑ Shoair OA, Nyandege AN, Slattum PW. Medication-related dizziness in the older adult. Otolaryngol Clin North Am. 2011 Apr;44(2):455-71, PMID: https://www.ncbi.nlm.nih.gov/pubmed/21474017
- ↑ Chan Y. Differential diagnosis of dizziness. Curr Opin Otolaryngol Head Neck Surg. 2009 Jun;17(3):200-3. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19365263
- ↑ Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizziness. Otolaryngol Head Neck Surg. 2003 Jan;128(1):54-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12574760
- ↑ Zhao JG, Piccirillo JF, Spitznagel EL Jr et al Predictive capability of historical data for diagnosis of dizziness. Otol Neurotol. 2011 Feb;32(2):284-90. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21178804
- ↑ Huh YE, Kim JS. Bedside evaluation of dizzy patients. J Clin Neurol. 2013 Oct;9(4):203-13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24285961 Free PMC Article
- ↑ 25.0 25.1 Geraghty AW, Essery R, Kirby S et al Internet-Based Vestibular Rehabilitation for Older Adults With Chronic Dizziness: A Randomized Controlled Trial in Primary Care. Ann Fam Med May/June 2017 vol. 15 no. 3 209-216 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28483885 Free Article <Internet> http://www.annfammed.org/content/15/3/209
Balance retraining website https://balance.lifeguidehealth.org/player/play/balance - ↑ van Vugt VA, Bas G, van der Wouden JC et al. Prognosis and survival of older patients with dizziness in primary care: a 10-year prospective cohort study. Ann Fam Med. 2020;18(2):100-109 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32152013 PMCID: PMC7062481 Free PMC article https://www.annfammed.org/content/18/2/100
- ↑ Gurley KL, Edlow JA. Acute Dizziness. Semin Neurol. 2019 Feb;39(1):27-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30743290 Review.
- ↑ 28.0 28.1 28.2 28.3 Das S, Annam CS, Bakshi SS, Seepana R. Persistent positional perceptual dizziness in clinical practice: a scoping review. Neurol Sci. 2023 Jan;44(1):129-135. Epub 2022 Aug 22. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35994134 Review.
- ↑ 29.0 29.1 29.2 29.3 Kaski D. Neurological update: dizziness. J Neurol. 2020 Jun;267(6):1864-1869. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32130499 PMCID: PMC7293664 Free PMC article. Review.
- ↑ 30.0 30.1 30.2 30.3 Staab JP Persistent Postural-Perceptual Dizziness. Semin Neurol. 2020 Feb;40(1):130-137. doi:http://dx.doi.org/ 10.1055/s-0039-3402736. Epub 2020 Jan 14. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31935771 Review.
- ↑ Chari DA, Rauch SD. The Efficient Dizziness History and Exam. Otolaryngol Clin North Am. 2021 Oct;54(5):863-874. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34294439 Review.
- ↑ Vestibular test American Hearing Reseach Foundation http://american-hearing.org/disorders/vestibular-testing/
- ↑ NIDCD Balance, Dizziness and You http://www.nidcd.nih.gov/health/balance/baldizz.asp