Introduction

• Giddiness / dizziness are similar in meaning about symptom and signs. In this article, I would like to use the word dizziness.

• Dizziness is a common presentation in primary care, especially among patients older than 75 years. It causes great psychological distress and greater perceived disability in the elderly.

• Dizziness affects approximately 20% to 30% of people in the general population.

• Dizziness is often dismissed as a trivial symptom. Establishing the diagnosis is essential in view of the wide variety of possible causes and also to enable effective management.

• Dizziness is a non-specific term that describes an unpleasant sensation of imbalance or altered orientation in space. The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical history and examination and often does not require hospital referral.

Symptom / Sign

Dizziness is a non-specific term which can mean true vertigo, light-headedness, unsteadiness, feeling faint (pre syncope), funny turns, visual disturbance or a psychological problem.

Causes of dizziness:

1. Cardiovascular:

   • postural hypotension

   • cerebrovascular disease (stroke)

   • carotid sinus syndrome

   • vertebrobasilar insufficiency

   • aortic stenosis

   • subclavian steal syndrome

   • cardiac arrhythmia

2. Neurological:

   • Post- head injury

   • Epilepsy

   • Multiple sclerosis

   • Parkinsonism

   • Dementia

   • Brain tumours

   • Benign intracranial hypertension

   • Normal pressure hydrocephalus

   • Peripheral neuropathy

3. Otological ( problem with inner ear):

   • Meniere’s disease

   • Benign positional vertigo

   • Labyrinthitis

   • Vestibular neuritis

   • Vestibular migraine

   • Otosclerosis  and Paget’s disease of bone

   • Vascular accidents

   • Middle ear trauma

   • Following surgery, e.g. stapedectomy, cochlear implant

   • Tumours, cholesteatoma

4. Metabolic:

   • Hypoglycaemia

   • Adrenal insufficiency

   • Hypothyroidism

5. Psychogenic:

   • Generalized anxiety

   • Agoraphobia

   • Panic attacks

   • Hyperventilation

6. Miscellaneous:

   • Viral fever

   • Migraine headaches

   • Ocular – visual impairment

   • Cervical – cervical spondylosis

   • Auto-immune/ connective tissue  disorder e.g. rheumatoid arthritis, systemic lupus erythematous ( SLE)

   • Drug intoxication e.g. acute intoxication with alcohol or drugs; carbon monoxide poisoning, chronic alcohol misuse

   • Iatrogenic: side–effect of medication,e.g. anti-hypertensive,anti-depressants,aminoglycoside  antibiotics, anti-arrhythmics.

Identifying the nature of the presenting symptom in terms of being true vertigo, syncope, presyncope or any other form of dizziness. Dizziness can usually be categorized into one of  four main groups:

• Vertigo: is defined as an abnormal sensation of movement, either of the surroundings or the person. It is usually rotatory but sensation of body tilt or impulsion may also occur. Vertigo is commonly associated with nystagmus, postural imbalance, sweating, pallor, nausea or vomiting (autonomic symptoms). Most cases seen in primary care due to peripheral vestibular disorders such as benign positional vertigo, acute vestibular neuronitis and Meniere’s disease.

• Presyncope: a feeling of near-fainting which may or may not be followed by a true faint (lost of conscious level). This episode may be accompanied by muscle symptoms such as weakness and cramps. Some may even feel numbness over the area around the mouth as well as sudden loss of vision. Feeling of light-headedness, muscular weakness and feeling faint. Other associated symptoms  may include : facial pallor or  ashen-gray appearance, visual dimming or gray out ,  palpitation, acral or  perioral paresthesias and carpopedal spasms (depending on the cause).

• Disequilibrium: a feeling of imbalance which is brought on by walking and diminishes with rest. This is usually due to multiple problem associated with sensory system in elderly which consist of the inner ear (vestibule), the eye (visual) and the sense of joint position (propioception).

• Psychophysiologic (psychogenic) dizziness: is a subjective feeling of dizziness due to the problem of the brain to integrate information from both body sensory and motor system. This condition is associated with acute or chronic anxiety disorder.

Symptoms

Actions that provoke symptoms may include:

• Change in posture (suggests postural hypotension)

• Movement of the head or neck ( suggests vertigo from any cause, cervical spondylosis or vertebral artery syndrome)

• Feeling anxious ( may indicate hyperventilation)

Associated symptoms may include:

• Syncope (faint)

• Consider any features suggestive of epilepsy

• Falls

• Tinnitus or hearing impairment ( suggests a vestibular cause)

• Oldfactory hallucination and amnesia may suggest a temporal lobe lesion.

Determine the level of anxiety:  anxiety is often present in elderly patient.

Consider a possible cardiovascular cause,  ask about smoking and any other risk factor for cardiovascular disease.

Review past medical history and drugs being taken.

Signs

Careful examination is required in order to assess a possible underlying cause (your doctor may perform the examinations as follow);

1. Cardiovascular: e.g.

   • Blood pressure – sitting position, and also lying and standing to assess any significant postural drop suggesting postural hypotension.

   • Heart murmur e.g. aortic murmur (aortic stenosis), carotid bruit.

2. Eyes:

   • visual impairment, nystagmus

3. Neurological :

   • Features of cerebrovascular disease, peripheral neuropathy or Parkinsonism

   • Gait abnormalities (to do heel to toe walking), if abnormal, test reflexes and tone in the lower extremities and test plantar responses.

   • Test co-ordination by asking the patient to put the opposite heel on the knee and to run the foot down and up the shin.

4. Dix-Hallpike positioning maneuvers (head up tilt test) to detect Benign Positional Vertigo.

Complication

Prognosis and complications are a function of the underlying causes.

Treatment

Initial  investigations may be required before to start treatment:

• Urinalysis for glucose (diabetes), urinary tract infection.

• Full blood count: anaemia, mean cell volume (MCV) high with alcohol abuse.

• Renal function, blood glucose, electrolytes, liver function tests: to detect systemic disease, alcohol abuse or electrolyte abnormalities.

• Dextrose stick : may be useful to diagnose if done during an episode.

• ECG and ambulatory 24-hour ECG for possible arrhythmia

Further investigations may include :

• EEG, CT Brain scan.

• Pure tone audiometry.

• Vestibular function tests. (e.g. electronystagmography).

• Echocardiogram (further cardiac assessment).

• Other investigations suggested by the presentation of each individual patient.

The treatment of dizziness varies by type and cause.

• In general it is symptomatic and directed at the underlying cause. Thorough discussion with the patient and explanation of the problem and any underlying cause.

• Evaluation and correction or amelioration of any associated medical problem.

• Great care should be given in prescribing drugs, especially to the elderly. These drugs have potential sedative effects and possible increase in risk of falls.

• Drugs should not be prescribed without a thorough assessment of the underlying cause of dizziness.

• Drugs that might be used include:

  • Anti-emetics used include hyosine, prochlorperazine, promethazine and metoclopramide.

  • Calcium-channel antagonists, cinnarizine and cyclizine have vestibule suppressant effects.

• Vertigo associated with migraine may respond to abortive and prophylactic anti-migraine treatments.

• Dizziness due to postural hypotension, medications should be carefully reviewed for potential contributions to the problem. Commonly implicated drugs include alcohol, anti- hypertensive medications , insulin, monoamine oxidase inhibitors, nitrate, opiates, anti-parkinsonian medications, phenothiazine and tricylic anti-depressant.

• Surgery is rarely indicated but might be required for:

  • Life-threatening complications of chronic middle ear disease,e.g. intracranial abscess.

  • Neoplasia  involving ontological structure , e.g. acoustic neuroma.

  • Trauma to the middle or inner ear, e.g. a perilymph fistula.

Prevention

Patients whose symptom of dizziness due to postural hypotension (after removal or adjustment of medications that may worsen the symptom) may response to the following non-pharmacological preventive measures:

• Sleep with the head elevated about 10 inches. Before standing up from lying position, let the leg hang at the side of the bed for a minute.

• Using a prescribed custom made, fitting elastic stocking up to thigh level may help push blood circulation from peripheral limbs to central body.

• For people without hypertension, liberal salt diet may also help.

• Ensure adequate fluid intake between 2.0 and 2.5 liters daily.

• Simple maneuvers like ankle pump (bending and straightening ankle joint), leg- crossing when standing and toe raises when standing aid to rapidly raise the blood pressure temporary to reduce the symptom of dizziness.

Rehabilitation

• Management plan for both acute treatment and long -term rehabilitation can be developed after a complete assessment. There are different treatment options.

• Special physiotherapy programme improving muscle power and the balance may be offered. Vestibular rehabilitation on the other hand, is aimed to reduce the system sensitivity so that the perceived dizziness will be reduced over time.

• When the symptom of dizziness fails to resolve completely despite treatment and therapy, realistic goals which involve psychological assessment and intervention may be useful.

Supportive Group / Referral

Sometimes, treatment of chronic dizziness in elderly may not be straight forward and long -term management and rehabilitation may be needed. In this instance, family support is of great importance. The involvement of family members or caregivers during the therapy sessions are essential part of patient’s management.