DIZZINESS Module # 1

1. DIZZINESSModule # 1 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512

2. PROCESS Series of 3 modules and questions on 1) Etiologies, 2) Evaluation, 3) Management Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives Upon completion of the module the learner will be able to: 1) Describe the four main classifications 2) Classify dizziness symptoms into one of four main groups 3) List the most common causes of each classification of dizziness • Describe the prognosis of dizziness

4. Incidence &Prevalence • Incidence • 7 million clinic visits year • the most common symptoms for referral to neurology and otolaryngology practices. • Prevalence: 13% to 38% of elders.

5. Challenges to evaluation and management • Precise classification often difficult. • Patients and clinicians alike may inappropriately worry about a serious cardiac or neurologic cause. • Specific therapyis not available for many patients with dizziness. • Dizziness will have multiple potentially causative factors at least half of the time.

6. CLASSIFICATION Symptom-oriented approach: (Drachman)[i] Classify as • Vertigo (rotational sensation), “spinning” • Presyncope (impending faint), “fainting” • Disequilibrium (loss of balance without vertigo or presyncope sensation), “falling” • Lightheadedness (ill-defined, not otherwise classifiable). • [i]Drachman DA, A 69 year old man with chronic dizziness JAMA 1998;280:2111-2118

7. Vertigo Three most common specific peripheral vestibular disorders: ( 35%-55% all causes dizziness) [i] • Benign positional vertigo • Labyrinthitis • Meniere's disease. [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478

8. Vertigo Benign positional vertigo (BPV) Symptoms: • spinning sensation of patient moving or room moving • episodic • aggravated or brought on by changes in position, • spells are often brief (5 to 15 seconds) • milder than the severe vertiginous attacks

9. Vertigo Labyrinthitis (sometimes called vestibular neuronitis) Symptoms: • Spinning sensation • Acute, lasts for several days, and resolves spontaneously • Often associated with viral infection

10. Vertigo Meniere's disease Symptoms: -Tinnitus -Fluctuating hearing loss, -Severe vertigo + progressive sensorineural hearing loss. -Vertigo may improve as hearing impairment worsens.

11. Vertigo Other:Central vestibular disorders • minority of cases of vertigo • ( ~ < 6 % of causes of dizziness) • etiologies: • Cerebrovascular disease • Brain tumors • Multiple sclerosis • Rare central causes.

12. Other:Central vestibular disordersCerebrovascular disease ( 5% of all causes dizziness)[i] Symptoms: • dizziness presenting symptom < 20% of the time. • more commonly, it is preceded or accompanied by other neurologic deficits in the distribution of the posterior circulation. [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478

13. Other:Central vestibular disordersCerebrovascular disease • Diagnosis • Note: verifying vertigo due to transient ischemic attack can be difficult in the absence of other neurologic deficits, • Tests: • Ultrasound can show flow, • MRA demonstrates anatomy but not flow

14. Other:Central vestibular disordersBrain tumors; Incidence: (< 1 % of all causes dizziness) [i] Acoustic neuroma: -most common tumor -associated with cochlear symptoms (tinnitus and hearing loss) -unilateral cochlear symptoms [i] Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478

15. 2) Nonvertiginous Dizziness (Presyncope) Symptoms:sensation of near fainting. Etiologies: Diminished cerebral perfusion. ( for further information see syncope module) P-A-S-S O-U-T(mnemonic) P ressure(hypotensive causes)O utput(cardiac)/O2 (hypoxia) A rrhythmiasU nusualcauses S eizuresT ransientIschemic Attacks S ugar(hypo/hyperglycemia)& Strokes, CNS dz’s

16. THE PROBLEM in DIAGNOSING PRESYNCOPE • Most presyncopal patients presenting with dizziness ( without true syncope) have symptoms attributable to postural change (with or without orthostatic hypotension) rather than more serious cardiac causes. • Postural symptoms without orthostatic blood-pressure changes are particularly common in elderly persons. • Likewise, orthostatic blood-pressure changes in the absence of symptoms are also quite common.

17. 3) Disequilibrium (loss of balance without “head” sensations) Symptoms:unsteady when standing or walking. Etiologies: • chronic vestibulopathics, • visual problems • musculoskeletal disorders weaknesses) • somatosensory or gait deficits Note: Balance depends on: vestibular system, visual and somatosensory systems. Therefore multi-factorials causes are common.

18. 4)Lightheadedness (ill-defined, not otherwise classifiable) Symptoms: • vague sensation • best described as “none of the other symptoms described in vertigo, presyncope, or disequilibrium, ie NOT:"spinning," "fainting," or "falling."

19. 4)Lightheadedness Etiologies: The two most prominent considerations; ( 1/3 of all cases of dizziness.) a. Psychiatric(10% - 25% all causes of dizziness) b. Idiopathic causes ( most common) Additional etiologies c, Prescription drug toxicity d. Other causes; -cervical arthritis* -visual disorders* -carotid sinus hyper-sensitivity* *(these factors as the actual cause are difficult to substantiate) • Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478

20. PROGNOSIS ~ 75% resolve within days to several months ~25% experience chronic or recurrent symptoms.

21. PROGNOSIS Associated with increased risk of: • falls • syncope • psychological distress • diminished social activities Not associated with change in: • mortality • hospitalization • severe disability

22. The End of Module One on Evaluation of Dizziness Credits: Adapted with permission from; • Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165