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DOWNWARD SPIRAL

DOWNWARD SPIRAL. Dizziness in Elders Presented by: Mary Sokolowski, BSN, RN. Introduction. Definition of Dizziness: Various abnormal sensations Generic term – giddiness, lightheadedness, faintness, vertigo, ataxia Syncope: Loss of consciousness + fall. SCOPE OF PROBLEM.

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DOWNWARD SPIRAL

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  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 → 8th 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 **1st 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 ??

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