# 019 Vertigo in the Elderly Patient Complaining of Dizziness

Fast Facts and Concepts #019 PDF

Authors: Cate Tsufis, Katherine Denson MD, Kathleen Williams MD, Gabe Manzi MD

Objectives: Recognize urgent vs. non-urgent causes of vertigo in the elderly.

ACGME Competencies: Patient care, Medical knowledge

Context: Emergency department visit

Action: Assess elderly patient complaining of vertigo with complexities of many underlying etiologies.

Definition: Vertigo is an episodic spinning or rotational sensation when one is stationary caused by disorders of the vestibular system.

Incidence/Prevalence: Dizziness and vertigo are common presenting complaints in the ambulatory care setting, with an estimated 7.5 million patients seen each year¹. The prevalence of vertigo increases with age (10% for every 5 years of age), and accounts for 54 % of dizziness in primary care [2]. Approaching a patient with dizziness is challenging due to the non-specific presentation and its broad differential diagnosis. As reported by Sloane et al, to facilitate the assessment of patient complaint of dizziness, Drachman and Hart (’76) classified dizziness into four categories: vertigo, pre-syncope, disequilibrium, and other (non-specific) [1].

The most common etiologies for dizziness were peripheral vestibulopathies (35% to 55% of patients) and psychiatric disorders (10% to 25% of patients). Cerebrovascular disease (5%) and brain tumors (<1%) were infrequent [3].

Assessment: Vertigo in older persons could be associated with a variety of cardiovascular and neurosensory conditions, and with use of medications². Initial evaluation should focus in differentiated peripheral from central causes to minimize morbidity and mortality associated with serious cardiovascular and neurovascular conditions.

Physical examination: A complete neurologic examination, including vestibular testing and the characteristics of nystagmus are important to help differentiate between central and peripheral causes of vertigo.

A simplified approach to the differential diagnosis of a patient with vertigo is illustrated in the following algorithm

Pathophysiology: Within the inner ear, the semicircular canals are paired structures that normally respond to motion of the head in a symmetrical manner. If the resting discharge or response to motion is altered in one ear (from stray otoliths, for example), the resulting sensation is vertigo. Nystagmus is caused by lesion-related asymmetry in the vestibular system (may be inner ear labyrinth, CN 8, vestibular nuclei, or cerebellum). The slow phase is pathologic, while the fast phase is a normal corrective mechanism by the cerebral cortex. The direction of nystagmus is classically named for the fast phase.

References

1. Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern Med. 2001;134(9 Pt. 2):823-832.
2. Kroenke K, Lucas CA, Rosenberg ML, Scherkman B, Herbers JE Jr, Wehrle PA, Boggi JO. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med 1992; 117:898-904.
3. Hoffman RM, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999; 107(5):468-78.
4. Burt CW, Scheppert SM. Ambulatory care visits to physician offices, hospital outpatient departments and emergency departments: United States 1999–2000.  Vital Health Stat 13  2004; 1.
5. Lawson J, Fitzgerald J, Birchall J, Aldren CD, Kenny RA. Diagnosis of Geriatric Patients with Severe Dizziness. Journal of the American Geriatrics Society, 1999, 47(1): 12-7.
6. Rosen’s Emergency Medicine: Concepts and Clinical Practice 7^th Ed., Editor-in-Chief John A. Marx, Philadelphia: Mosby/Elsevier, 2009.
7. Tintinalli’s Emergency Medicine, A Comprehensive Study Guide 7^th Ed., Editor-in-Chief Judith E. Tintinalli, New York: McGraw-Hill, 2004.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Cate Tsufis, Katherine Denson MD, Kathleen Williams MD, Gabe Manzi MD, Fast Fact #19:Vertigo in the Elderly Patient Complaining of Dizziness, September, 2012, Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

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