# 021 Non-vertigo Dizziness in the Elderly Patient
Authors: Catherine Tsufis, Kathryn Denson MD, Colleen Crowe MD, Gabriel Manzi MD, Yana Thaker, Judi Rehm, Bambi Wessel
Objectives: Recognize and assess non-vertigo causes of dizziness in the elderly.
Context: Emergency department visit.
Action: Assess non-vertigo dizziness in elderly emergency department patients. Approaching a patient with dizziness is challenging due to the non-specific presentation and its broad differential diagnosis. To facilitate the assessment of the patient complaining of dizziness, Drachman and Hart classified dizziness into four categories: vertigo, near-syncope, disequilibrium, and other (non-specific)1.
Definition: Non-vertigo dizziness describes a wide range of sensations experienced by the patient. Patients may report feeling light headed, weak, unsteady, or motion sickness, unevenness, or restlessness. These sensations are distinct from the classical description of vertigo dizziness, which is the sensation of spinning or rotation sensations in the absence of movement. For vertigo causes of dizziness see Geriatric Fast Fact #19.
Incidence/Prevalence: Patients presenting with dizziness have been documented to account for 5% of out-patient visits and 4% of ED visits [2]. The major difference between these two groups is that 30% of ED dizziness visits have serious causes (e.g. strokes, cardiac arrhythmia); whereas the outpatient etiologies tend to be more benign. Having knowledge of the prevalence of diseases in the elderly helps stratify the differential diagnosis of the underlying cause of dizziness. Formulating a clear differential diagnosis is important to permit correct and efficient diagnostic testing (imaging/lab tests), while not having a clear approach to working-up dizziness leads to wasted resources and missed diagnoses2.
Assessment: ED patients who present with dizziness may describe symptoms of syncope, near-syncope, imbalance, weakness, loss of equilibrium, or agitation. It is useful to approach common causes of these symptoms by a systems-based approach:
Table 1. Causes of non-vertigo dizziness by systems-based approach3,4
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System
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Features in patient history
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Cause
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Further testing
|
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Cardiovascular
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History of arrthymias or MI, symptoms of chest pain, palpitations
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Dysrhythmias
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ECG, telemetry, holter monitor
|
|
History of previous MI, CAD, symptoms of crushing substernal chest pain, SOB, diaphoresis, pain that radiates to arm/neck/shoulder
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Myocardial Infarction
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ECG, troponin, CK-MB
|
|
Symptoms upon exertion, history of vavular heart disease
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Valvular disease
|
Echocardiogram
|
|
Neurological
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Presence of prodromal symptoms of nausea, diaphoresis, changes in vision; situational dizziness
|
Vasovagal
|
Tilt test
|
|
History of Diabetes Mellitus, Parkinson’s disease, or other neurological disease
|
Autonomic insufficiency
|
Hb A1C,electrolytes
|
|
History of seizure, confusion after episode of syncope
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Seizure
|
EEG, electrolytes, CBC with differential CT head
|
|
Metabolic
|
Malaise, SOB, pale skin, and rapid heartbeat
|
Anemia
|
CBC, iron studies, stool guaiac
|
|
Hunger, anxiety, tremors, sweating, stupor
|
Hypoglycemia
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Blood glucose levels, HbA1C
|
|
History of thyroid disease, symptoms of weight loss, palpitations, sweating, hyperactivity
|
Thyrotoxicosis
|
TSH, T3, and T4 levels
|
|
Malaise, fatigue, confusion, cardiac arrhythmias, dehydration
|
Electrolyte imbalance
|
Electrolytes
|
|
Psychiatric
|
History of depression, symptoms of anhedonia, weight loss, malaise
|
Depression
|
Geriatric depression scale
|
|
History of psychiatric disorder, situational, provoked by anxiety or fear
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Panic disorder
|
|
|
Other
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Bruises; dependent upon family members; weight loss
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Elderly neglect or abuse
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Report to social services/ authorities
|
|
Use of multiple medications, especially digoxin, anti-hypertensives, tricyclic antidepressants, antihistamines, benzodiazepines
|
Medications
|
Blood levels of medication(s), use of diuretics and/or supplements
|
|
Recent symptoms of URI including fever, chills, cough, or UTI including dysuria, hematuria, increased urinary frequency
|
Sepsis
|
CBC with differential,, electrolytes, blood cultures, CXR, UA
|
|
History of hemorrhage, vomiting, diarrhea, or history consistent with dehydration
|
Hypovolemia
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Microstatic or microcytic vital signs, CBC,, Electrolytes, med list review for diuretics
|
|
Symptoms exacerbated by diminished ambient light, unfamiliar surroundings, and improved by grasping objects or furniture
|
Disequilibrium of aging
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Check for disequilibrium, perform eye exam, telemetry
|
|
Symptoms vary but may include confusion, delirium, altered level of consciousness, respiratory distress, cardiac arrhythmias
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Alcohol or non-prescription drugs
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Electrolytes, CBC, urine studies, toxicology labs
|
Underlying Basic Science: The perception of dizziness may represent different pathologic processes (i.e. pre-syncope, disequilibrium, and vertigo, other or mixed type) and in the older adult it may be mixed. Normal physiologic changes with aging can predispose older adults to develop dizziness including cardiovascular (decrease in beta adrenergic stimulation, delayed in baroreceptor response leading to decreased heart rate and possible orthostatic changes), sensory (visual and auditory decline), and neurologic changes (decreased proprioception and sensory perception). It is also worth mentioning that maintenance of balance and equilibrium is complex and achieved by integration of sensory information obtained from vestibular, proprioceptive, visual, and auditory systems by the cerebral cortex and cerebellum. Any comorbidity affecting these organ systems may also contribute to the presentation of dizziness.
ACGME Competencies: Patient care, Medical knowledge
References:
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Sloane PD, Coeytaux RR, Beck RS, et al. Dizziness: state of the science. Ann Intern Med. 2011;134:823-832
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Newman, DE, Hsieh, YH, Camargo, CA, Pelletier AJ, Butchy GT, Edlow JT. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008; 83(7): 765-775.
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Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. Chapter 24, New York, NY: American Geriatrics Society; 2010.
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Hazzard’s Geriatric Medicine and Gerontology. Chapter 56. New York: McGraw-Hill Medical. 2009.
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: Catherine Tsufis, Kathryn Denson MD, Colleen Crowe MD, Gabriel Manzi MD, Yana Thaker, Judi Rehm, Bambi Wessel, Non-vertigo Dizziness in the Elderly Patient, September, 2012.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.