- •
Dizziness is a common but challenging complaint in the elderly because it is often difficult to describe and encompasses a broad differential diagnosis from the life threatening to the relatively benign.
- •
Dizziness in the elderly patient must be approached as a syndrome, not a discrete medical diagnosis.
- •
The history is often critical to determining the most likely cause of dizziness.
- •
Common tests in the evaluation of dizziness, including magnetic resonance imaging, have suboptimal sensitivity and
Geriatric Dizziness: Evolving Diagnostic and Therapeutic Approaches for the Emergency Department
Section snippets
Key Points
Epidemiology
A 2012 review using the National Health Interview Survey, which is a national database, reported that 19.6% of people aged 65 years and older had dizziness or balance problems in the previous year.10 This estimate is comparable with the quoted prevalence range of 21% to 29% in other community-based and population-based surveys of elderly persons in the United States6, 11 and the United Kingdom.12 Data on the incidence of dizziness is lacking, particularly in elderly persons, although a Dutch
Temporal characteristics of dizziness
Dizziness tends to be episodic; fewer than 5% of patients with dizziness report having continuous symptoms.6, 14 Estimates of the frequency of symptoms have varied across different study populations. A community survey found 35% reported having dizziness daily, 14% weekly, and 51% monthly.6
The underlying cause of dizziness
The causes of dizziness in the older adult are many and varied (Fig. 1). Studies have varied on the distribution of underlying causes for dizziness The discrepancy stems from the differences between study populations (eg, community vs clinic patients, all ages vs elderly), sampling methods (eg, random sample vs volunteers), case definition (eg, stroke vs central vertigo) and diagnostic criteria (eg, physician impression vs ICD-9 diagnostic codes). In a study of the National Hospital Ambulatory
Risk factors for dizziness
Aside from increasing age and female gender, several clinical characteristics have been independently associated with dizziness as shown in Table 1. These data were derived from multivariate analyses of 3 population-based studies from the United States,6 the United Kingdom,12 and the Netherlands.13 Tinetti and colleagues6 also reported a dose-response relationship involving these characteristics, whereby the prevalence of dizziness increased with increasing number of characteristics present,
Impact of dizziness
The most obvious impact of dizziness in the elderly is a fall. Dizziness increases the risk of falls in the elderly,19, 20, 21 with approximately half of patients with vestibular disease reporting a fall, and half of that group reporting more than 1 fall in the past year.21 Accidental falls have been reported to increase the risk of head injury in the elderly,22 and the elderly are at increased risk of mortality from a traumatic head injury compared with younger people.23
Even in the absence of
Overview
The challenge for the ED physician taking care of a dizzy elderly patient is to rule out potentially life-threatening causes of dizziness, identify the cause of dizziness (to the extent possible), and design a management plan. Overlap exists in the presentation of benign and dangerous dizziness, and seemingly benign features, such as isolated dizziness, can mask a potentially life-threatening cause, although this is rare (<1%).26, 27
A detailed list of recommended history, physical examination,
Pharmacologic Therapies for Vertigo Symptoms
There are 2 categories of pharmacologic therapies for dizziness (Table 7): those that offer symptom relief and those that are disease specific. Symptom relief medications are known as vestibular suppressants, which can be used to reduce the sensation of movement in vertigo and, in some cases, the associated motion sickness symptoms (usually nausea, vomiting, or diarrhea).
Unfortunately there are few high-quality studies confirming the efficacy of these medications. Meclizine is the most commonly
Outpatient and prehospital management of the dizzy patient
The evaluation and management of dizziness can be challenging due to (1) the subjective nature of the patient’s symptom complaint, (2) the absence of an objective and reliable measure of dizziness, and (3) the suboptimal accuracy of bedside examinations.
Therefore, the authors propose the following courses of action. If the patient has an established benign and recurrent condition, such as BPPV, and is being evaluated by the primary care provider most familiar with the patient, then the
ED management
Patients whose dizziness symptoms are new or different from previous episodes are of particular concern. The priority for the ED is to rule out a dangerous cause of dizziness. In particular, an ST-segment elevation myocardial infarction (STEMI) and an acute stroke must be ruled out, as these two disease entities have a specific time window within which optimal treatment should be administered.87, 88, 89, 90 Screening for an acute stroke is enhanced by the use of the Cincinnati Prehospital
Clinical and medicolegal pitfalls
Given the complexities of diagnosing and managing dizziness in the elderly, it is reasonable to anticipate that unintentional errors may occur.
Few studies have evaluated the accuracy of physician’s dizziness assessments. Royl and colleagues93 found that among German patients presenting with vertigo to the ED, 44% of the diagnoses were incorrect, based on further evaluation by neurologists. Seven percent of patients had a more serious diagnosis mistaken as benign, and 23% were given a serious
Discharge from the ED
At discharge, patients diagnosed with peripheral vestibular dizziness or in whom a life-threatening cause has been ruled out, should be provided with the following:
Referral: Patients should be referred to their primary care provider for follow-up within 1 to 2 weeks or sooner if symptoms return. Referral for vestibular rehabilitation, if available locally, can help patients with vestibular retraining.
Treatment: When indicated, a prescription for any of the medications discussed earlier should
Future directions
Further research is needed to optimize the ED management of the dizzy patient. Studies are needed to better understand the epidemiology of dizziness, as well as the diagnostic accuracy of bedside tests, how best to identify patients whose dizziness is due to stroke, and which therapies are best to mitigate the symptoms of vertigo. Disease-specific therapies also need extensive investigation. Cost-effectiveness studies would be invaluable in optimizing ED management. Older adults should be a
Summary
As shown by the often discrepant data on geriatric dizziness, there is limited evidence to guide bedside diagnostic, therapeutic, or disposition decision making for the geriatric patient with dizziness in the ED. Sloan and Dallara3 compared the evidence on geriatric dizziness with the story of the three blind men, each of whom described different parts of the elephant and had different impressions of what an elephant looks like. Despite such ambiguity, dizziness is a common complaint. The
References (104)
- et al.
Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample
Mayo Clin Proc
(2008) Vertigo and dizziness in the emergency department
Emerg Med Clin North Am
(2009)- et al.
Practice variation in neuroimaging to evaluate dizziness in the ED
Am J Emerg Med
(2012) - et al.
A directed approach to the dizzy patient
Ann Emerg Med
(1989) - et al.
Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting
Mayo Clin Proc
(2007) - et al.
Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians
Mayo Clin Proc
(2007) - et al.
Dizziness and vertigo: emergencies and management
Neurol Clin
(2012) - et al.
A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack
Lancet
(2005) - et al.
Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack
Lancet
(2007) - et al.
Diagnosis and management of dizziness and vertigo
Med Clin North Am
(2006)
Audiovestibular testing in patients with Meniere's disease
Otolaryngol Clin North Am
Clinical practice guideline: benign paroxysmal positional vertigo
Otolaryngol Head Neck Surg
Atypical presentations among Medicare beneficiaries with unstable angina pectoris
Am J Cardiol
National trends in use of computed tomography in the emergency department
Ann Emerg Med
Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison
Lancet
Vestibular rehabilitation: useful but not universally so
Otolaryngol Head Neck Surg
The role of vestibular rehabilitation in the balance disorder patient
Otolaryngol Clin North Am
Efficacy of vestibular rehabilitation
Otolaryngol Clin North Am
Cincinnati Prehospital Stroke Scale: reproducibility and validity
Ann Emerg Med
Dizziness presentations in U.S. emergency departments, 1995-2004
Acad Emerg Med
Clinical research and geriatric dizziness: the blind men and the elephant
J Am Geriatr Soc
Dizziness: state of the science
Ann Intern Med
Dizziness among older adults: a possible geriatric syndrome
Ann Intern Med
Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome
CMAJ
The evidence base for the evaluation and management of dizziness
J Eval Clin Pract
Balance disorders in the elderly: epidemiology and functional impact
Laryngoscope
Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004
Arch Intern Med
Epidemiology of balance and dizziness in a national population: findings from the English longitudinal study of ageing
Age Ageing
Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics
BMC Fam Pract
Dizziness in a community elderly population
J Am Geriatr Soc
Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care
Ann Intern Med
Pitfalls in the diagnosis of cerebellar infarction
Acad Emerg Med
Burden of dizziness and vertigo in the community
Arch Intern Med
A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study
Osteoporos Int
Clinical practice. Preventing falls in elderly persons
N Engl J Med
Falls in patients with vestibular deficits
Am J Otol
Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70
J Neurosurg Sci
The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury
Surgery
Impact of dizziness on everyday life in older primary care patients: a cross-sectional study
Health Qual Life Outcomes
The development of fear of falling among community-living older women: predisposing factors and subsequent fall events
J Gerontol A Biol Sci Med Sci
Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study
Stroke
Does intracerebral haemorrhage mimic benign dizziness presentations? A population based study
Emerg Med J
An approach to the dizzy patient
Neurology
Persistent dizziness in geriatric patients
J Am Geriatr Soc
Diagnosis of geriatric patients with severe dizziness
J Am Geriatr Soc
Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department
Stroke
Letter by Maarsingh and van der Wouden regarding article, “Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department”
Stroke
Causes of persistent dizziness in elderly patients in primary care
Ann Fam Med
Gentamicin ototoxicity: clinical features and the effect on the human vestibulo-ocular reflex
Acta Otolaryngol
Acute migrainous vertigo: clinical and oculographic findings
Brain
Cited by (12)
Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up
2022, Brazilian Journal of OtorhinolaryngologyCitation Excerpt :This problem occurs approximately in 30% of the elderly in the community and its prevalence increases with age.1 Patient with a history of dizziness have limitations in daily activities, associated with increased fear of falling and fall-risk.2,3 It has been shown that vestibular rehabilitation programs including postural control and balance exercises have positive effects on dizziness, balance, and risk of falling in the elderly.4,5
Vertigo and Dizziness: Understanding and Managing Fall Risk
2018, Otolaryngologic Clinics of North AmericaCitation Excerpt :Prevention of motion sickness None, however, is appropriate for long-term use in chronic dizziness, and many investigators recommend discontinuation after 3 days.21 Vestibular suppressants compromise physiologic compensation, prolonging symptoms of dizziness, and may lead to dependency.
A comparative analysis of the clinical symptoms of benign paroxysmal positional vertigo between older and young and middle‑aged patients
2023, Chinese Journal of Internal Medicine/Zhonghua Neike ZazhiEmergency Presentations for Dizziness - Radiological Findings, Final Diagnoses, and Mortality
2023, International Journal of Clinical PracticeClinical effectiveness of a physiotherapy-led, hospital-based vestibular service
2019, OtorinolaringologiaNon-drug therapy of vertigo
2018, Zhurnal Nevrologii i Psihiatrii imeni S.S. Korsakova
Supported by a grant from the John Hartford Foundation.