Geriatric Dizziness: Evolving Diagnostic and Therapeutic Approaches for the Emergency Department

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Key Points

  • 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

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

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References (104)

  • M.E. Adams et al.

    Audiovestibular testing in patients with Meniere's disease

    Otolaryngol Clin North Am

    (2010)
  • N. Bhattacharyya et al.

    Clinical practice guideline: benign paroxysmal positional vertigo

    Otolaryngol Head Neck Surg

    (2008)
  • J.G. Canto et al.

    Atypical presentations among Medicare beneficiaries with unstable angina pectoris

    Am J Cardiol

    (2002)
  • K.E. Kocher et al.

    National trends in use of computed tomography in the emergency department

    Ann Emerg Med

    (2011)
  • J.A. Chalela et al.

    Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison

    Lancet

    (2007)
  • D.E. Krebs et al.

    Vestibular rehabilitation: useful but not universally so

    Otolaryngol Head Neck Surg

    (2003)
  • C.D. Hall et al.

    The role of vestibular rehabilitation in the balance disorder patient

    Otolaryngol Clin North Am

    (2009)
  • S.L. Whitney et al.

    Efficacy of vestibular rehabilitation

    Otolaryngol Clin North Am

    (2000)
  • R.U. Kothari et al.

    Cincinnati Prehospital Stroke Scale: reproducibility and validity

    Ann Emerg Med

    (1999)
  • K.A. Kerber et al.

    Dizziness presentations in U.S. emergency departments, 1995-2004

    Acad Emerg Med

    (2008)
  • P.D. Sloane et al.

    Clinical research and geriatric dizziness: the blind men and the elephant

    J Am Geriatr Soc

    (1999)
  • P.D. Sloane et al.

    Dizziness: state of the science

    Ann Intern Med

    (2001)
  • M.E. Tinetti et al.

    Dizziness among older adults: a possible geriatric syndrome

    Ann Intern Med

    (2000)
  • A.A. Tarnutzer et al.

    Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

    CMAJ

    (2011)
  • K.A. Kerber et al.

    The evidence base for the evaluation and management of dizziness

    J Eval Clin Pract

    (2010)
  • H.W. Lin et al.

    Balance disorders in the elderly: epidemiology and functional impact

    Laryngoscope

    (2012)
  • Y. Agrawal et al.

    Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004

    Arch Intern Med

    (2009)
  • K.N. Stevens et al.

    Epidemiology of balance and dizziness in a national population: findings from the English longitudinal study of ageing

    Age Ageing

    (2008)
  • O.R. Maarsingh et al.

    Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

    BMC Fam Pract

    (2010)
  • P. Sloane et al.

    Dizziness in a community elderly population

    J Am Geriatr Soc

    (1989)
  • K. Kroenke et al.

    Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care

    Ann Intern Med

    (1992)
  • S.I. Savitz et al.

    Pitfalls in the diagnosis of cerebellar infarction

    Acad Emerg Med

    (2007)
  • H.K. Neuhauser et al.

    Burden of dizziness and vertigo in the community

    Arch Intern Med

    (2008)
  • S.M. Pluijm et al.

    A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study

    Osteoporos Int

    (2006)
  • M.E. Tinetti

    Clinical practice. Preventing falls in elderly persons

    N Engl J Med

    (2003)
  • S.J. Herdman et al.

    Falls in patients with vestibular deficits

    Am J Otol

    (2000)
  • P. Gaetani et al.

    Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70

    J Neurosurg Sci

    (2012)
  • G.R. Fortuna et al.

    The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury

    Surgery

    (2008)
  • J. Dros et al.

    Impact of dizziness on everyday life in older primary care patients: a cross-sectional study

    Health Qual Life Outcomes

    (2011)
  • S.L. Murphy et al.

    The development of fear of falling among community-living older women: predisposing factors and subsequent fall events

    J Gerontol A Biol Sci Med Sci

    (2003)
  • K.A. Kerber et al.

    Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study

    Stroke

    (2006)
  • K.A. Kerber et al.

    Does intracerebral haemorrhage mimic benign dizziness presentations? A population based study

    Emerg Med J

    (2012)
  • D.A. Drachman et al.

    An approach to the dizzy patient

    Neurology

    (1972)
  • P.D. Sloane et al.

    Persistent dizziness in geriatric patients

    J Am Geriatr Soc

    (1989)
  • J. Lawson et al.

    Diagnosis of geriatric patients with severe dizziness

    J Am Geriatr Soc

    (1999)
  • B.B. Navi et al.

    Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department

    Stroke

    (2012)
  • O.R. Maarsingh et al.

    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

    (2012)
  • O.R. Maarsingh et al.

    Causes of persistent dizziness in elderly patients in primary care

    Ann Fam Med

    (2010)
  • G. Ishiyama et al.

    Gentamicin ototoxicity: clinical features and the effect on the human vestibulo-ocular reflex

    Acta Otolaryngol

    (2006)
  • M. von Brevern et al.

    Acute migrainous vertigo: clinical and oculographic findings

    Brain

    (2005)
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    Supported by a grant from the John Hartford Foundation.

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