‘Dizziness’ David Bourne Consultant Physician and Geriatrician UHSM 5 th March 2007.

‘Dizziness’

David BourneConsultant Physician and

GeriatricianUHSM

5th March 2007

Agenda

• Dizziness• Orthostatic and Postprandial

Hypotension• Blackouts• Summary and discussion

Dizziness

• Nonspecific term• Vertigo ~50%• Presyncope• Disequilibrium

– Presyncope and disequilibrium ~25%

• Nonspecific dizziness ~15%• Psychiatric ~10%

Dizziness History

• Open ended questions• Positional changes in symptoms• Rx• Presyncome

– Prodrome to fainting– Lasts seconds to minutes

• History most most sensitive:– Vertigo 87%– Presyncope 74%– Psychiatric 55%– Disequilibrium 33%

Dizziness Vertigo

• Acute asymmetry of the vestibular system– Illusion of motion– Whirling– Tilting– Moving– Imbalance– Panic attacks– Agoraphobia / Fear of falling

Dizziness Examination

• Confirms the diagnosis• Most useful components

– Orthostatic BP– Pulse changes– Systolic murmur ?AS– Gait observation– Eye movements– Romberg’s Test• Peripheral neuropathy• Hallpike’s Test• Psychological testing

• No patient volunteered a psychiatric explanation

Dizziness in the elderly

• ~1/3 elderly• Multiple pathology

– Geriatric syndrome (5th Geriatric Giant)

• Associations– Postural hypotension– 5 or more medications– Hearing impaired– Impaired balance– Anxiety / depression– Previous MI

Disequilibrium

• Sense of imbalance/ unsteadiness• Often multifactorial

– Peripheral neuropathy– Visual impairment– Muscular skeletal– Gait– Vestibular– Do they cause dizziness?

• Vertebrobasilar insufficiency• Cervical spondylosis

Nonspecific dizziness• Arrhythmias• PE• Head injury• Psychiatric

– Major depression 25%– Generalised anxiety 25%– Somatisation

• Hyperventilation– Mildly stressful situations– Purposeful hyperventilation while observing for

nystagmus

DizzinessMedications

• Antidpressants• Hypnotics• Anticholinergics• Antihypertensives• Lots more

Orthostatic and Postprandial Hypotension

• Orthostatic hypotension ~20% >65yrs• Postprandial (15-90mins) ~30% NH residents• Symptoms

– Light-headed– Generalised weakness– Blurred vision– Legs buckling– Neck pain / headaches– Stroke– Angina

Orthostatic and Postprandial Hypotension

• BP on standing and at 2 and 5mins• Fall in BP + symptoms

– Systolic 20mmHg– Diastolic 10mmHg

• Many will have systolic hypertension• Assosciations

– Anti hypertensives– Oral hypoglycaemics– Antidepresants– Opiates– Alcohol

Orthostatic and Postprandial Hypotension

Normal response to orthostatic stress

• Normal response to standing• 500-1000ml pool in lower extremities

and splanchnic (most) circulation VR – SBP 5-10mmHg– DBP 5-10mmHg– HR 10-25/min

• Baroreceptor reflex SNS + PSNS • PR VR CO • ADH

Orthostatic and Postprandial Hypotension

Mechanism of autonomic failure

• Autonomic failure– NA Na in prox renal tubule

Na excretion new steady state plasma vol

– Absent HR (except POTS young tilt)

Orthostatic and Postprandial Hypotension

Causes of autonomic failure• Autonomic failure

– Neurological conditions• Impaired baroreceptor response in the elderly• Postprandial hypotension• PD • MSA• DM• Paraneoplastic syndromes

– Neurogenic syncope / CSH– Micturition / defaecation syncope– Rx

• antidpressants often overlooked

Orthostatic and Postprandial Hypotension

Cause of volume depletion

• Volume depletion– Hyperglycamia– Haemorrhage– D+V– Rx

• Diuretics

Orthostatic and Postprandial HypotensionTreatment

• Nonpharmacological

• Pharmacological

Orthostatic and Postprandial Hypotension

Treatment - Nonpharmacological• Volume replacement• Rx review

blockers– Antidepressants

• Education and physical manoeuvres– Standing– Weather– Meal times

• Salt• Water with a meal• Small meals• Low carbohydrate• Alcohol• Avoid standing quickly and exercise

Orthostatic and Postprandial Hypotension

Treatment - Nonpharmacological• Education and physical manoeuvres

– Leg crossing CO ~15%– Clench fists– Squatting– Straining

• Rx chronic cough

– Tilt bed renin system nocturnal diuresis– Compression stockings to lower abdomen– Exercise

• Cardiac reconditioning

Orthostatic and Postprandial Hypotension

Treatment - pharmacological• Fludrocortisone

– Long t½ Blood volume vessel sensitivity to catecholamines– ? NA release– 50ug titrated weekly max 500ug– SE oedema / supine HT / K / CCF

Orthostatic and Postprandial Hypotension

Treatment - pharmacological• Sympathomimetics• Midodrine

– Doesn’t cross BBB avoiding some SE agonist 2.5mg od 10mg tds– SE supine HT / GI / urinary retention

• Caffeine• NSAIDS• Desmopressin blockers eg pindolol• DA antagonists• Erythropoitin in context of anaemia

Blackouts

• Abrupt loss of consciousness and loss of postural tone

• Rapid and complete recovery• ~ 3% A+E attendances• ~1% hospital admissions• Cardiac syncope risk of sudden death• Lifetime risk 30%• Framingham rise >70yrs

BlackoutsRisk factors

• IHD

• CVD

• HT

• Low body mass index

• Alcohol

• DM

BlackoutsCause

• Vasovagal• Cardiac• Unknown 30%

BlackoutsCardiovascular

• Arrhythmia– Cf vasovagal without warning

• Well tolerated – Persistent arrhythmia– Bradycardias

BlackoutsCardiovascular

• Blood flow obstruction– AS– HOCM– PS– PE

Blackouts Noncardiac

• Neurocardiogenic• Orthostatic hypotension

• CSH– Relatively benign nb injuries

• Seizures

• Metabolic

• CVD

Blackouts Noncardiac

• Seizures– 5-15% syncope– Post ictal

• Metabolic– Hypoglycaemia

• CVD

Summary and discussion

• History

• Targeted examination

• Undertake simple interventions

• Consider appropriate referral

• Discussion