Comprehensive Management of Dizziness in Elderly Clients

Sandra M. Nettina, MSN, RN, CS, ANP
© 2001 Medscape, Inc.]

Abstract

Dizziness is a symptom experienced by one quarter to one third of older
adults. Etiology includes a variety of central nervous system,
cardiovascular, otologic, and sensory causes. One of the most common causes
is benign positional vertigo, a peripheral vestibular dysfunction. Although
benign positional vertigo and many other causes are not life threatening,
dizziness from any cause can negatively affect the client's life and cause
injury. Since the cause of dizziness may be difficult to diagnose, nursing
management should focus on the impact of dizziness. Treatment strategies
should include frequent monitoring to improve overall health or to deal with
other conditions that may contribute to dizziness, safety measures to
prevent falls, patient education about antivertiginous medications, and
referral for vestibular rehabilitation. The advanced practice nurse (APN)
plays a significant role in the assessment of dizziness and the reduction of
its impact on the elderly client.

Case Study

Mrs. Smith is a 72-year-old woman residing in an assisted living facility
who complains of intermittent, daily episodes of dizziness, usually while
arising from bed. The episodes last several hours and diminish in the early
afternoon. She notes that the room spins and the feeling is exacerbated by
turning her head. Past medical history is significant for myocardial
infarction, mild heart failure, atrial fibrillation, and hypothyroidism.
Medications include atenolol 100 mg daily, verapamil 180 mg daily,
furosemide 20 mg daily, levothyroxine 0.1 mg daily, coumadin 5 mg daily, and
docusate 100 mg daily. She told her doctor about the dizziness, and was
prescribed meclizine 25 mg 3 times a day as needed, with only minor relief.
Mrs. Smith takes her meals in the dining room but often skips breakfast for
fear of falling on her way. She is worried about going to her niece's home
for a family party next week.

Introduction

Dizziness is a common symptom in people of all ages, particularly the older
adult. Dizziness is a generic term used to describe a variety of experiences
including giddiness, lightheadedness, faintness, vertigo, fogginess,
imbalance, unsteadiness, and ataxia. The etiology of a person's complaint of
dizziness is often difficult to identify. Origins include problems of the
inner ear and vestibular branch of the eighth cranial nerve, cerebrovascular
insufficiency and other problems of the central nervous system,
cardiovascular dysfunction, metabolic disorders, sensory deficits, and
emotional disorders (Table 1). A combination of causes occurs in many cases.
Older adults may accept dizziness as a symptom of aging without seeking
treatment. Others may become alarmed, associating dizziness with
life-threatening stroke or cardiovascular disease. Despite the etiology,
however, dizziness represents a significant hardship for many older adults.
Despite appropriate medical work up and interventions, the person's life
might continue to be greatly affected by dizziness. In many cases, the
diagnosis is not identified, or dizziness persists despite diagnosis and
treatment. Quality of life may be impaired, and falls and other injuries may
result.
The APN can play an instrumental role in the management of dizziness. The
APN can help the person adapt to dizziness, ensure safety, and even help
alleviate the symptoms of dizziness. While the medical team of specialists
will focus on differentiating the underlying cause, the APN can take a more
patient-centered and holistic approach.

Scope of the Problem

Studies have shown that approximately one quarter to one third of elderly in
the community are dizzy.[1,2] One study showed that 1 in 10 respondents
suffered from current, handicapping dizziness.[3] Many patients report
dizziness to their primary care provider (PCP), and 5% to 10% of new primary
care visits are for dizziness.[4]
The differential diagnosis of dizziness often presents a dilemma to the PCP.
Most people presenting with dizziness will have a normal physical
examination despite significant, often life-altering and debilitating,
symptoms. Laboratory testing and imaging studies usually prove worthless in
determining the diagnosis of dizziness.[5] The PCP often tries to narrow the
differential diagnosis by symptomatology to determine the appropriate
referral. Patients are more likely to be referred to a specialist if
symptoms last 1 year or longer, there is more than 1 visit to the PCP for
dizziness, and there are additional symptoms pointing to a cardiac;
neurologic; or ear, nose, or throat disorder.[6] Some researchers have set
out to show that patients with dizziness are underreferred[6] and that most
cases of unexplained dizziness can be diagnosed if work up is sufficiently
extensive.[7,8] In fact, numerous studies have been done to find out the
diagnostic breakdown of dizziness in the elderly and to determine predictors
of certain causes that might assist in better evaluation and referral
criteria.[7-10] However, little outcome research has been done to show
improved quality of life or decreased morbidity and mortality with
aggressive evaluation and treatment for the vast differential of dizziness.
Work by Tinetti and colleagues[11] takes a different approach to dizziness.
They have proposed that dizziness should be treated as a geriatric syndrome
rather than a symptom of an underlying disorder. They found that chronic
dizziness was not associated with increased mortality or
hospitalizations.[11] They did find that dizziness was associated with
worsening of some quality-of-life indicators, as have other studies,[2] as
well as with risk of falling and depression. Falls or fear of falling may be
the greatest threat with dizziness. Burker and colleagues[12] found that 47%
of the elderly who are dizzy have a fear of falling, as opposed to 3% of
controls. Von Renteln-Kruse and colleagues[13] reported that elderly
patients with dizziness were 10 times more likely to report falls than those
without dizziness. Tinetti and colleagues[1] suggested that impairment
reduction strategies might prove more effective in reducing the disability
of dizziness than focusing on identifying and treating particular causes.

Screening and Assessment


Screening

Psychogenic dizziness is often listed as an etiology of the complaint of
dizziness. This seems to be a diagnosis of exclusion when no other etiology
can be found and the patient suffers from anxiety, depression, or some other
emotional malady. Many studies have shown a correlation of dizziness to
anxiety and depression, but have not proven a cause and effect
relationship.[2,14] Dizziness should be regarded as a significant symptom
with important impact on an elderly individual's well being, and, therefore,
all elderly people should be regularly screened for the symptom of
dizziness, especially those who also have anxiety and depression. Likewise,
a person who has complained of dizziness should also be screened for
emotional effects, including anxiety and depression.

General History

The approach to the patient with dizziness should begin with an assessment
of the complaint. Many patients will have complained to their PCP of
dizziness in the past. They may have seen specialists, had diagnostic
testing, and been told that it was nothing serious. Antivertiginous
medication such as meclizine may have been prescribed but may not have
worked, or the patient might have believed it wasn't worth taking.
This scenario is not a reason to stop the data gathering about dizziness;
rather, it is the perfect opportunity to explore the impact of dizziness on
the patient's life. Standard assessment parameters should be explored, such
as type of sensation experienced, frequency, duration, intensity,
precipitating and alleviating factors, and associated symptoms. History
findings may point to the etiology of dizziness, but, more importantly, show
areas for further evaluation, the impact of dizziness on the person, and
areas for intervention.
A number of patients have more than 1 sensation of dizziness.[1] A spinning
sensation without lightheadedness is more likely related to benign
positional vertigo.[14] Syncope is often associated with cardiovascular
disorder.[9,10] Many patients -- but not all -- with benign positional
vertigo will report dizziness precipitated by position change.[15]
Associated symptoms may be subtle and not previously reported by the
patient. Therefore, review of systems should be broad and include questions
about such things as general health, headache, visual or hearing problems,
tinnitus, signs of peripheral neuropathy, arthritis, neck pain, shortness of
breath and hyperventilation, palpitations, and nausea and vomiting.

Medication History

The patient's current and recent medications should be evaluated. Use of
aminoglycoside antibiotics may cause ototoxicity, as can the loop diuretic
ethacrynic acid. Use of any diuretics may be associated with volume
depletion, leading to lightheadedness. Antihypertensives and vasodilators
may cause postural lightheadedness.[16] Antihistamines, anticholinergic
agents, antidepressants, antianxiety agents, nonsteroidal anti-inflammatory
drugs, and just about any drug that works through the central nervous system
may cause dizziness in some people. A study of hospitalized patients ages 75
years and older found that neuroleptics, antidepressants,
hypnotics/sedatives, and combinations of drugs with hypotensive effects were
prescribed more frequently in patients who reported dizziness.[13]
Some research has focused on the number of medications taken by the elderly
as being a factor in dizziness and falls. However, Hendrich and
colleagues[17] found that the presence of medication side effects was a
better predictor of falls than the medications themselves. Therefore,
medication history should include questioning about potential medication
side effects such as sedation, impaired balance, and dizziness.
Additionally, medications used to reduce dizziness should be reviewed.
Although meclizine and a few other antivertiginous agents are approved for
the treatment of vestibular-related dizziness, they may actually cause or
exacerbate dizziness. Paradoxic effects such as restlessness, irritability,
insomnia, euphoria, auditory and visual hallucinations, and diplopia may
occur in the elderly.[18] Antivertiginous medications are more effective for
motion sickness and acute labyrinthitis rather than benign positional
vertigo and other causes.[18,19] Therefore, if positive results are not
seen, these agents should be discontinued.

General Physical Examination

Physical examination should follow history. If a thorough neurologic exam
was done and no focal deficits were documented, then it need not be
repeated. However, there are several areas on which the APN should focus. If
the history reveals possible sensory deficits, then vision, hearing,
proprioception, light touch, and vibratory sensation should be evaluated
thoroughly. Dysequilibrium or other sensations of dizziness may arise from
multiple sensory deficits. Otoscopic assessment of the ears should be
conducted to screen for impacted cerumen or infection, which may contribute
to dizziness. A cardiovascular exam should include assessment for vital
signs, orthostatic blood pressure changes, carotid bruits, and auscultation
of the heart for rate, rhythm, and murmur. A new arrhythmia or valvular
dysfunction may contribute to dizziness.
Orthostatic changes. Physical assessment of the dizzy patient should also
focus on postural blood pressure changes. Orthostatic hypotension occurs
more commonly in the elderly and may be related to such conditions as
cardiovascular disorders, Parkinson's disease, or medication side effects.
Results of studies on the relationship between postural hypotension and
dizziness have varied based on varying parameters used to define orthostatic
changes.[1,20] Orthostatic hypotension is frequently defined as a drop in
systolic blood pressure of 20 mm on position change from supine to standing;
however, many studies have found more modest changes that relate to
dizziness. Hillen and colleagues[21] found that systolic decrease of 15 mm
Hg and diastolic decrease of 5 mm Hg related to dizziness. Tinetti and
colleagues[1] found a relation only between mean blood pressure change and
dizziness, possibly because mean blood pressure correlates better with
cerebral perfusion.
In any case, blood pressure and pulse responses to position change should be
assessed immediately and at 2 minutes to screen for orthostatic hypotension
that may be related to dizziness. The patient should also be observed for
clinical signs and symptoms such as nausea, pallor, dizziness, visual
dimming, and decreased consciousness in assessing orthostasis.[22]
Dix-Hallpike maneuver. Provocation tests for dizziness often identify
dizziness of a vestibular nature and thus rule out the need for a more
thorough cardiac work up. The Dix-Hallpike maneuver (also called the Nylen
maneuver, Barany maneuver, or drop test) should be performed on all patients
complaining of dizziness. It can be done on an examination table or in the
patient's bed, provided there is room for the patient's head to hang over
the edge of the bed. The procedure should be explained to the patient
thoroughly prior to the maneuver (Table 2).
The Dix-Hallpike is diagnostic for benign positional vertigo when dizziness
is reproduced by this maneuver with nystagmus to 1 side that occurs after a
4-5 second latent period. If nystagmus occurs immediately upon this
maneuver, lasts more than 30 seconds, is exclusively vertical, or is
nonfatiguable with repeated maneuvers, then a serious central nervous system
lesion may be present.[18,23]
In a study[15] of 191 patients referred to a neurology clinic with a variety
of diagnoses and complaints such as unusual sensations of dizziness, neck
pain, and headache, 36 were identified with benign positional vertigo. The
Dix-Hallpike had not been performed on any of these patients prior to
referral. The authors concluded that the Dix-Hallpike is mandatory for all
patients complaining of dizziness or vertigo. Had it been performed in the
primary care or long-term care setting, unnecessary work up and referral
might have been avoided.

Management


Treatment of Etiologic Factors

Obviously, etiologic factors for dizziness should be treated whenever
possible. The APN can ensure that identified cardiovascular disorders are
monitored and controlled adequately. The APN should facilitate additional
testing such as electrocardiogram (EKG) and echocardiogram, and refer to the
cardiologist if the patient becomes symptomatic, has difficulty adhering to
the medication regime, or shows signs of decompensation such as heart
failure. For sensory deficits related to dizziness, the APN can help the
patient obtain a hearing aid, visual correction, and ambulatory aids. The
APN can treat impacted cerumen and make referral for additional ear
problems. The APN should make recommendations for adjustments to the
medication regime if dizziness is thought to be a side effect of 1 or a
group of medications.

Vestibular Rehabilitation

Vestibular rehabilitation, also known as vestibular exercises, canalith
repositioning maneuver, or the Epley maneuver, is the one definitive
treatment for vestibular causes of dizziness. It can greatly reduce the
symptom of dizziness, but unfortunately is not widely used in many settings.
It may be done by the clinician immediately following a positive
Dix-Hallpike maneuver[23] and often produces a dramatic decrease in
dizziness.
Because benign positional vertigo results from the free movement of
dislodged particulate debris into the posterior semicircular canal,
vestibular rehabilitation acts to reposition the loose particles from the
posterior semicircular canal into the utricle. This is accomplished by
maneuvering the patient's head into certain positions
<http://www.mayo.edu/balance/crp1.htm> . For patients with central causes of
dizziness, vestibular rehabilitation may also include gait training and
strengthening of other sensory functions to compensate for vestibular
dysfunction.[16] A physical therapist may be consulted in any case.
Vestibular exercises may be performed several times by the therapist, then
taught to the patient to perform at home. Antivertiginous and central
nervous system medications should be avoided during therapy because the
sensation of dizziness is required for effective compensation.[18]


Efficacy of vestibular rehabilitation was retrospectively studied[24] in 37
patients with both peripheral and central vestibular etiologies of dizziness
by comparing dizziness handicap inventory scores pretreatment and
posttreatment within 1 year of vestibular rehabilitation. A significant
improvement in test scores was found posttreatment. There was no significant
difference in improvement between patients who performed home exercises for
at least 1 month and those who participated in initial therapy only. Gordon
and colleagues[15] found complete resolution of dizziness in 83% of patients
diagnosed with benign positional vertigo following 1 physical therapy
session. The APN should use this knowledge to facilitate referral of the
patient with chronic dizziness to a physical therapist who provides
vestibular rehabilitation. This is an option that may not have been
considered by the PCP or specialist evaluating the patient in the past.

Antivertiginous Medications

Antivertiginous medications, particularly meclizine, are prescribed widely
for all ages of people who are dizzy. These agents, however, are most
effective for motion sickness and only possibly effective for vertigo caused
by vestibular disorders. These drugs may have central nervous system
depressant effects or paradoxic effects in the elderly. They have
anticholinergic effects so should be avoided with narrow angle glaucoma,
benign prostatic hyperplasia, and gastric and genitourinary outlet
obstruction. Additional anticholinergic side effects, which may be additive
with other anticholinergics, may include xerostomia, blurred vision,
constipation, urinary retention, and mental status changes.
Despite the precautions, meclizine 12.5 mg to 25 mg may be used 2 to 3 times
daily to control or prevent dizziness. It works by decreasing labyrinth
excitability and conduction in the vestibular-cerebellar pathways. Onset of
action is 20 minutes to 60 minutes, so meclizine may do little to treat a
vertiginous attack already in progress. Elderly patients should be cautioned
to avoid activities that require mental alertness, such as driving, until
the effects of the medication are fully revealed.
Diphenidol is another antivertiginous and antiemetic medication that is
sometimes used for vertigo associated with nausea and vomiting. It is not a
first-line agent because of its propensity for central nervous system side
effects such as mental status changes, hallucinations, disorientation, and
confusion. Dimenhydrinate is an antihistamine used for motion sickness. It
may cause central nervous system side effects and photosensitivity.
The APN should take an active role in educating patients about these drugs,
their side effects, proper use, and limitations. Care should be taken to
avoid interactions of other drugs with anticholinergic and central nervous
system effects. The APN can monitor drug effectiveness with the patient and
should recommend discontinuing the drug if significant side effects occur or
no benefit is seen.

Ensuring Safety

Safety is a primary concern for the elderly patient who is dizzy, both to
prevent injury and to prevent inactivity and withdrawal due to fear of
falling. There are a number of ways the APN can intervene to ensure the
elderly patient's safety. First, the patient's immediate environment should
be safety-proofed to prevent injury if the patient becomes dizzy and
unsteady. The patient should be encouraged to wear properly fitting nonslip
footwear. Furniture should be removed that has sharp edges or that may be an
obstruction. Throw rugs should be removed, lighting should be good, and
steps should be fully visible with handrails on 2 sides. The patient should
be taught how to arise slowly and avoid sudden position changes if postural
or position changes aggravate dizziness. T'ai Chi may be helpful for
improving balance in people with dizziness and dysequilibrium. Research has
shown significant improvement in people with mild balance disorders.[25]
The topic of driving should be discussed with the dizzy patient. Although
many elderly patients depend on driving for daily functioning, dizziness
poses a potentially lethal threat. In 1 study,[26] few dizzy subjects had
been warned by their doctors not to drive, and 52% said that if they were
warned to stop driving, they would not. Therefore, the topic needs to be
approached sensitively, in an effort to help the patient avoid dependence on
driving while dizzy. Plans should be made for alternate transportation if
the patient is dizzy, and an emergency plan can be made to stop the car in a
safe place if dizziness ensues while driving.

Summary

The APN is in a unique position to intervene with the elderly client who is
dizzy, no matter what the cause. While the medical work up is progressing,
as well as following the diagnosis, the APN can address the impact of
dizziness on the patient. The APN should determine if a thorough neurologic
and cardiovascular examination has been performed. Unless focal neurologic
deficits, severe headache, and vertical nystagmus are present, neuroimaging
is not necessary. The Dix-Hallpike maneuver should be performed on all dizzy
patients to rule out a benign peripheral vestibular etiology for the
dizziness. A positive test indicates the need for vestibular rehabilitation.
The APN should facilitate this referral to a physical therapist and involve
the patient's family and other caregivers to help address issues of fall
prevention, driving safety, and careful use of antivertiginous medications.

Case Study -- Conclusion

The medical record for Mrs. Smith indicated a normal neurologic examination
with negative Romberg test and intact proprioception, reflexes, and light
touch sensation, but the Dix-Hallpike maneuver had not been performed.
Cardiac and audiologic evaluations were normal. The APN repeated an ear
exam, which revealed no abnormalities. The APN also evaluated for postural
hypotension, which was absent, obtained an EKG that revealed normal sinus
rhythm, and performed a Dix-Hallpike maneuver. The Dix-Hallpike revealed
positive horizontal nystagmus toward the left that disappeared when tried
again. This finding with history of intermittent positional vertigo
confirmed a diagnosis of benign positional vertigo. The APN recommended that
Mrs. Smith's meclizine be discontinued since it was not effective. A
referral was made for treatment by a physical therapist for vestibular
rehabilitation. Following 2 treatments, Mrs. Smith's dizziness was
significantly better and she began going to the dining room every morning.
The physical therapist suggested that a cane could be obtained if Mrs. Smith
desired until she became completely steady. Mrs. Smith refused. The APN
asked the staff to make sure that Mrs. Smith wear appropriate footwear at
all times, and to keep her room free from clutter. The APN continued to
monitor Mrs. Smith's cardiac status and coagulation profile and reinforced
patient and staff education to prevent bleeding with anticoagulant use.

Table 1. Differential Diagnosis of Dizziness

Character of Dizziness
Mechanism
Examples
Lightheadedness, faintness, presyncope
Vaso-vagal mediated
Carotid sinus hypersensitivity
Neuromediated
Volume depletion
Autonomic neuropathy of diabetes
Severe anemia
Aortic stenosis
Drugs
Metabolic disturbance
Hypoglycemia
Hypoxia
Vertigo
Peripheral vestibular
Benign positional vertigo
Labyrinthitis
Meniere's disease
Ototoxic drugs
Acoustic neuroma
Central vestibular
Vertebrobasilar insufficiency
Multiple sclerosis
Drugs in excess
Ataxia, dysequilibrium
Multiple sensory deficits
Diabetes mellitus
Impaired vision
Motor problems
Cerebellar disease
Cerebellar degeneration
Cerebellar hemorrhage
Ill-defined dizziness, anxiety, fogginess, malaise
Psychiatric illness
Anxiety
Depression
Psychosis
.

Table 2. The Dix-Hallpike Test

1.
With patient sitting on the exam table, maximally extend the neck (to 45
degrees) and turn the head 45 degrees to one side.
2.
Support the patient's upper body and ask the patient to keep eyes open and
look at your forehead.
3.
Suddenly drop the patient backward with the head over the edge of the table.
4.
Observe the patient's eyes for at least 15 seconds for the presence of
nystagmus.
5.
Repeat with the head rotated in the opposite direction. The side with the
down ear that produces nystagmus is the side with the vestibular lesion.

References

1.      Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a
possible geriatric syndrome. Ann Intern Med. 2000;132:337-344.
2.      Grimby A, Rosenhall U. Health-related quality of life and dizziness in
old age. Gerontology. 1995;41:286-298.
3.      Yardley L, Burgneay J, Andersson G, Owen N, Nazareth I, Luxon L.
Feasibility and effectiveness of providing vestibular rehabilitation for
dizzy patients in the community. Clin Otolaryngol. 1998;23:442-448.
4.      Healthtouch Online. General information on dizziness. Available at:
http://www.healthtouch.com/bin/EContent_HT/hdShowLfts.asp?lftname=NINDS014&c
id=HTHLTH
<http://www.healthtouch.com/bin/EContent_HT/hdShowLfts.asp?lftname=NINDS014&
cid=HTHLTH> . Accessed April 10, 2001.
5.      Colledge NR, Barr-Hamilton RM, Lewis SJ, Sellar RJ, Wilson JA. Evaluation
of investigations to diagnose the cause of dizziness in elderly people: a
community based controlled study. BMJ. 1996;313:788-792.
6.      Bird JC, Beynon GJ, Prevost AT, Baguley DM. An analysis of referral
patterns for dizziness in the primary care setting. Br J Gen Pract.
1998;48:1828-1832.
7.      Bath AP, Walsh RM, Ranalli P, et al. Experience from a multidisciplinary
"dizzy" clinic. Am J Otol. 2000;21:92-97.
8.      O'Mahony D, Foote C. Prospective evaluation of unexplained syncope,
dizziness, and falls among community-dwelling elderly adults. J Gerontol A
Biol Sci Med Sci. 1998;53;M435-M440.
9.      Lawson J, Fitzgerald J, Birchall J, Aldren CP, Kenny RA. Diagnosis of
geriatric patients with severe dizziness. J Am Geriatr Soc. 1999;47:12-17.
10.     Allcock LM, O'Shea D. Diagnostic yield and development of a
neurocardiovascular investigation unit for older adults in a district
hospital. J Gerontol A Biol Sci Med Sci. 2000;55:M458-M462.
11.     Tinetti ME, Williams CS, Gill TM. Health, functional, and psychological
outcomes among older persons with chronic dizziness. J Am Geriatr Soc.
2000;48:417-421.
12.     Burker EJ, Wong H, Sloane PD, Mattingly D, Preisser J, Mitchell CM.
Predictors of fear of falling in dizzy and nondizzy elderly. Psychol Aging.
1995;10:104-110.
13.     Von Renteln-Kruse W, Micol W, Oster P, Schlierf G. Prescription drugs,
dizziness and accidental falls in hospital patients over 75 years of age. Z
Gerontol Geriatr. 1998;31:286-289.
14.     Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized
benign positional vertigo in elderly patients. Otolaryngol Head Neck Surg.
2000;122:630-634.
15.     Gordon CR, Aur O, Furas R, Kott E, Gadoth N. Pitfalls in the diagnosis
of benign positional vertigo. Harefuah. 2000;138:1024-1027, 1087.
16.     Goroll AH, May LA, Mulley AG. Primary Care Medicine: Office Evaluation
and Management of the Adult Patient. Philadelphia, Pa: Lippincott, Williams
& Wilkins; 2000.
17.     Hendrich A, Nyhuis A, Kippenbrock T, Soja ME. Hospital falls:
development of a predictive model for clinical practice. Appl Nurs Res.
1995;8:129-139.
18.     Cohen H, Mesad SM. Dizziness, vertigo, and ataxia. In: Primary Care.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999.
19.     Pepper RM. Dizziness. In: Rakel RE, ed. Saunders Manual of Medical
Practice. Philadelphia, Pa: Saunders; 1996.
20.     Tilvis RJ, Hakula SM, Valvanne J, Erkinjuntti T. Postural hypotension
and dizziness in a general aged population: a four-year follow-up of the
Helsinki Aging Study. J Am Geriatr Soc. 1996;44:809-814.
21.     Hillen ME, Wagner ML, Sage JI. "Subclinical" orthostatic hypotension is
associated with dizziness in elderly patients with Parkinson disease. Arch
Phys Med Rehabil. 1996;77:710-712.
22.     Winslow EH, Lane LE, Woods RJ. Dangling: a review of relevant
physiology, research, and practice. Heart Lung. 1995;24:263-272.
23.     Orient JM. Sapira's Art & Science of Bedside Diagnosis. 2nd ed.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.
24.     Cowand JL, Wrisley DM, Walker M, Stasnick B, Jacobson JT. Efficacy of
vestibular rehabilitation. Otolaryngol Head Neck Surg. 1998;118:49-54.
25.     Hain TC, Fuler L, Weil L, Kotsias J. Effects of T'ai Chi on balance.
Arch Otolaryngol Head Neck Surg. 1999;125:1191-1195.
26.     Sindwani R, Parnes LS, Goebel JA, Cass SP. Approach to the vestibular
patient and driving: a patient perspective. Otolaryngol Head Neck Surg.
1999;121:13-17.
  _____


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.