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. 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

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Edward E. Rylander, M.D.

Diplomat American Board of Family Practice.

Diplomat American Board of Palliative Medicine.