Iwona Physio: Older adults with dizziness

I meet many older people in my practise with dizziness. It usually affects their function and limit from going out. Here are some evidence based information how to assess and manage person with dizziness.

Dizziness is a common problem in elderly people. Although, it raises with age (54% of the over 90s), only 1/3 of them report the symptom. Dizziness is a non-specific word and it can be described as vertigo or light-headedness, presyncopal symptoms or a sensation of disequilibrium. That is why it is important to identify what the patient means by ‘dizzy’, because it can ease the diagnosis.

Dizziness
Vertigo	is described as objects in their surroundings are moving or that they are moving in relation to their environment; benign paroxysmal positional vertigo (BPPV) is provoked by head movements: turning over in bed or looking upwards;
Disequilibrium	refers to a feeling of unsteadiness or ‘veering’ to one side, primarily when walking. It is typically worsened when vision is simultaneously impaired (e.g. in the dark or if the patient closes their eyes)
Presyncope	is a feeling of light-headedness, sometimes associated with nausea or sweating and ‘clamminess’. Positive responses to questions such as ‘Does it feel as if you are about to faint?’ and ‘Does it feel similar to how you feel when you stand up too quickly?’ can be detected by sudden change in posture e.g. postural hypotension; if preceded by more prolonged standing, it can be due to a malignant vasovagal syndrome.

Every patients suffering from dizziness should undergo the following assessments:

Standing/lying blood pressures- if the patient’s symptoms do not occur in association with a postural drop, it should not be assumed that the observed postural hypotension is the cause of recurrent symptoms.

Pulse- sustained or paroxysmal tachy- and brady-arrhythmias can cause presyncopal symptoms.

Nystagmus’ this can help in differentiating between central and peripheral causes of vertigo.

· peripheral vertigo- nystagmus is horizontal and unidirectional, with the fast phase away from the lesion; visual fixation inhibits the nystagmus. Tinnitus and deafness can be present.

· central vertigo- nystagmus can be in any direction. Vertical and purely torsional nystagmus often with associated focal neurological signs.

Neurological examination - including the cranial nerves, to identify focal neurology ( a central cause of vertigo e.g. stroke or multiple sclerosis); to identify factors that may contribute to disequilibrium such as peripheral neuropathy and reduced visual acuity.

Examination of gait- to identify features contributing to disequilibrium, such as a wide-based gait, and can provide evidence of focal neurological disease.

Bedside hearing tests - hearing can be assessed simply at the bedside by gently whispering into each ear and asking the patient to repeat what was said. Weber’s and Rinne’s tests are used to differentiate between conductive and sensorineural hearing loss.

Classification of dizziness


Type of dizziness	Associated symptoms	Episode duration	Possible aetiology
Vertigo Central	Headache	Several minutes to 1 hour	Posterior circulation transient ischaemic attack
	Vomiting	Several hours	Migraine
	Double vision	Days	Posterior circulation stroke
	Staggering gait		Multiple sclerosis
	Clumsiness		Migraine
	Dysarthria
	Numbness of the face or body
Peripheral	Hearing loss	Few seconds	Acute vestibular neuronitis
	Tinnitus	Few seconds to a few minutes	BPPV
	Feeling of fullness in the ear		Perilymphatic fistula
	Nausea and vomiting	Several minutes to 1 hour	Perilymphatic fistula
		Several hours	Acoustic neuroma
			Meniere’s	disease
			Perilymphatic fistula
Presyncope	Sweating	Few seconds to a few minutes	Orthostatic hypotension
	Blurred or tunnel vision		Situational syncope (e.g. post-micturition, post-cough)
	Palpitations		Vasovagal e mediated by emotional distress
	Breathlessness		Arrhythmia
	Fatigue
Disequilibrium	Numbness of the feet	Weeks to months	Cerebellar disease
	Impaired vision		Parkinson’s disease
	Gait disturbance		Gait disorders
			Peripheral neuropathy
			Reduced visual acuity
Other		Weeks to months	Psychogenic

Subjective (or self-report) and objective (or observed performance) measures are commonly undertaken during the initial physiotherapy assessment. The majority of these are disease-specific measures, designed or validated specifically for insight into the impact of balance disorders. However, some non-disease-specific subjective measures, e.g. HADS, are also useful in determining the effects of balance disorders on an individual. Research has shown that specific items on the DHI can predict the presence of benign paroxysmal positional vertigo (BPPV).

The outcome measures provide both diagnostic and prognostic insights. They enable a comprehensive evaluation of a patient’s baseline function and problem profile, such that the progress of the balance disorder or the effectiveness of therapy can be gauged on subsequent re-evaluation.

Dizziness Handicap Inventory	(DHI)	Functional Gait Assessment	(FGA)
Vertigo Symptom Scale	(VSS)	Dynamic Visual Acuity Test	(DVAT)
Situational Characteristics Questionnaire	(SCQ)
Vestibular Disorders Activities of Daily Living Scale	(VADL)
Hospital Anxiety and Depression Scale	(HADS)

Regarding the vestibular physiotherapy, Cawthorne exercises are broadly used. The initial series of exercises challenges one’s spatial orientation during repetitive movements of the eyes, head or body. These are appropriate for patients who have developed self-motion hypersensitivities due to the vestibular disorder.

The latter series of exercises in the Cawthorne programme is directed at challenging postural stability. There is a degree of sensory manipulation in that patients have to maintain stability, first with eyes open and then with eyes closed. The latter may aid in decreasing patients’ over-reliance on visual cues for balance, which can be a result of peripheral vestibular disorders.

Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is mainly in older people. The most common cause is degeneration of the vestibular system of the inner ear (otoliths).

Main cause of BPPV :

head injury/trauma (8-20%),

migraine,

viruses affecting inner ear causing vestibular neuritis, Meniere’s Disease

Diagnsosis of BPPV:

The diagnosis in based on history, fidings on physical examination (see above). Also, the Dix-Hallpike test is a standard with either the classical or side-lying manoeuvres.

The management pathway for patients with BPPV is founded on the AAO HNS 2008 BPPV guideline:

https://pdfs.semanticscholar.org/d708/707c80563cba239e5baa068a42a2a1de9910.pdf

BPPV treatment

BPPV is described as ‘ self-limiting’ because symptoms often subside or desapear within 1-2 months of onset. It is recommended that patients use two or more pillows at night and avoid sleeping on ‘bad’ side. In the morning, they should remember to get up slowly and sit on the edge of bed for a minute. During the day, they should avoid bending down or picking things from the floor.

In the clinic BPPV is treated with:

the Semont Maneuver

https://www.youtube.com/watch?v=pK9qaprUU64

the Epley Maneuver