Dizziness, Syncope, and Falls in the Elderly
Richard Brunader
Janet Leah Retke
CLINICAL PEARLS
Dizziness is the result of a dysfunction in the sensory, central integrative, or motor systems affecting the orienting mechanisms and resulting in a perception of disequilibrium.
With rare exceptions, dizziness is a benign, self-limited condition not associated with excess mortality.
Dizziness can be subclassified as vertiginous, lightheadedness, disequilibrium, or “other.”
Brain imaging in patients with dizziness without focal neurological findings is generally not helpful.
Vestibular rehabilitation therapy is based on central nervous system compensation for the dysfunctioning labyrinth.
The etiology of syncope may remain undiagnosed in up to 40% of cases.
Because elderly patients may be amnesic for a syncopal event and recall only having fallen, the history obtained from the patient may be misleading.
Patients with a normal 12-lead electrocardiogram are extremely unlikely to have an arrhythmia causing syncope and have a very low risk of sudden death.
Four percent of patients undergoing prolonged ambulatory cardiac monitoring as part of a syncopal evaluation have arrhythmias that are associated with symptoms.
The fifth leading cause of death in persons older than 65 is accidents. Falls constitute two thirds of these accidents.
Each year, at least one third of community-dwelling persons who are 65 and older fall.
Most falls result from the accumulated effects of multiple impairments of the sensory, central integrative, cardiovascular, and musculoskeletal systems, any one of which alone might not have caused falling.
Multifactorial interventions can reduce the incidence of falls between 12% and 37%.
All older persons who report a single fall should be evaluated with the “Timed Up and Go Test.”
Dizziness, syncope, and falls are often frustrating to physicians because of the frequent vagueness of the complaints and the difficulty in determining a diagnosis. Most causes are benign, but the possibility of the rare life-threatening cause often drives a medical evaluation to be more extensive than necessary. Dizziness, syncope, and falls are combined into a single chapter because of the considerable overlap in their symptoms and etiologies.
NORMAL GAIT AND BALANCE
Decline of gait and balance begins well before the rise in prevalence of falling. Already beginning in the second decade of life and greatly accelerating after the age of 40, balance and gait decline well before attention is generally paid to testing of balance or considering strategies to maintain or improve the balance.1
CASE ONE
C.H. is an 84-year-old woman who presents complaining of at least five falls that occurred over the last 12 months. Two weeks ago, while working in her garden, as she extended her neck, she felt a swimming sensation and fell backwards. She relates that she often feels unsteady with neck extension. Approximately 3 months ago, while in the kitchen, she made a sudden turn to answer the telephone, lost her balance and fell. She notices that she becomes unsteady when she makes sudden turns. She is unable to provide any further specifics about her other falls, except to say she believes they occurred in a manner similar to the two that she described, and that she experiences frequent periods of unsteadiness with ambulation. She denies any orthostatic symptoms, true vertigo, or hearing difficulty.
Approximately 6 months ago she suffered a severe upper respiratory infection. As she arose from the dinner table and went into the bathroom, she suddenly fell forward on her face. She suffered a laceration to her forehead and was unresponsive for approximately 1 minute. She was taken by ambulance to a nearby hospital where she stayed overnight. She was informed that all her test results were normal. There has been no reoccurrence of the syncope.
On evaluation, asymptomatic orthostatic hypotension is found. Her screening audiogram and 12-lead electrocardiogram are unremarkable. Her physical examination is otherwise normal except for osteoarthritic changes of her hands and feet. Gait and balance assessment confirm a fall risk and suggest vestibular dysfunction. A cervical x-ray reveals severe osteoarthritis.
You order physical therapy for vestibular rehabilitation and desensitization of cervical-induced dizziness. In terms of her asymptomatic orthostasis, you note in her medical records to titrate her blood pressure medication to standing blood pressure and inform her to be extra cautious at times of illness.
DIZZINESS IN THE ELDERLY
Dizziness is the result of a dysfunction in the sensory, central integrative, or motor systems affecting the orienting mechanisms, resulting in a perception of disequilibrium.2
Although the symptoms of dizziness may represent life-threatening conditions such as cardiac arrhythmia, seizure, transient ischemic attack, stroke, hypotension, or pericarditis, these are the unusual presentations. Most cases are benign, self-limited, and not associated with excess mortality.3
Differential Diagnosis
Conditions that lead to dizziness, syncope, and falls in the elderly are shown in Table 13.1.
Benign Positional Vertigo
Benign positional vertigo (BPV) is felt to be caused by otoconia that have come loose from the utricle or saccule and have moved to the posterior semicircular canal. BPV is manifested by a sudden onset of vertigo caused by head turning, which resolves within a minute. The diagnosis can be confirmed by the Dix-Hallpike maneuver.4
With the Dix-Hallpike maneuver, the patient’s head is rapidly shifted from an upright position to a head-down position and tilted 30 degrees to the left. The maneuver is then repeated on the right. In BPV, the side toward which the head is turned when symptoms are induced is the side of dysfunction. Characteristics of a peripheral lesion such as BPV include: Vertiginous symptoms brought on by a rapid change in head position; vertiginous symptoms that subside within 60 seconds; rotatory nystagmus associated with vertiginous symptoms; dizziness and nystagmus occurring after a 2- to 10-second latency following a change in head position; and repetitive induction of the provocative maneuver causing extinction of the symptoms.3
In patients with central integrative pathology, such as mass lesions, or demyelinating or other pathology of the posterior fossa, nystagmus onset is immediate, fatigue of nystagmus does not occur, and subjective vertigo is minimal or absent.2 Patients slowly improve and are generally back to normal within 4 to 6 weeks.3
Other Types of Vestibular Dysfunction
Severe vertigo of abrupt onset, which then decreases over the next 1 to 3 weeks is either due to labyrinthitis (if
hearing is affected) or vestibular neuronitis (if hearing is not affected). When vestibular dysfunction occurs, the central nervous system is eventually able to compensate to some degree. However, recovery in the elderly may be prolonged because central nervous system compensation is slower, and patients are left with unsteadiness if the compensation is incomplete. A viral infection is felt to be the etiology in younger individuals. In the elderly, infarction is more often the cause. Ménière disease is the likely diagnosis when vertigo is accompanied by tinnitus and gradual development of unilateral low-frequency hearing loss. Recurrent vestibulopathy is the diagnosis when auditory symptoms are absent. The typical patient has an attack about once a year, which lasts a day, and has a more benign prognosis than those with Ménière disease.4
hearing is affected) or vestibular neuronitis (if hearing is not affected). When vestibular dysfunction occurs, the central nervous system is eventually able to compensate to some degree. However, recovery in the elderly may be prolonged because central nervous system compensation is slower, and patients are left with unsteadiness if the compensation is incomplete. A viral infection is felt to be the etiology in younger individuals. In the elderly, infarction is more often the cause. Ménière disease is the likely diagnosis when vertigo is accompanied by tinnitus and gradual development of unilateral low-frequency hearing loss. Recurrent vestibulopathy is the diagnosis when auditory symptoms are absent. The typical patient has an attack about once a year, which lasts a day, and has a more benign prognosis than those with Ménière disease.4
TABLE 13.1 CONDITIONS THAT LEAD TO DIZZINESS, SYNCOPE, AND FALLS IN THE ELDERLY | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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An acoustic neuroma grows so slowly that the disruption in brainstem input from the side affected by the tumor is compensated for by central mechanisms. Therefore, the vertigo is generally absent or minimal.5
Postural Dizziness
Postural dizziness is generally due to postural hypotension. However, the elderly with symptoms of postural dizziness do not always meet the criteria for orthostatic hypotension, defined as a reduction of systolic blood pressure by at least 20 mm Hg and diastolic blood pressure by at least 10 mm Hg within 3 minutes of standing.6 It is not uncommon that the sensation of postural dizziness occurs without postural blood pressure changes. Some older patients pool enough blood in their lower extremities to compromise cerebral perfusion without lowering their blood pressure. Sometimes, marked blood pressure declines do not occur until 10 to 30 minutes following standing. Finally, in some patients, the sensation of postural dizziness without postural blood pressure changes is caused by the same conditions as those causing dysequilibrium (see section “Subtypes of Dizziness”).3
Cervical Dizziness
Pathology in the neck is a frequent cause of dizziness in the elderly. Cervical dizziness may be either proprioceptive or vascular induced. Proprioceptive cervical dizziness occurs when osteoarthritis of the facet joints of the cervical spine impair somatosensory information coming from the neck, which can lead to lightheadedness or vertiginous sensations. Vascular cervical dizziness typically occurs when turning the head or looking up causes an osteoarthritic spur to pinch the vertebral artery.4
Physical Deconditioning
Deconditioning is the consequence of physiologic changes following a period of inactivity or low activity that result in functional losses, including loss of muscle strength, third spacing of fluid with development of postural dizziness, and reduced coordination. Similar changes are seen when patients with dizziness restrict their activities because of fear of falling. The inactivity leads to physiologic changes that actually worsens the dizziness and increases the risk of falling.3
Therefore, exercise is one of the most useful therapies for chronic dizziness in the elderly. Exercise in the elderly can reverse the orthostasis brought on by lack of movement, rebuild muscle strength, recover joint mobility, and improve vestibular function.3
Stroke
The abrupt onset of vertigo can be seen in vertebrobasilar stroke. Because of damage to adjacent brainstem structures, however, vertigo due to cerebral ischemia rarely occurs in isolation without other associated neurological deficits.2
Severe vertigo, ataxia, and vomiting can be findings in cerebellar infarction. Because brainstem signs are often absent, it can be mistaken for labyrinthitis; within 24 to 96 hours however, cerebellar edema may lead to progressive brainstem dysfunction.3
Unexplained dizziness in the elderly is often attributed to lacunar strokes.3 The diagnosis, however, can be quite difficult, as revealed in a study comparing magnetic resonance imaging (MRI) scanning of the head and neck in dizzy and nondizzy elderly patients. There were no significant differences found in the prevalence of cerebral atrophy, the number of white matter lesions, the number of cerebral infarcts, or disease of the semicircular canals or cerebellopontine angle in subjects with and without dizziness. The only difference in MRI between them was that midbrain white matter lesions (whose clinical significance is uncertain) were more common in patients with dizziness.8
Multiple Sensory Impairments
The visual, proprioceptive, vestibular, cerebellar, and neuromuscular systems must all work in an integrated manner to keep the body balanced and free of dizziness. In multiple neurosensory impairments, separate lesions in more than one area of this postural control system combine to induce dizziness. Because of impaired physiologic function in several systems associated with aging (peripheral neuropathy, impaired visual acuity, reduced labyrinthine function), older persons are particularly susceptible to this type of dizziness.3
Medication-Associated Dizziness
A wide variety of medications have been associated with dizziness, including multiple cardiovascular drugs as well as medications with anticholinergic effects. In addition, a number of medications are potentially ototoxic and can cause labyrinthine damage with resultant disequilibrium (see Table 13.2).3
TABLE 13.2 DRUG-ASSOCIATED DIZZINESS | ||||||||||||||||||||||||||||||||||||||
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Hyperventilation Syndrome
Although frequently associated with psychiatric disorders, hyperventilation by itself can produce lightheadedness secondary to reflex decreased cerebral blood flow. However, this finding is more common in younger individuals as opposed to the elderly.2
Psychologic Factors
Anxiety and depression lead to a continuous dizziness that is a common etiology in younger adults. This is in contrast to the elderly in whom psychological disorders are rarely the primary cause of dizziness. Most patients have other associated somatic symptoms and dizziness is often present for years.3
Pathophysiology
The vestibular labyrinth, and the ocular and proprioceptive systems interact to maintain equilibrium. Any disturbance in either the function or interrelationships of these structures can lead to a loss of equilibrium. When loss of function occurs in one system, the other two systems may gradually compensate so that balance and gait in most situations are maintained.9
With advancing age, function of the body’s balance control system is affected by a combination of disease, deconditioning, and age-related changes. Aging is associated with a loss of vestibular sensory epithelial cells and vestibular nerve fibers. In addition, hypertension and atherosclerosis affect vestibular pathways in the central
nervous system.10 Presbyopic changes, a decline in contrast sensitivity, along with cataracts, glaucoma, and macular degeneration affect the visual system. Finally, peripheral neuropathy affects more than 25% of persons aged 65 to 75, and 54% of patients older than 85 in the United States.11 Though these changes are often subclinical with respect to balance control, they do lower the threshold of imbalance. In addition, cardiovascular factors, cognitive impairment, muscle weakness, and medications also contribute. 9,12 All this results in older persons walking more slowly, turning more carefully, and being more susceptible to dizziness, imbalance, and falls.3 Superimposed upon this functional decline, minor stresses such as anemia, medication effects, electrolyte disturbances, and glucose or thyroid imbalance may cause dizziness and falling.9,12
nervous system.10 Presbyopic changes, a decline in contrast sensitivity, along with cataracts, glaucoma, and macular degeneration affect the visual system. Finally, peripheral neuropathy affects more than 25% of persons aged 65 to 75, and 54% of patients older than 85 in the United States.11 Though these changes are often subclinical with respect to balance control, they do lower the threshold of imbalance. In addition, cardiovascular factors, cognitive impairment, muscle weakness, and medications also contribute. 9,12 All this results in older persons walking more slowly, turning more carefully, and being more susceptible to dizziness, imbalance, and falls.3 Superimposed upon this functional decline, minor stresses such as anemia, medication effects, electrolyte disturbances, and glucose or thyroid imbalance may cause dizziness and falling.9,12
Incidence and Prevalence
Dizziness is reported in approximately 30% of people 65 years and older, and is the third most common cause of falls in the community-dwelling elderly. It is the most common presenting complaint in primary care office practices among patients 75 years and older.13 Annually, 18% of older persons experience dizziness severe enough to result in a physician visit, use ofmedication, or interference with daily activities.3
There is wide variability in the reported prevalence of many diagnoses causing dizziness in published clinical studies.14 Vestibular disease has been reported in 4% to 64% of cases of dizziness. Cerebrovascular causes were identified in 0% to 70% of cases, psychiatric causes in 0% to 40%, and cervical spondylosis in 0% to 66%. The frequency with which no diagnosis could be made has ranged from 8% to 22% of cases, and multiple diagnoses in 0% to 85% of cases. Carotid hypersensitivity was diagnosed in 48% of patients in one study.15
Reasons for such wide variability in prevalence of findings have been attributed to different populations studied, nonuniform criteria in assigning diagnoses,12 and bias caused by investigators tending to diagnose conditions in their specialty.14 However, realizing that dizziness is a syndrome often caused by more than one of several interrelated and interacting conditions, leads to an approach of evaluating each patient with dizziness for multifactorial causes as opposed to looking for discrete conditions.15
Signs and Symptoms
To assist in determining an etiology, categorizing dizziness into one of the following four subtypes as well as whether the dizziness is continuous or intermittent is helpful.
Subtypes of Dizziness
Vertigo
An imbalance of the vestibular signals arising from the inner ear, middle ear, brainstem, or cerebellum can lead to vertigo. The vestibular imbalance leads to a misleading sensation of spinning or motion of either the individual or the environment. Causes of vertigo in older persons include BPV, cerebrovascular disease, acute labyrinthitis/vestibular neuronitis, panic disorder, cervical spine disease, serous otitis media, sinusitis, and, in some, drug toxicities.3
Presyncopal Lightheadedness
Presyncopal lightheadedness is due to diffuse cortical or brainstem ischemia from vascular or cardiac causes. It is a sensation of impending loss of consciousness. Common causes include vasovagal episodes, postural hypotension, and cardiac disease (arrhythmias, conduction disorders, and low-output states) and are outlined in the syncope section.3
Dysequilibrium
Dysequilibrium is an ill-defined sensation of unsteadiness and being off balance. The body is felt to be disoriented as opposed to the head. It can be due to almost any disturbance of neurosensory structures related to the body’s balance control system (visual, vestibular, proprioceptive, cerebellar, or motor function). It has been commonly attributed to lacunar strokes, multiple neurosensory deficits, severe unilateral or bilateral vestibular dysfunction, peripheral neuropathy, cerebellar disease, and deconditioning.3
Other
Symptoms of floating or nonpresyncopal lightheadedness, or other ill-defined sensations related to balance are placed in this category. Psychological disorders, such as conversion reaction, panic disorder, depression, and generalized anxiety with related somatic symptoms are most often attributed as the cause.3
Episodic or Continuous Dizziness.
Unfortunately, many dizziness symptoms in older persons cannot be reliably assigned to a single category, and often older persons with dizziness describe several of the above subtypes.14 Because certain diagnoses produce dizziness continuously, whereas other diagnoses cause symptoms only intermittently with symptom-free periods, this lends to another classification scheme.2
Continuous Dizziness.
Conditions in this category include psychiatric disorders; deconditioning; certain medications (Table 13.2); and structural damage from stroke, cerebellar atrophy, aminoglycoside-induced vestibular damage, residual labyrinthitis, and peripheral neuropathy.2
Episodic Dizziness.
Episodic dizziness is the result of diseases causing temporary disruption of the body’s balance control system. The three most common causes in this category are BPV, transient ischemic attacks, and Ménière disease. Other causes include recurrent vestibulopathy and migraine.2
Impact on Function
Dizziness does not independently predict an increased probability of death or becoming disabled when cofounding factors, such as age and diseases, are controlled for. Instead, dizziness is a marker for other conditions that increase a patient’s risk of becoming disabled. These conditions include advanced age, nonwhite race, vascular disease, sensory impairment, and level of morbidity from arthritis, hypertension, and diabetes.16 However, many patients with dizziness do report great impairment of functional activities, depression, or fear secondary to dizziness.14
Workup/Keys to the Diagnosis
A clinical history and focused physical examination will establish the diagnosis in most cases of dizziness.3 In terms of the physical examination, concentrating on the cardiac and neurologic assessment, neck range of motion, Dix-Hallpike maneuver, and otologic examination are most helpful.
Laboratory tests should be ordered to confirm suspected etiologies. In patients with unclear diagnoses or in whom multiple etiologies are suspected, obtaining thyroid function studies, assessing renal and liver function, blood glucose, calcium, complete blood count, and syphilis serologies can be considered.3,4
To screen for acoustic neuroma, audiometry with speech discrimination is best. Other tests useful in select cases include electronystagmography, the Saccade test, rotational testing, posturography, Doppler examination of the carotid and vertebral arteries, brainstem auditory-evoked potentials, electroencephalography, and brain imaging, though with the limitations outlined in the preceding text.4
Management
General Measures
The overall prognosis for dizziness is generally good. Anemia, cardiac arrhythmias, adverse drug effects, systemic infections, cerumen against the tympanic membrane, acoustic neuroma, and serous (or acute) otitis media will respond to specific treatments. Migraine, neck osteoarthritis, physical deconditioning, and psychological diagnoses, while not curable, can be improved with therapy. Viral illnesses, labyrinthitis, and BPV are generally self-limited and will often self-resolve.3
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