Dizziness, light-headedness and vertigo are common with multiple and often multi-factorial causes. People may mean different things by \u201cdizziness\u201d. This page relates to the assessment and management in Older Adults.<\/p>\n\n\n\n
Common Presentations of dizziness in the Elderly<\/strong><\/strong><\/p>\n\n\n\n There are a number of conditions that can contribute to the symptom of dizziness in any group of patients. The two most common contributing factors in Older Adults are BPPV and Postural Hypotension:<\/p>\n\n\n\n 1)<\/strong> Benign Paroxysmal Positional Vertigo (BPPV)<\/strong> <\/p>\n\n\n\n The most common vestibular disorder in the elderly, brought on by a change in head position e.g. turning head or turning over in bed, often accompanied by a sensation of \u201ctrue vertigo\u201d (the room moving or the patient moving) but can be also described as general dizziness or light headedness.<\/p>\n\n\n\n 2)<\/strong> Postural (Orthostatic) hypotension<\/strong><\/p>\n\n\n\n Defined as a significant drop in blood pressure on standing of systolic BP>20mmHg or diastolic >10mmHg or any systolic drop to less than 90mmHg. Symptoms are of dizziness or light headedness on standing, either rapidly from sitting\/lying down, or on prolonged stand. Baroreflexes are less sensitive in older people, reducing the compensatory increase in heart rate in response to a fall in BP, making them more susceptible to postural hypotension.<\/p>\n\n\n\n Exacerbating factors:<\/p>\n\n\n\n There are other causes of dizziness in older adults that cause dizziness in isolation, or as part of a multifactorial presentation:<\/p>\n\n\n\n 3)<\/strong> Cardiovascular causes other than postural hypotension<\/strong><\/p>\n\n\n\n Any other factor which can reduce cerebral perfusion can also cause dizziness, for example:<\/p>\n\n\n\n 4) Vertigo (Peripheral or Central) other than BPPV<\/strong><\/p>\n\n\n\n Symptoms of continuous dizziness, nausea and\/or vomiting, unsteady gait and nystagmus lasting over24 hours are classified as an Acute Vestibular Syndrome (AVS). This can be caused by either peripheral or central causes.<\/p>\n\n\n\n <\/p>\n\n\n\n 5) Other conditions<\/strong> <\/p>\n\n\n\n There are a number of other conditions which contribute to a patient feeling \u201coff balance\u201d include<\/p>\n\n\n\n JB and AS 24-09 2025<\/strong><\/p>\n\n\n\n Frail patients over age 65 with CFS \u00b3 4 with dizziness, light headedness or vertigo, and<\/strong> who have:<\/p>\n\n\n\n Services at Ellen’s Glen Community Hospital<\/strong><\/p>\n\n\n\n Services at Western General Hospital (ARC)<\/strong><\/p>\n\n\n\n Services at Leith CTC (OPRA)<\/strong><\/p>\n\n\n\n Services in Mid Lothian (IOPS)<\/strong><\/p>\n\n\n\n Services in East Lothian (MOE OPD)<\/strong><\/p>\n\n\n\n Services in West Lothian<\/strong><\/p>\n\n\n\n SCI Gateway referral: St John\u2019s Hospital >> Geriatric Medicine >> LI Templar Day Hospital<\/p>\n\n\n\n SCI Gateway referral: St John\u2019s Hospital >> Geriatric Medicine >> LI WL Geriatric Medicine<\/p>\n<\/div><\/div>\n\n\n\n People often mean different things by the word \u201cdizzy\u201d, and many have more than one type of dizziness.<\/p>\n\n\n\n One approach is to try and assess whether they mean:<\/p>\n\n\n\n Many will experience more than one of these sensations, and some feel them all<\/strong>.<\/p>\n\n\n\n All patients should have:<\/p>\n\n\n\n Examination<\/strong><\/strong><\/p>\n\n\n\n Investigations<\/strong><\/p>\n\n\n\n (Biochemistry advice re timing of cortisol: cortisol levels peak between 6am and 9am \u2013 early morning random cortisol should ideally be sampled between 7am and 9am and definitely before 9.30am)<\/p>\n\n\n\n Other possible<\/em> investigations<\/p>\n\n\n\n HiNTS in someone with vertigo is reassuring if they have all of<\/strong> unidirectional nystagmus (i.e. fast phase always in one direction); normal test of skew and Abnormal Head impulse (indicating a peripheral rather than central cause). HiNTS is concerning if they have any of<\/strong>: bi-directional nystagmus or <\/strong>abnormal test of skew or normal <\/strong>head impulse test in the context of vertigo<\/p>\n\n\n\n A video and explanation of the HiNTS test can be found in the resources section.<\/p>\n\n\n\n Management in General Practice<\/strong><\/p>\n\n\n\n BPPV<\/strong><\/strong><\/p>\n\n\n\n Please see BPPV page<\/a> for diagnosis, management and patient information leaflets<\/p>\n\n\n\n Postural (Orthostatic) hypotension:<\/strong><\/p>\n\n\n\n Measures are aimed at maintaining adequate cerebral perfusion.<\/p>\n\n\n\n Patient advice on fluid intake and self-help tips can be found Postural hypotension patient leaflet<\/strong><\/a><\/p>\n<\/div><\/div>\n\n\n\n Chartered Society of PT – “Super” Six exercises for staying steady (video)<\/a><\/p>\n\n\n\n BMJ Best Practice Guide on Assessing Dizziness<\/a><\/p>\n\n\n\n Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome<\/a><\/p>\n\n\n\n HiNTS (Head impulse, Nystagmus, Test of Skew) video (8 minutes)<\/a><\/p>\n\n\n\n HiNTs to diagnose stroke in the acute vestibular syndrome. Kattah JC et al; Stroke 2009<\/a><\/p>\n\n\n\n NHS Lothian patient information on management of postural hypotension<\/a><\/p>\n\n\n\n\n
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Who to refer:<\/h4>\n\n\n\n
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Who not to refer:<\/h4>\n\n\n\n
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How to refer<\/strong>:<\/h4>\n\n\n\n
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Assessment in Primary care<\/strong><\/h4>\n\n\n\n
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References\/Resources:<\/strong><\/h4>\n\n\n\n