Dizziness is a common complaint and has a very broad list of possible underlying causes. Dizziness is a nonspecific term which can mean true vertigo, light-headedness, weakness (neurological impairment), unsteadiness, feeling faint (presyncope - see separate article Syncope), funny turns, visual disturbance, or a psychological problem.¹

Dizziness is often dismissed as a trivial symptom. However patients often suffer significant social and occupational morbidity and establishing the diagnosis is essential in view of the wide variety of possible causes and also to enable effective management.² Expensive investigations are rarely helpful in dizzy elderly people. The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical history and examination and often does not require hospital referral.³

Epidemiology

• Dizziness is a common presentation in primary care, especially among patients older than 75 years.⁴
• Dizziness affects approximately 20% to 30% of people in the general population.⁵

Causes of dizziness²

• Cardiovascular:
  • Postural hypotension.
  • Cerebrovascular disease.
  • Carotid sinus syndrome.
  • Vertebrobasilar insufficiency.
  • Aortic stenosis.
  • Subclavian steal syndrome.
  • Cardiac arrhythmia.
• Neurological:
  • Post head injury.
  • Epilepsy.
  • Multiple sclerosis.
  • Parkinsonism.
  • Dementia.
  • Brain tumours, especially brainstem and cerebellar tumours.
  • Benign intracranial hypertension.
  • Normal pressure hydrocephalus.
  • Peripheral neuropathy (imbalance or unsteadiness may occur as a result of peripheral neuropathy, spinal posterior column lesions or cerebellar disease).
• Otological:
  • Ménière's disease.
  • Benign positional vertigo.
  • Labyrinthitis.
  • Vestibular neuritis.
  • Vestibular migraine (generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migraine symptoms).⁶
  • Otosclerosis and Paget's disease of bone.
  • Vascular accidents.
  • Middle ear trauma.
  • Following surgery, e.g. stapedectomy, cochlear implant.
  • Tumours, cholesteatoma.
• Metabolic:
  • Hypoglycaemia.
  • Adrenal insufficiency.
  • Hypothyroidism.
• Haematological:
  • Anaemia.
  • Hyperviscosity.
• Psychogenic: e.g. generalised anxiety, agoraphobia, panic attacks, hyperventilation.
• Miscellaneous:
  • Viral illness.
  • Migraine headaches.
  • Other infections, e.g. acute bacterial infections, Lyme disease, HIV infection.
  • Ocular: visual impairment.
  • Cervical, e.g. cervical spondylosis.
  • Multisensory dizziness syndrome: occurs when there are reduced inputs from more than one sensory system, e.g. reduced vision, vestibular dysfunction, peripheral neuropathy, autonomic neuropathy.
  • Autoimmune/connective tissue disorders, e.g. rheumatoid arthritis, systemic lupus erythematosus.
  • Drug intoxication, e.g. acute intoxication with alcohol or drugs; carbon monoxide poisoning; chronic .alcohol misuse.
  • Iatrogenic: side-effect of medication, e.g. antihypertensives, antidepressants, aminoglycoside antibiotics, antiarrhythmics.

One study found the most common causes for dizziness were peripheral vestibular problems, e.g. benign paroxysmal positional vertigo, labyrinthitis, acute vestibular neuronitis, and Ménière's disease (35% to 55% of patients), and psychiatric disorders (10% to 25% of patients). Cerebrovascular disease (5%) and brain tumours (<1%) were infrequent. The history and physical examination led to a diagnosis in about 75% of patients. At least 10% of patients could not be diagnosed. Symptoms were usually self-limiting and not associated with an increased risk of mortality.⁷

Assessment

See also separate article Neurological History and Examination. A thorough history and examination usually provide a clear guide to initial investigations, treatment and the need for referral. Assessment involves:

• An assessment for any serious underlying disorder requiring urgent treatment, e.g. ischaemic heart disease, cerebrovascular disease.
• Identifying the nature of the presenting symptom in terms of being true vertigo, syncope, presyncope or any other form of dizziness. Dizziness can usually be categorised into one of four main groups:⁸
  • Vertigo:
    • Vertigo is defined as an abnormal sensation of movement, either of the surroundings or the person (see also separate Vertigo article). Descriptions of vertigo include spinning, tilting, and moving sideways.
    • Most cases seen in primary care are due to peripheral vestibular disorders such as benign positional vertigo, acute vestibular neuronitis and Ménière's disease, but causes also include central nervous system disorders such as vascular incidents or multiple sclerosis.⁸
  • Presyncope:
    • Feeling of lightheadedness, muscular weakness and feeling faint. Features may suggest a specific diagnosis.
    • See separate Syncope article.
  • Disequilibrium:
    • A sensation of unsteadiness, not localised to the head, that occurs when walking and is relieved with rest.
    • The most common cause of disequilibrium is 'multiple sensory deficits' in elderly patients, who may have deficits with all three balance-preserving senses, i.e. vestibular, visual and proprioceptive.
  • Nonspecific dizziness:
    • Many patients with dizziness do not have specific features of vertigo, disequilibrium or presyncope.
    • The history is vague beyond a complaint of dizziness and there are no features that would point to causes in one of the other categories.
• Identification of the precise underlying cause.

Symptoms

• Actions that provoke symptoms may include:
  • Change in posture (suggests postural hypotension).
  • Movement of the head or neck (suggests vertigo from any cause, cervical spondylosis or vertebral artery syndrome).
  • Feeling anxious (may indicate hyperventilation).
• Associated symptoms may include:
  • Syncope (see separate Syncope article).
  • Consider any features suggestive of epilepsy.
  • Falls: refer elderly patients to a geriatrician.
  • Tinnitus or hearing impairment: suggests a vestibular cause.
  • Olfactory hallucinations and amnesia may suggest a temporal lobe lesion.
• Determine the level of anxiety: anxiety is often present in elderly patients but not usually the only cause.
• Consider a possible cardiovascular cause; ask about smoking and any other risk factor for cardiovascular disease.
• Review past medical history and drugs being taken.

Examination

Careful examination is required in order to assess a possible underlying cause; for example:

• Cardiovascular (see also separate article Cardiovascular History and Examination):
  • Blood pressure: sitting position, and also supine and standing to assess any significant postural drop suggesting postural hypotension.
  • Aortic murmur (may suggest aortic stenosis and therefore prompt cardiology referral), carotid bruit.
• Eyes: visual impairment, nystagmus (see also separate articles Examination of the Eye and Nystagmus).
• Dix-Hallpike test (see separate Benign Positional Vertigo article).
• Neurological:
  • Features of cerebrovascular disease, peripheral neuropathy or Parkinsonism.
  • Examine gait and ask the patient to do heel to toe walking - if these are abnormal, test reflexes and tone in the lower extremities, and test plantar responses. See also separate article Abnormal Gait and Cerebellar Signs including Cerebellar Ataxia.
  • Test co-ordination by asking the patient to put the opposite heel on the knee and to run the foot down and up the shin (assuming the patient is physically able to do this).

Investigations

Most causes of 'funny turns' in the elderly can be elicited from taking a history and performing an examination; extensive investigations are rarely helpful.³ However, if the diagnosis is still not obvious after completing this process, then consider referral to secondary care. Initial investigations may include:

• Urinalysis for glucose (diabetes), urinary tract infection.
• Full blood count: anaemia; mean cell volume (MCV) high with alcohol abuse.
• Renal function, blood glucose, electrolytes, liver function tests: systemic disease, alcohol abuse, electrolyte abnormalities.
• BM stick: may be useful to diagnose hypoglycaemia if done during an episode.
• ECG and ambulatory 24-hour ECG for possible arrhythmia.

Further investigations may include EEG, CT brain scan, pure tone audiometry, vestibular function tests (e.g. electronystagmography), further cardiology investigations (e.g. echocardiogram) or other investigations suggested by the presentation of each individual patient.

Management

Management depends on the underlying cause but, in general terms, management includes:²

• Thorough discussion with the patient and explanation of the problem and any underlying cause.
• Evaluation and correction or amelioration of any associated medical problem.
• Drug treatment for symptoms of vertigo and any associated nausea, vomiting, sweating or diarrhoea. Great care should be given in prescribing drugs, especially to the elderly, in view of potential sedative effects and possible increase in risk of falls. Drugs should not be prescribed without a thorough assessment of the underlying cause of the dizziness. Drugs that might be used include:
  • Antiemetics used include hyoscine, prochlorperazine, promethazine and metoclopramide (drugs may need to be prescribed as suppositories or to be taken via the buccal membrane).
  • Calcium-channel antagonists, cinnarizine and cyclizine have vestibulosuppressant effects.
• Vestibular rehabilitation, including correction of remedial problems, a general fitness programme, specific exercises to make the balance system less sensitive, psychological assessment and realistic family, social and occupational goals.
• Psychological intervention, e.g. cognitive behavioural therapy.
• Surgery is rarely indicated but might be required for:
  • Life-threatening complications of chronic middle ear disease, e.g. intracranial abscess.
  • Neoplasia involving otological structures, e.g. acoustic neuroma.
  • Trauma to the middle or inner ear, e.g. a perilymph fistula.

Document references

1. Chawla N, Olshaker JS; Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006 Mar;90(2):291-304. [abstract]
2. Luxon LM; Evaluation and management of the dizzy patient. J Neurol Neurosurg Psychiatry. 2004 Dec;75 Suppl 4:iv45-52.
3. Colledge NR, Barr-Hamilton RM, Lewis SJ, et al; Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study. BMJ. 1996 Sep 28;313(7060):788-92. [abstract]
4. McGee SR; Dizzy patients. Diagnosis and treatment. West J Med. 1995 Jan;162(1):37-42.
5. Karatas M; Central vertigo and dizziness: epidemiology, differential diagnosis, and common Neurologist. 2008 Nov;14(6):355-64. [abstract]
6. Eggers SD; Migraine-related vertigo: diagnosis and treatment. Curr Neurol Neurosci Rep. 2006 Mar;6(2):106-15. [abstract]
7. Hoffman RM, Einstadter D, Kroenke K; Evaluating dizziness. Am J Med. 1999 Nov;107(5):468-78. [abstract]
8. Hanley K, O'Dowd T, Considine N; A systematic review of vertigo in primary care. Br J Gen Pract. 2001 Aug;51(469):666-71. [abstract]

Internet and further reading

• Samy HM; Dizziness, Vertigo, and Imbalance, eMedicine, Jan 2010
• Shaia WT; Inner Ear, Evaluation of Dizziness, eMedicine, May 2010
• Zapanta PE; Vestibular Rehabilitation, eMedicine, Nov 2009

Acknowledgements