Dizziness, Giddiness and Feeling Faint

There are separate articles that discuss Vertigo, Benign Positional Vertigo, Labyrinthitis, Meniere's Disease, Neurological History and Examination, and Nystagmus.

• Dizziness may be a symptom with a very broad list of possible underlying causes. As a term, dizziness itself may indicate a wide range of problems, including weakness, light-headedness, unsteadiness, presyncope, neurological impairment, vertigo, visual disturbance, or a psychological problem.¹
• Dizziness is a presentation that tends to cause ‘‘heartsink’’ in many clinicians and 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 examination and do not require hospital referral.³

Dizziness is a common presentation in primary care, especially among patients older than 75 years.⁴

• 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
  • Peripheral neuropathy
• Otological:
  • Meniere’s disease
  • Benign positional vertigo
  • Viral infections such as vestibular neuronitis or labyrinthitis
  • Vestibular migraine (generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migraine symptoms)⁵
  • Otosclerosis and Paget’s disease
  • Vascular accidents
  • Tumours
• Metabolic:
  • Hypoglycaemia
  • Adrenal insufficiency
• Haematological:
  • Anaemia
  • Hyperviscosity
• Psychogenic: e.g. anxiety, panic attacks, hyperventilation
• Miscellaneous:
  • Viral illness
  • 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
  • Drug intoxication, e.g. acute intoxication with alcohol or drugs; carbon monoxide poisoning; chronic alcohol misuse
  • Iatrogenic: side effect of medication, e.g. anti-hypertensives, antidepressants

One study found the most common causes for dizziness were peripheral vestibular problems, e.g. benign paroxysmal positional vertigo, labyrinthitis, acute vestibular neuronitis, and Meniere'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.⁶

Dizziness can usually be categorised into one of four main groups:⁷

• Vertigo: an illusion of movement, either of the person's body or of the environment. Descriptions of vertigo include spinning, tilting, and moving sideways. Most cases seen in primary care are due to benign positional vertigo, acute vestibular neuronitis and Ménière's disease, but vascular incidents and neurological causes, such as multiple sclerosis.⁷
• 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.
• Presyncope: lightheadedness or a near-faint. Features may suggest specific diagnoses, e.g.:
  • Sudden onset of presyncope suggests a possible cardiac arrhythmia.
  • Exertional presyncope classically suggests aortic stenosis. Exertional presyncope or syncope is always a serious cardiac symptom and needs investigating.
  • Presyncope with emotional stress or on urination suggests benign, vasomotor syncope.
  • Presyncope on standing suggests postural hypotension.
• Non-specific lightheadedness: 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.

Symptoms

• Actions that provoke symptoms may include:
  • Change in posture (suggest postural hypotension)
  • Movement of head or neck (suggests vertigo from any cause, cervical spondylosis or vertebral artery syndrome)
  • Feeling anxious (suggests hyperventilation)
• Associated symptoms may include:
  • Syncope suggests a dysrhythmia (e.g. heart block, atrial fibrillation) or carotid sinus hypersensitivity; refer for further assessment, which may include 24 hour continuous ECG and carotid sinus massage
  • Falls: refer elderly patients to geriatrician
  • Tinnitus or hearing impairment: suggests a vestibular cause, so refer to ENT for further assessment
  • Olfactory hallucinations and amnesia may suggest a temporal lobe lesion
• Determine level of anxiety: often present in elderly patients but not usually the only cause.
• Ask about smoking (increases suspicion of cerebrovascular cause)
• Review drugs being taken

Examination

Careful examination is required in order to assess possible underlying cause, e.g.

• Blood pressure: sitting position, and also supine and standing to assess any significant postural drop suggesting postural hypotension.
• Cardiovascular: aortic murmur (may suggest aortic stenosis and therefore prompt cardiology referral), carotid bruit.
• Eyes: visual impairment, nystagmus.
• Hallpike test for benign positional vertigo:
  • With head turned to one side, move patient from sitting to supine with neck extended below plane of body over end of couch, repeat with head turned to other side (positive if causes nystagmus).⁸
  • The test is positive for benign positional vertigo if symptoms or nystagmus occur after a latent interval of approximately 10 seconds, and then settle after about 1 minute.
  • Immediate or persistent symptoms or nystagmus suggest a central rather than a vestibular cause.
• Neurological:
  • Features of cerebrovascular disease, peripheral neuropathy or parkinsonism.
  • Examine gait and ask patient to do heel to toe walking - if abnormal test reflexes and tone in lower extremities, and test plantar responses.
  • Romberg test; ask the patient to stand still with the heels together, and then to close their eyes. Marked unsteadiness with the patient's eyes closed is seen with cerebellar or vestibular dysfunction.

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, consider referral to secondary care if symptoms warrant this. Initial investigations may include:

• Urinalysis for glucose: diabetes, urinary tract infection
• Full blood count: anaemia; MCV high with alcohol abuse
• Renal function, 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, brain scan or other investigations suggested by the presentation of each individual patient

• Depends on 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 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, general fitness programme, specific exercises to make the balance system less sensitive, psychological assessment and realistic family, social and occupational goals.
• Psychological intervention.
• Surgery is very rarely indicated but may be indicated for:
  • Life threatening complications of chronic middle ear disease
  • Neoplasia involving otological structures, e.g. acoustic neuroma
  • Trauma to the middle or inner ear, e.g. a perilymph fistula