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Family Health Magazine
GROWING OLDER

Dizziness
All about Vertigo

The incidence of dizziness increases with age and can be a very disabling condition in an older person. Often it is a vague symptom which is very disruptive to performing everyday activities. Difficulties may include doing household chores, shopping, walking or doing leisure activities such as golf.

Dizziness is a major cause of falls in seniors and is one of the reasons falls are more common as age increases. Falls in seniors account for a large portion of disabling injuries and hospitalizations. Falls may lead to hip fractures, bruises, fear of falling again, increasing immobilization and deconditioning, and finally institutionalization. One year after a hip fracture 23.6 per cent of women and 33 per cent of men died. Four years after the date of the hip fracture, the death rates in women and men were 44.4 per cent and 55.3 per cent respectively.

Investigating dizziness

Your physician may ask you these questions to determine the type and cause of your dizziness:

• Can you describe your symptoms without using the word dizzy?
• Is the dizziness associated with feeling faint or a sense of blacking out?
• Do you have a tendency to fall?
• Do you lose your balance while walking?
• Is there a sensation that the world is spinning or you are spinning?
• Does position affect your symptoms? Does getting up from bed or chair to an upright position worsen your symptoms? Does rolling over in bed worsen your symptoms?
• Do you have headaches?
• Is the dizziness constant or does it come and go? What makes it start or what makes it worse? Can you stop the dizziness?
• Do you have allergies?
• Do you use tobacco, alcohol, prescription or non-prescription drugs especially sleeping medications, anti-anxiety pills, antidepressants or antihypertensive medications?
• Do you have changes in your hearing?
• Does being anxious bring it on or make it worse?
• Do you have other symptoms with the dizziness, such as nausea and vomiting, weakness in limbs, or double vision?

The causes of dizziness

There are three segments to the system that maintains a stable upright posture: one, the vestibular labyrinth in the inner ear; two, good vision; and three, intact brain function (brain stem, cerebellum, cerebral cortex, spinal cord, and sensory input especially from joints). All of these functions change with age, making seniors more predisposed to dizziness.

Dizziness, lightheadedness, dysequilibrium and unsteadiness are very vague symptoms, but a good history, physical examination and laboratory work-up can help the family physician identify the problem.

Causes of Vertigo

There are four main categories of dizziness that can be identified in the senior dizzy patient by taking a good history. There are:

• Type 1 True Vertigo
• Type 2 Lightheadedness
• Type 3 Anxiety
• Type 4 Dysequilibrium
• Type 1 (True Vertigo)

Type 1 True Vertigo is a feeling of disorientation in space, combined with a sensation of motion. The motion is always rotary in nature. True sense of rotation may have nausea and vomiting,tinnitus (ringing in the ears), sweating, difficulty maintaining balance, and may fall during an episode of vertigo. True vertigo can be separated into central and peripheral vestibular dysfunction. Central vestibular lesions were found in 50 per cent and peripheral lesions in 34 per cent of the elderly referred to a vestibular clinic.3

A. Peripheral (Inner Ear Problems)

• Acute viral labyrinthitis is a common disorder. Usually there are spells of vertigo. Nausea and vomiting resolve in a few days, although some imbalance may persist for a few weeks. Hearing loss is temporary. When no hearing loss occurs, the disorder is called vestibular neuronitis. It is caused by a virus and is self-limiting.
• Benign positional vertigo is a frequent cause of dizziness in the elderly. Intense vertigo is brought on by movement such as rolling over in bed. Symptoms last a few seconds to less than one minute, then resolve quickly. The vertigo is associated with debris that stimulates the semicircular canal in the inner ear when the patient’s head turns to a certain position. The condition is harmless and exercises have been shown to decrease uncomfortable symptoms. Patients can be referred to a physiotherapist for Cawthorne’s Exercises for Vertigo.
• Meniere’s disease is intermittent, chronic and recurrent attacks which may last a few minutes to 24 hours. These may recur weekly, monthly or yearly. Along with vertigo symptoms, these patients may have low tone hearing loss. Antivertigo medications (Bonamine, Antivert) may be helpful in reducing some of the vertigo symptoms. Severe cases may require referral to a specialist for consideration of surgery.

B. Central Lesions

Central lesions in the brain are common causes of vertigo in the elderly. Strokes and tumors can cause dizziness. Proper control of blood pressure is important in preventing strokes. Medication such as a blood thinner (couradin sintrom) may be needed for preventing some types of stroke.

Type II (Lightheadedness)

This causes a sensation of feeling faint, as if a blackout may occur. Type II Lightheadedness is due to impaired quality or quantity of blood going to the brain. Low blood sugar in someone with diabetes is one of the important causes of poor quality of blood being supplied to the brain. Irregular pulse may reduce the quantity of blood to the brain. The patient may need an ECG or 24-hour Holter tape to monitor the heartbeat for irregularities. Medication may cause the blood pressure to drop on standing. If the drop is too great, there may be inadequate blood flow to the brain.

To make this diagnosis, the doctor will check the blood pressure lying, sitting and standing. If there is a drop exceeding 30 mmHg systolic and 15 mmHg diastolic, we say the patient has postural hypotension. This problem often requires a medication adjustment.

Type III (Anxiety)

The patient complains of a dizzy feeling associated with anxiety. The individual may describe shortness of breath or hyperventilation and may have a psychiatric disorder. Deep breathing for three minutes reproduces the symptoms. This disorder is not common in the elderly. Type III anxiety and depression can cause the symptoms of dizziness. It is important to treat these conditions if they occur.

Type IV (Dysequilibrium)

This dizziness is characterized by a feeling of unsteadiness, not vertigo, but a perception of difficulty maintaining balance when walking or turning. This is most common in frail older persons. The senior patient will describe a disturbance in gait or difficulty with balance.

Often there are many reasons for this unsteadiness. There are sensors in the joints of the cervical spine (neck) which are important for posture control. Dizziness associated with head rotation may be caused when these receptors aren’t working properly. These patients may feel worse with a restricted cervical collar. They should be prescribed exercises to improve the range of neck movements and they must learn to rely more on vision.

Circulation problems in the base of the brain (vertibrobasilar ischemia) is suggested by evidence of brain stem dysfunction trouble speaking, double vision, numbness around the mouth and limb paralysis. Poor vision from cataracts or retinal damage can contribute to impaired balance. Drugs and medication which dull brain function can impair walking and balance. Examples include alcohol, benzodiazepines, sleeping medication and antianxiety pills. The family doctor can evaluate motor strength, balance sensation, joint function, hearing and vision in the elderly patient.

By understanding the cause of dizziness, your doctor can take steps to help manage the problem. Education will help those with ongoing problems to cope with their disability. Sometimes there is no cure for the dizziness, but it is always important for a person to understand their limitations and to get help to maximize their quality of life.

Occupational therapy can help to prevent falls in the home, through grab bars in the bathroom and raised toilet seats. Physiotherapy can improve motor strengthening and instruct in the use of walking aides (cane or walker) and gait training. Your family doctor can review medication, treat anemia, manage irregular heart beat and advise about alcohol avoidance and continue monitoring your medical condition.

Much can be done to help a person suffering from this often frustrating and sometimes dangerous condition. Help can begin with a trip to your family doctor.