Am Fam Physician. 1999;59(10):2877-2878
Dizziness is a common symptom in older adults; it is also associated with a greater risk of disability. Appropriate treatment or referral depends on accurate diagnosis, which is usually undertaken at the primary care level. Lawson and associates conducted a prospective case control study of the clinical features of dizziness in elderly patients to determine if diagnosis of this condition can be improved.
Fifty patients older than 60 years of age who presented with dizziness were matched with 22 control subjects who did not have dizziness. All patients were interviewed and examined by a single clinician. A description of the symptoms associated with the dizziness, provoking factors and medical history were sought during the interview. The clinical examination included mental status testing, a full neurologic examination and psychiatric screening, as well as routine laboratory tests. Patients were then referred to a neurocardiovascular investigation unit and an otolaryngology department. At that point, all patients had electrocardiography, ambulatory blood pressure monitoring and orthostatic blood pressure measurements. Tilt testing, otoscopy, Weber and Rinne testing, and audiometry were also done. If indicated, patients had echocardiograms, carotid Doppler studies and computed tomography of the head.
After completion of the work-up, an attributable diagnosis was made. The initial history and physical examination were used to determine which factors predicted the eventual diagnosis. Dizziness was classified, when possible, into one of the following diagnoses: (1) peripheral vestibular disorder (including benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis and Meniere's disease); (2) orthostatic hypotension; (3) arrhythmia; (4) carotid sinus hypersensitivity; (5) vasovagal syncope; or (6) central neurologic disorders. In the patients with dizziness, symptoms had been present for two weeks to 30 years and occurred an average of three times per week. Symptoms lasted three minutes on average, but in some patients as long as 180 minutes. About 26 percent of patients also had syncope, 16 percent had unexplained falls and 4 percent experienced both syncope and falls.
A cardiovascular disorder was the attributable diagnosis for the dizziness in 28 percent of patients, while 18 percent were diagnosed with a peripheral vestibular problem and 14 percent had a central neurologic cause. Multiple diagnoses were present in 18 percent of patients, and no diagnosis was made in 22 percent. A variety of associated symptoms or descriptions made a cardiovascular diagnosis more likely: syncope, a “lightheaded” dizziness, pallor with the dizziness or a history of other cardiovascular problems (such as angina or peripheral vascular disease). Dizziness during prolonged standing was also associated with a cardiovascular diagnosis. When the patient described the dizziness as vertigo, the diagnosis was more likely to be peripheral vestibular dysfunction. Some physical examination maneuvers, namely visual acuity testing, the Weber and Rinne tests and the Hallpike maneuver, did not help to predict the attributable diagnosis. Similarly, routine laboratory testing, which included urinalysis, did not lead to a diagnosis.
The authors conclude that a thorough history, a focused examination and appropriate referral (if needed) may allow appropriate risk factor modification and treatment in elderly patients with dizziness. Cardiovascular assessment is much more likely to lead to an accurate diagnosis of dizziness than is otolaryngologic evaluation.