Non-Vertigo Dizziness - #21
Take QuizLearn a systems-based approach to evaluation non-vertigo dizziness.
ED patients who present with dizziness may describe symptoms of syncope, near-syncope, imbalance, weakness, loss of equilibrium, or agitation. It is useful to approach common causes of these symptoms by a systems-based approach:
Table 1. Causes of non-vertigo dizziness by systems-based approach3,4
Cardiovascular System
| Features in patient history | Cause | Further Testing |
|---|---|---|
| History of arrthymias or MI, symptoms of chest pain, palpatations | Dysrhythmias | ECG, telemetry, holter monitor |
| History of previous MI, CAD, symptoms of crushing substernal chest pain, SOB, diaphresis, pain that radiates to arm/neck/shoulder |
Myocardial |
ECG, troponin, |
| Symptoms upon exertion, history of vavular heart disease | Valvular disease | Echocardiogram |
Neurological System
| Features in patient history | Cause | Further Testing |
|---|---|---|
|
Presence of prodromal symptoms of nausea, diaphoresis, changes in vision; situational dizziness |
Vasovagal |
Tilt test |
|
History of Diabetes Mellitus, Parkinson’s disease, or other neurological disease |
Autonomic insufficiency |
Hb A1C,electrolytes |
|
History of seizure, confusion after episode of syncope |
Seizure |
EEG, electrolytes, CBC with differential CT head |
Metabolic System
| Features in patient history | Cause | Further Testing |
|---|---|---|
|
Malaise, SOB, pale skin, and rapid heartbeat |
Anemia |
CBC, iron studies, stool guaiac |
|
Hunger, anxiety, tremors, sweating, stupor |
Hypoglycemia |
Blood glucose levels, HbA1C |
|
History of thyroid disease, symptoms of weight loss, palpitations, sweating, hyperactivity |
Thyrotoxicosis |
TSH, T3, and T4 levels |
|
Malaise, fatigue, confusion, cardiac arrhythmias, dehydration |
Electrolyte imbalance |
Electrolytes |
Psychiatric System
| Features in Patient History | Cause | Further Testing |
|
History of depression, symptoms of anhedonia, weight loss, malaise |
Depression |
Geriatric depression scale |
|
History of psychiatric disorder, situational, provoked by anxiety or fear |
Panic disorder |
Bruises; dependent upon family members; weight loss |
Other
| Features in Patient History | Cause | Further Testing |
|---|---|---|
|
Elderly neglect or abuse |
Report to social services/ authorities |
Use of multiple medications, especially digoxin, anti-hypertensives, tricyclic antidepressants, antihistamines, benzodiazepine |
|
Medications |
Blood levels of medication(s), use of diuretics and/or supplements |
Recent symptoms of URI including fever, chills, cough, or UTI including dysuria, hematuria, increased urinary frequency |
|
Sepsis |
CBC with differential,, electrolytes, blood cultures, CXR, UA |
History of hemorrhage, vomiting, diarrhea, or history consistent with dehydration |
|
Hypovolemia |
Microstatic or microcytic vital signs, CBC,, Electrolytes, med list review for diuretics |
Symptoms exacerbated by diminished ambient light, unfamiliar surroundings, and improved by grasping objects or furniture |
|
Disequilibrium of aging |
Check for disequilibrium, perform eye exam, telemetry |
Symptoms vary but may include confusion, delirium, altered level of consciousness, respiratory distress, cardiac arrhythmias |
|
Alcohol or non-prescription drugs |
Electrolytes, CBC, urine studies, toxicology labs |
|
Emergency department visit.
Assess non-vertigo dizziness in elderly emergency department patients. Approaching a patient with dizziness is challenging due to the non-specific presentation and its broad differential diagnosis. To facilitate the assessment of the patient complaining of dizziness, Drachman and Hart classified dizziness into four categories: vertigo, near-syncope, disequilibrium, and other (non-specific)1.
Non-vertigo dizziness describes a wide range of sensations experienced by the patient. Patients may report feeling light headed, weak, unsteady, or motion sickness, unevenness, or restlessness. These sensations are distinct from the classical description of vertigo dizziness, which is the sensation of spinning or rotation sensations in the absence of movement. For vertigo causes of dizziness see Geriatric Fast Fact #19.
Patients presenting with dizziness have been documented to account for 5% of out-patient visits and 4% of ED visits [2]. The major difference between these two groups is that 30% of ED dizziness visits have serious causes (e.g. strokes, cardiac arrhythmia); whereas the outpatient etiologies tend to be more benign. Having knowledge of the prevalence of diseases in the elderly helps stratify the differential diagnosis of the underlying cause of dizziness. Formulating a clear differential diagnosis is important to permit correct and efficient diagnostic testing (imaging/lab tests), while not having a clear approach to working-up dizziness leads to wasted resources and missed diagnoses2.
Recognize and assess non-vertigo causes of dizziness in the elderly.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
- Sloane PD, Coeytaux RR, Beck RS, et al. Dizziness: state of the science. Ann Intern Med. 2011;134:823-832
- Newman, DE, Hsieh, YH, Camargo, CA, Pelletier AJ, Butchy GT, Edlow JT. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008; 83(7): 765-775.
- Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. Chapter 24, New York, NY: American Geriatrics Society; 2010.
- Hazzard’s Geriatric Medicine and Gerontology. Chapter 56. New York: McGraw-Hill Medical. 2009.
Users are free to download and distribute Geriatric Fast Facts for informational, educational and research purposes only. Citation: Catherine Tsufis, Kathryn Denson MD, Colleen Crowe MD, Gabriel Manzi MD, Yana Thaker, Judi Rehm, Non-vertigo Dizziness in the Elderly Patient, September, 2012.
Disclaimer: Geriatric Fast Facts are for informational, educational and research purposes only. Geriatric Fast Facts are not, nor are they intended to be, medical advice. Health care providers should exercise their own independent clinical judgment when diagnosing and treating patients. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
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