Dr. Peter J. Lin Director Primary Care Initiative Canadian Heart Research

I’m Weak and Dizzy

Dr. Peter J. Lin Director Primary Care Initiative Canadian Heart Research Centre CNS Lack of Blood • TIA/Stroke Endocrine • Migraine • Hypoglycemia Damaged Tissue • Hypothyroidism • Trauma/concussion • Encephalitis Drug Induced • MS • Tumors Psychiatric CVS • Anxiety Hypotension • Cardiac Ischemia Vestibular Disorders • Valvular Disease • Arrythmias • Dehydration • Anemia Brain Facts

•100 billion neurons •1,000 to 10,000 synapses per neuron (1,000 –10,000 other neurons, muscle cells, glands, etc.). •100 trillion synapses • Weight 46 - 50 ounces (≈ 3 pounds) Four symptom categories

A. Sensation of Motion (vertigo)

B. Sensation of Impending Faint (pre-syncope)

C. Sensation of Losing one’s balance (dysequilibrium)

D. Ill-Defined Lightheadedness (not A,B,C) Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Selected Differentials Characteristics

Vertigo Spinning or Motion Episodic or BPPV Meniere’s Disease Sensation Continuous Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage

Presyncope Feeling Faint, or Episodic, may last for Dehydration Anemia about to pass out seconds, may be Cardiac Ischemia alleviated by lying Arrhythmia Infection down Hypo/Hyperglycemia

Disequilibrium Unsteady feeling in Continuous, but may Multiple Sensory Deficits Peripheral Neuropathy the lower extremities vary in intensity Vision Loss

Lightheadedness Vague complaints, Medication Related Psychiatric Disorders including nonspecific Anxiety, Depression, Panic Attacks Hyperventilation

Dizziness ‐ Nonspecific dizziness

• Many patients with dizziness have neither vertigo, disequilibrium, nor presyncope. • Their history is distinguished mostly by its vagueness e.g. feeling of floating, disconnectedness, unreality, (depersonalization) or fear of losing control. • These patients tend to have a psychiatric disorder such as anxiety or panic disorder. • sleep pattern, loss of appetite, concentration disturbance, and suicidal ideation) and panic symptoms (diaphoresis, flushing, palpitations, chest pressure, paraesthesias, and nausea) should be sought. Dizziness : Disequilibrium

• ‐is a sensation of unsteadiness, not localized to the head, that occurs when walking and that resolves at rest.

• The most common cause of disequilibrium is "multiple sensory deficits" in elderly patients with reduction in vestibular, visual and proprioceptive function—all three of the balance‐preserving senses.

• Exclude peripheral neuropathy / cerebellar degeneration ‐ alcohol consumption, nutrition, diabetes mellitus, and family history

• Hearing loss would be associated with many causes of gradual vestibular dysfunction, such as acoustic neuroma, so ASK in history. Dizziness : Presyncope

• is the lightheadedness of a near‐faint. • Features of a patient’s dizziness may suggest specific diagnoses, so • sudden onset of presyncope is suspicious for arrhythmia • exertional presyncope classically suggests aortic stenosis; • presyncope with emotional stress or on urination suggests vasomotor syncope. • Presyncope on standing, or orthostatic hypotension, has an enormous differential diagnosis. • Medications are a common cause of orthostasis. • Peripheral neuropathy is also a common cause, most often from diabetes.

Atrial Fibrillation • Atrial fibrillation (AF) is the most common heart rhythm disturbance • It is estimated that 1 in 4 individuals aged 40 will develop AF

Normal rhythm AF Lloyd-Jones DM, et al. Circulation 2004;110:1042-1046

How common is it that patients with TIA/Stroke present with dizziness?

• 3.2% of “dizzy” (any type) patients in ER have TIA/stroke

• ~1 % of all patients with isolated dizziness have TIA/stroke (translates into large #)

• 17% of TIA/stroke present with isolated dizziness

Kerber. Stroke 2006; 37: 2484‐7 *Newman‐Toker. Neurology 2008; 70:2378‐85 Definition of Hypoglycemia 1. Development of neurogenic or neuroglycopenic symptoms Neurogenic Neuroglycopenic (autonomic) Trembling Difficulty Concentrating

Palpitations Confusion Sweating Weakness Anxiety Drowsiness Hunger Vision Changes Nausea Difficulty Speaking Dizziness 2. Low blood glucose (<4 mmol/L if on insulin or secretagogue) 3. Response to carbohydrate load guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Severity of Hypoglycemia • Mild – Autonomic symptoms present – Individual is able to self-treat • Moderate – Autonomic and neuroglycopenic symptoms – Individual is able to self-treat • Severe – Requires the assistance of another person – Unconsciousness may occur – Plasma glucose is typically <2.8 mmol/L

¾ cup OJ 3‐4 glucose tablets 3 packs sugar

6 LifeSavers 1 tablespoon of honey * CHO – Carbohydrate Food Choices Canadian Diabetes Association Clinical Practice Guidelines. Can J Diabetes 2008;32(Suppl 1):S62

Copyright © Canadian Heart Research Centre 2012. This presentation may not be reproduced without written authorization from the Canadian Heart Research Centre Network Meta-analysis Comparing Non-Insulin Antihyperglycemic Drugs With PBO as Add-on to Metformin

Change in A1C Goal Change in Overall A1C (%) Achieved Body Weight (kg) Hypoglycemia Mean RR Mean RR Diff. Diff. PBO (Ref) 0101 Sulfonylureas -0.79 2.49 2.06 4.57 Meglitinides -0.65 2.25 1.77 7.50 TZDs -0.85 2.71 2.08 0.56 AGIs -0.64 ND -1.80 0.42 DPP-4 Inhib. -0.78 2.51 -0.14 0.63 GLP-1R agonists -0.97 3.20 -1.74 0.89

Phung, O. J. et al. JAMA 2010;303:1410-1418. Published online April 14, 2010. Network Meta-analysis Comparing Non-Insulin Antihyperglycemic Drugs With PBO as Add-on to Metformin

Phung, O. J. et al. JAMA 2010;303:1410-1418. Published online April 14, 2010. Advance Study - Hypoglycemia may increase the risk of morbidity and mortality in T2DM patients

Adjusted hazard ratio for primary and secondary clinical outcomes, ADVANCE patients who developed severe hypoglycemia vs those who didn't

End point Severe No severe HR (95% CI) hypoglycemia, hypoglycemia, n=231 (%) n=10 909 (%) Major macrovascular 15.9 10.2 3.53 (2.41–5.17) event* Major microvascular 11.5 10.1 2.19 (1.40–3.45) event* All-cause mortality 19.5 9.0 3.27 (2.29–4.65) Cardiovascular mortality 9.5 4.8 3.79 (2.36–6.08)

Noncardiovascular 10 4.3 2.80 (1.64–4.79) mortality

Zoungas S. et al. N Engl J Med 2010; 363(15): 1410-8 AZT-ONGL-11001 ON-SL-TW1105002 Vertigo

• An illusion of movement, either of body or of environment‐ spinning, tilting, and moving sideways but must be some abnormal sensation of movement • Sub‐classify vertigo according the duration of symptoms, and whether the vertigo is brought on by changes in position or occurs spontaneously. • Association of vertigo with hearing loss or tinnitus also provides important diagnostic information. MisMatch

MisMatched Signals

Caloric Testing

Hallpike Maneuver Epley Maneuver

 1. Sit upright.  2. Turn your head to the symptomatic side at a 45 degree angle, and lie on your back.  3. Remain up to 5 minutes in this position.  4. Turn your head 90 degrees to the other side.  5. Remain up to 5 minutes in this position.  6. Roll your body onto your side in the direction you are facing; now you are pointing your head nose down.  7. Remain up to 5 minutes in this position.  8. Go back to the sitting position and remain up to 30 seconds in this position.

 The entire procedure should be repeated two more times, for a total of three times.

 During every step of this procedure the patient may experience some dizziness.

I can’t hear you? Meniere’s disease:

 Characterized by triad of: • vertigo • tinnitus • hearing loss (sensorineural)  Chronic relapsing illness (? familial)  Due to a build-up of endolymphatic pressure in the labyrinth.

RINNE Webber

Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Selected Differentials Characteristics

Vertigo Spinning or Motion Episodic or BPPV Meniere’s Disease Sensation Continuous Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage

Presyncope Feeling Faint, or Episodic, may last for Dehydration Anemia about to pass out seconds, may be Cardiac Ischemia alleviated by lying Arrhythmia Infection down Hypo/Hyperglycemia

Disequilibrium Unsteady feeling in Continuous, but may Multiple Sensory Deficits Peripheral Neuropathy the lower extremities vary in intensity Vision Loss

Lightheadedness Vague complaints, Medication Related Psychiatric Disorders including nonspecific Anxiety, Depression, Panic Attacks Hyperventilation

Cawthorne’s Head Exercises

 Exercises are to be carried out for 15 minutes twice a day, increasing to 30 minutes.

 EYE EXERCISES  Look up, then down – at first slowly, then quickly, 20 times.  Look from one side to the other – at first slowly, then quickly, 20, times.  Focus on your thumb at arm’s length, moving it one foot toward you and back again, 20 times.

 HEAD EXERCISES  Bend head forward then backward with eyes open – slowly, later quickly, 20 times.  Turn shoulders to right, then to left, 20 times.  Bend forward and pick up objects from the ground and sit up 20 times.

 STANDING  Change from sitting to standing and back again, 20 times with eyes open. Repeat with eyes closed.  Throw a small rubber ball from hand to hand above eye level. Throw ball from hand to hand under one knee.

 MOVING ABOUT  Walk across the room with eyes open, then closed, 10 times.  Walk up and down a slope with eyes open, then closed, 10 times.  Walk up and down steps with eyes open, then closed, 10 times.  Any game involving stooping or turning is good. Serc Bonamine Gravol Ginger

Thanks for staying awake.