Postgrad Med J: first published as 10.1136/pgmj.68.801.558 on 1 July 1992. Downloaded from Postgrad Med J (1992) 68, 558 561 The Fellowship of Postgraduate Medicine, 1992 The evaluation ofdizziness in elderly patients N. Ahmad, J.A. Wilson', R.M. Barr-Hamilton2, D.M. Kean3 and W.J. MacLennan Geriatric Medicine Unit, City Hospital, Edinburgh and Departments of'Otolaryngology, 2Audiology and 3Radiology, Royal Infirmary, Edinburgh, UK Summary: Twenty-one elderly patients with dizziness underwent a comprehensive medical and otoneurological evaluation. The majority had vertigo, limited mobility and restricted neck movements. Poor visual acuity, postural hypotension and presbyacusis were also frequent findings. Electronystagmo- graphy revealed positional nystagmus in 12, disordered smooth pursuit in 18, and abnormal caloric responses in nine. Magnetic resonance imaging showed ischaemic changes in six out of eight patients. Although dizziness in the elderly is clearly multifactorial, the suggested importance of vertebrobasilar ischaemia warrants further consideration as vertigo has been shown to be a risk factor for stroke. Introduction More than one third of individuals over the age of Patients and methods 65 years experience recurrent attacks of dizziness.' Serious consequences include a high incidence of The subjects were 21 patients who had been falls in patients with non-rotating dizziness, and an referred to either the care ofthe elderly unit or ENTcopyright. increased risk of stroke in those with vertigo (a Department in Edinburgh for the investigation of sensation ofmovement relative to surroundings)." 2 dizziness. There were five males and 16 females The causes ofdizziness are legion.3 Its diagnosis, aged 68-95 years (median = 81 years). A carefully therefore, presents the clinician with a considerable structured history was used to evaluate indoor and challenge particularly in old people in whom ageing outdoor mobility, and symptoms of lightheaded- of the vestibular neuroepithelium or other com- ness, vertigo and unsteadiness. Physical examina- ponents of the balance mechanism may be respon- tion by a physician included measurement of sible for the symptom.4 A further problem is that passive movement in the neck, hips and knebs, and http://pmj.bmj.com/ adequate investigation may require expertise in a of lower limb muscle power, tone and reflexes. wide range of disciplines including geriatrics, Peripheral cerebellar signs were sought and neurology, neurophysiology, radiology and oto- measurement ofsupine and standing (at 2 minutes) logy. Techniques implemented have included ques- blood pressures performed. A Snellen chart was tionnaire surveys, clinical assessment of gait and used to test visual acuity. Balance was graded on a balance, force platform measurements,5 6 echo- 7-point scale ranging from being unable to sit cardiography,7 electronystagmography (ENG)8 and steadily, to being able to stand steadily for 20 on September 26, 2021 by guest. Protected imaging ofthe cental nervous system.9- 12 The latter seconds with no aid, with a long base and with eyes two tests are time consuming and their diagnostic closed.'3 Cognitive function was evaluated by com- value has yet to be fully established. pleting a brief mental status questionnaire.'4 The aim of this study was to compare the clinical Otolaryngological examination was performed evaluation of elderly patients with dizziness by a independently by a second observer and included a geriatrician with an otolaryngology (ENT) assess- further clinical assessment, otoscopy and a brief ment and the results of electronystagmography neurological examination including corneal reflex and, where possible, magnetic resonance imaging testing. Pure tone audiometry was carried out using (MRI). a Kamplex AC3 audiometer. Threshold measure- ments were performed at octave frequencies from 250 Hz to 8 kHz by air conduction and 500 Hz to 4 kHz by bone conduction. Air conduction thres- holds at 0.5, 2, 4 and 8 kHz were averaged. Where Correspondence: Professor W.J. MacLennan, M.D., indicated, acoustic admittance measurements were F.R.C.P., Geriatric Medicine Unit, City Hospital, performed using a Gray Stad GSI-33; and brain- Edinburgh EH1O 5SB, UK. stem electrical response (BSER) audiometry using Accepted: 5 February 1992 an Amplopid MklO system (stimulus 11 clicks/ Postgrad Med J: first published as 10.1136/pgmj.68.801.558 on 1 July 1992. Downloaded from DIZZINESS IN THE ELDERLY 559 second and 70 clicks/second at 90 dB nHL inten- Table I Clinical features of 21 dizzy elderly patients. sity). Only abnormal features are noted In all the vestibular tests, ENG was performed with a Peters AP210 recorder. Where practicable, Number of recordings were made (with eyes open and with Feature patients eyes closed) of spontaneous nystagmus, positional Symptom nystagmus and pendulum tracking. Bithermal vertigo 15 caloric testing (again using ENG) was performed, falls 6 in most cases using water at 44°C and at 300C, with deafness 3 30 seconds irrigation. In cases where a perforated nausea and vomiting 2 drum was present or suspected, air at 50°C and tinnitus 1 24°C was used with 50 seconds irrigation. Caloric diplopia 1 responses were recorded with the patient's eyes Walk with aid (zimmer/stick) 10 closed, and after about 60 seconds recording the Mobile indoors only 7 patient was instructed to open the eyes to assess the Mobile < 300 yards outdoors 6 effect of optic fixation (OF) on thermally induced Limitation of neck movements 12 nystagmus. with pain 3 MRI was performed using a 0.08 Telsa resistive with dizziness 2 system situated in the Royal Infirmary, Edin- Visual acuity > N18 burgh"5 in those patients where a central causative bilateral 3 factor was suspected from clinical or ENT findings. unilateral 3 Transverse and sagittal T1- and T2-weighted images were obtained on all Postural systolic BP drop of subjects. (T1-weighted images > 20 mmHg 5 from an interleaved saturation recovery + inversion symptomatic 2 recovery sequence with TR = 1 second, TI = 200 milliseconds, T2-weighted images from a spin echo Abnormal lower limb findings 0 sequence with TR = 1.4 seconds, TE = 96 milli- Truncal ataxia 1 copyright. seconds). Horizontal jerk nystagmus 3 Mental test score < 8/10 2 Results Of the 21 patients recruited, 19 completed all parts Table II Balance gradings recorded during clinical of the study. One patient defaulted from the ENT examination of patients clinic and a second during the course of her http://pmj.bmj.com/ investigation was admitted as an emergency with Balance characteristics Number of drowsiness following a fall. A CT scan revealed a patients space occupying lesion with midline shift and Unsafe seated 0 hydrocephalus. The lesion, a meningioma, was Safe seated, unsafe standing 2 subsequently excised with good postoperative Steady standing for 20 seconds with 4 recovery. aid I Steady standing for 20 seconds with 7 Table gives details of the clinical features on September 26, 2021 by guest. Protected identified in the 21 patients while Table II gives no aid on wide base details on a clinical evaluation ofbalance in all but Steady standing for 20 seconds with I one of them. no aid on narrow base Steady standing for 20 seconds with 4 The results of pure tone audiometry showed an no aid on long base average threshold of 50 dB HL (range 29 to 100, Steady standing for 20 seconds with 2 SD = 18 dB) in the right ear with similar readings no aid for the left side. In most patients the pattern was Total 20 consistent with simple presbyacusis but three patients' average thresholds at the frequencies tested showed an interaural asymmetry of greater than 15 dB. BSER audiometry on one of these right side associated with a flat tympanogram. A showed an N5 wave interaural latency difference right myringotomy was performed but the middle greater than our upper limit of normal of 0.3 ear space was found to be dry and the dizziness was milliseconds. In accordance with our routine unaltered after this procedure. The ENG results are clinical practice, therefore, a CT scan was per- summarized in Table III. Four patients had limited formed. No intracranial lesion was detected. One examinations, two because of restricted head patient had a slight low tone component on the movements and two because of nausea and vomit- Postgrad Med J: first published as 10.1136/pgmj.68.801.558 on 1 July 1992. Downloaded from 360 N. AHMAD et al. Table III Electronystagmographic findings in 20 with normal scans had signs and symptoms of patients vertebrobasilar ischaemia. Observation Number of patients Discussion Calibration overshoot No overshoot 19 Dysequilibrium in old people is linked to damage to vestibular end organs or to their central con- Positional nystagmus absent 8 trol"6 and to a multiplicity of sensory defects Amplitude <2 0/s 2 such as impaired vibration sense, which is closely 2-4 0/s 7 correlated with ataxia."7,8 Falls are also assoc- > 5 0/s iated with many causes of ataxia or dizziness test restricted 2 whose relative importance can be hard to deter- mine.'9 In the a Pendulum tracking normal 2 present study detailed clinical mild disorder 5 assessment was accompanied by an otoneuro- gross break-up 13 logical and neuroradiological work-up. As in many previous studies, we found a high preva- Caloric responses normal 9 lence of postural hypotension20 but this was unilateral canal paresis 7 bilateral canal paresis 2 symptomatic in only two patients which empha- not tested 2 sizes the variable causal association of postural hypotension and dizziness. The severity of the Effect of optic fixation on caloric nys- drop, the absolute level of the steady systolic tagmus total suppression 9 pressure, and the presence of cerebral athero- variable/partial suppression 3 sclerosis may all be critical determinants of this no effect 7 relationship.2' enhancement It is noteworthy that almost one third of patients had major visual defects (Table I).