30% of 65+. Nearly all causes
Central & peripheral neurological system
CVS: especially postural blood pressure, must wait 2m after standing. Check for aortic stenosis, HOCM
CT brain (strokes), audiometry, glucose, U+Es (hydration, renal function, FBC), 24h ECG, echocardiogram
Anti-emetics, vestibular suppressants
Benign Positional Vertigo
Claim to Fame:
Most comon cause of dizziness in old age. Idiopathic.
Recent trauma, virus. Occurs with change in head position. Resolves quickly after. No auditory/neuro symptoms.
Rotatory nystagmus: lie the pt down & induce rapid head movement to one side (Hallpike)
Resolves spontaneously in weeks/monthss. Exercises to provoke symptoms help some.
Inflammation of inner ear causing dizziness & hearing loss.
Acute onset. Bacterial/viral infections especially URTI often precede the disease.
Triad of dizziness, unilateral fluctuating hearing loss, tinnitus (but
may have only one of these). Associated with syncope sometimes
Drugs to supress vestibular system (promethazine). Labyrinthectomy
The elderly are often on many drugs. Common culprits include:
Antihypertensives: postural hypotension
Sedatives (benzodiazepams, antidepressants, tranquilisers)
Aspirin overdose: w tinnititus
Isolated dizziness not explained by stroke/TIA.
Brainstem/cerebellar symptoms neccessary (e.g. ataxia, nystagmus)
Rare. Cerebello-pontine tumours e.g. acoustic neuroma or meningioma
Orthostatic (postural) Hypotension
Common. May be caused by anti-hypertensives.
20mmHg difference in systolic BP between sitting & standing
Transient loss of consciousness associated with loss of postural tone
due to reductions in cerebral blood flow. Recovery is spontaneous &
complete. Systolic BP falls to 70mmHg.
Loss of memory. 3rd party vital. May be associated with jerking of limbs and this does not necessarily imply epilepsy
Claim to Fame:
Must lead to a full cardiac and neuro investigation unless obviously hypoglyacamia or vasovagal
Exclude epilepsy & hypoglycaemia
stenosis most important (usually congenital bicuspid valves), HOCM less
commonly. Both present with syncope on exertion. Also consider a
massive PE and MI.
the presence of known cardiac pathology syncope will be explained by
arrhythmia. Sick sinus syndrome, type II/III heart block,
supra/ventricular arrythmias, failed pacemaker.
24h ECG or memo-ECG device
Withdrawel of SNS tone to blood vessels (↓venous tone & ↓BP) & unopposed PS discharge (↓HR).
Simple faint (vasovagal): stimulus
Visceral: following e.g. micturition
Carotid sinus hypersensitivity
Neurocardiogenic: syncope on standing that is not the above. Due to blood pooling in legs causing bradycardia. Tilt table.
A number of conditions & drugs are responsible, e.g. Guillain-Barre
syndrome, diuretics, dehydration, DM (denervation). Ex: postural BP
The underlying cause. Cannot drive for 12m.
minimise diuretics, avoid dehydration, support stochings, ↑Na, ↑water, fludrocortisone
Act on warning signs (lie down). Vasoconstrictors (alpha). Tilt table training.