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DIZZINESS Module # 3 Management

DIZZINESS Module # 3 Management. Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512. PROCESS. Series of modules and questions Step #1: Power point module with voice overlay

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DIZZINESS Module # 3 Management

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  1. DIZZINESSModule # 3Management Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512

  2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

  3. Objectives Upon completion of the module the learner will be able to: • Describe the management of the most common causes of dizziness • Describe the Epley maneuver • List the physiology blood pressure maintenance and the changes with aging

  4. MANAGEMENT “Tincture of time” • spontaneously resolution in > 50% or • substantially improves within 2 weeks. • Often associate with viral or other self-limited illnesses 50 % or more will be MULTIFACTORAL

  5. Acute vertigo attacks occur with peripheral vestibular disorders such as labyrinthitis Meniere's disease SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9 Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003. Vol 58, No 4, 46-52 Treatment First choice avoid medications, hydrate Second choice trial of “Epley Maneuvers If fails may benefit from meclizine or Prednisone or if needed, a benzodiazepine. Often “trade” vertigo for increased fall risk, sedation and anticholinegic effects Meclizine overprescribed for chronic vestibulopathies and non-vertiginous dizziness. MANAGEMENT

  6. MANAGEMENT Benign positional vertigo • usually can be treated with simple reassurance • For severe or persistent symptoms: • the canalolith repositioning procedure (Epley's maneuver) • home habituation exercises SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9

  7. MANAGEMENT Meniere's disease If attacks are frequent or disabling • may benefit from prophylactic treatment with salt restriction or diuretic therapy or both. • Occasional require referral to otolaryngology for consideration of surgery SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9 Eaton DA, et. al. Dizziness in the older adult. Geriatrics April 2003. Vol 58, No 4, 46-52

  8. Orthostatic hypotension Correct reversible causes of Syncope Etiologies:P-A-S-S O-U-T (mnemonic) • P ressure(hypotensive causes) • A rrhytmias • S eizures • S ugar(hypo/hyperglycemia) • O utput(cardiac) /O2 (hypoxia) • U nusual causes • T ransient Ischemic Attacks & Strokes

  9. P ressure (Hypotensive induced causes) Why elderly are predisposed to hypotension problems

  10. Mechanisms of compensation for gravitational effects of standing Autonomic Endocrine Carotid/aortic baroreceptors  renin release  angiotensin II  aldosterone sympathetic tone vasoconstriction  sodium retention peripheral vasoconstriction & heart rate Atrial Natriurectic factor  vasodilator  renin-angiotensin

  11. Aging, Physiology and Blood Pressure

  12. General Causes of P ressure Problems: 1)Vasovagal • 1-29 % of all causes syncope. 2) Orthostatic Hypotension • 5-29 % of all causes syncope

  13. The List of causes: a) Volume loss b) Medications c) Situational d) Primary Autonomic Disease e) Secondary Autonomic Disease f) Adrenal Insuffiency a)Volume Loss blood loss fluid loss (diarrhea, sweating, diuresis, dehydration) b) Medications; antihypertensives B-blockers alcohol anticholinergics antianginals vasodilators antiparkinsonian Orthostatic HypotensionCAUSES

  14. Orthostatic HypotensionCAUSEScontinued c)Situational (many of these involve the Vasovagal mechanism) • micturition • postprandial* • cough • carotid sinus sensitivity • defecation • laughing

  15. d) Primary Autonomic Disease Idiopathic Multi-System Atrophy (e.g.Shy-Dragger) Parkinson’s disease e) Secondary Autonomic disease Neuropathic e.g.DM, amyloid, alcoholism, auto-immune Cancer, B12 def., porphyria CNS e.g. CVA’S, MS, Tumors, Wernickes, spinal cord lesions Renal failure Orthostatic HypotensionCAUSEScontinued

  16. Disequilibrium: Vision Improve MSK Re-strengthening Gait evaluation and therapy Balance training Assistive device evaluation and use Chronic vestibulopathy: Vestibular rehabilitation? SOURCE: Adapted from Khan A, Kroenke K. Diagnosis and treatment of the dizzy patient. Prim Care Case Rev. 1999;2(1}:9. MANAGEMENT

  17. MANAGEMENT Lightheadness Psychiatric issues depression, anxiety & somatoform disorders • Antidepressants? • Counseling? Prescription drug toxicity • usually cardiovascular, antihypertensive, psycho-tropic and diuretics.

  18. MANAGEMENT Lightheadness Other causesTreatment • cervical arthritis: pain control, ROM • visual disorders: maximize vision • carotid sinus hyper-sensitivity: Avoid neck pressure, Medication review

  19. Practical Approach to Evaluating the Dizzy Patient History( start with Brief, focused evaluation and simple follow-up) Step #1; Describe symptoms Step #2: Pass out?( syncope often requires early cardiac w/u) Step # 3: Classify*into 3 key sensations: (spinning, fainting, or falling?) Step #4: Positional effect on symptoms? • worsen with head movements? (eg, benign positional vertigo), • standing up (eg, orthostatic hypotension) • associated with ambulating (eg, disequilibrium) Step # 5; Associated symptoms? • syncope ( needs syncope eval.) • nausea or vomiting, ( vertigo) • hearing, ear symptoms ( Meniere's disease, acoustic neuroma) • ataxia or focal neurologic deficits (central neurological cause) • multiple somatic complaints (depression, anxiety, somatoform disorder) Step #6: Medications review: (especially new around the time of onset ) • *CLASSIFICATION • Symptom-oriented approach--- Classify as: • Vertigo (rotational sensation), …………………….“spinning” • Presyncope (impending faint),…………………… “fainting” • Disequilibrium (loss of balance without head sensation)“falling” • Lightheadedness (ill-defined, not otherwise classifiable).

  20. Practical Approach to Evaluating the Dizzy Patient Physical examination • Orthostatic blood pressure and pulse • Nystagmus exam:1st: Primary position. 2nd: Gaze-evoked 3rd: Dix-Hallpike test, 4th Head-shaking. • Cardiovascular exam • Neurologic (cerebellar, propioceptive, motor, sensory) ( include “Up and go test”) • Vision & Hearing Diagnosis & Treatment • Assume multi-factorial • Classify Symptoms • List Factors derived from “ Classification”) and their etiologies • Treat multiple factors and the easiest first • Time is on your side ( go slow), see patient back often

  21. The End of Dizziness Modules Request “Dizzy Pearls” summary card from 402.559.3964 or kfturner@unmc.edu Credits: Adapted with permission from; • Kroenke K. Dizziness. Geriatrics Review Syllabus, 5th Edition chapter 23, ppg 159-165

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