1 / 24

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

straus
Download Presentation

DIZZINESS Module # 3 Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related