The Real Cause of Dizziness in Elderly Patients
Abstract & Commentary
By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California
Dr. Ferris reports no financial relationship to this field of study. Editor Stephen Brunton, MD, Adjunct Clinical Professor, University of North Carolina, Chapel Hill, is a consultant for Amylin, Novo Nordisk, Shionogi Pharma, Takeda, and Teva; he serves on the speaker's bureau of Boehringer Ingelheim, Novo Nordisk, and Teva. Peer reviewer Gerald Roberts, MD, Assistant Clinical Professor of Medicine, Albert Einstein College of Medicine, New York, NY, reports no financial relationships to this field of study.
This article originally appeared in the September 29, 2010 issue of Internal Medicine Alert.
Synopsis: When complaints of dizziness in elderly patients were evaluated in primary care offices, the most common cause was cardiovascular disease, combined with contributions from adverse drug reactions. This contradicts many previous studies done in tertiary care settings where vertigo or vestibular disease was found to be the most common cause.
Source: Maarsingh OR, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med 2010;8:196-205.
Consecutive elderly patients seeking care for dizziness from primary care offices in the Netherlands were recruited for a study that followed them with extensive testing over 19 months. The investigators were able to use a database of all visits to confirm retrospectively that no cases had been missed. The tests included standardized diagnostic testing and inventories, physical exam, and laboratory tests from five trained physicians. A panel of three clinicians independently reviewed the collected data from 417 patients to categorize types of dizziness and possible causes; two of the three reviewers had to agree for the data to be accepted. The panel represented three medical disciplines: geriatrics, nursing home physician, and family physician.
Most patients (62%) had two or more contributory causes of their dizziness. Cardiovascular disease was the most common (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). In 23% of cases, an adverse drug reaction was a contributory cause. The most common dizziness subtype was presyncope (69%), followed by vertigo (41%) and disequilibrium (2%). A large number (44%) also had two or three dizziness subtypes.
Commentary
Dizziness is a very common complaint in the elderly, and often presents diagnostic challenges since it can be caused by many factors. Studies of consecutive geriatric patients in a university neurology clinic found 26% caused by benign positional vertigo and 22% by cerebrovascular disorders.1 However, as this current study and others show, research in primary care offices produces much different conclusions. Referral populations can have a very different mix of patients than those commonly seen in primary care offices.
A more accurate analysis of dizziness in the elderly reveals it to be a multifactorial problem, frequently caused by cardiovascular disease in combination with adverse drug reactions, depression and anxiety, and mobility impairments. The recommended approach to these complaints is "functional," which means working with the patient to correct what is possible and improve activities of daily living. While an outright "cure" of dizziness may not be possible, this more realistic approach of considering multiple factors can yield better outcomes for our affected elderly patients.
Reference
- Sloane PD, et al. Persistent dizziness in geriatric patients. J Am Geriatr Soc 1989;37:1031-1038.
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