S Diagnostic approach to evaluation. S Treatment modalities. S Effectiveness of treatment modalities. S Symptoms are nonspecific

Transcription

1 Objectives Dizziness Leslie Griffin MD MPH Assistant Professor University of Tennessee Family Medicine Diagnostic approach to evaluation Treatment modalities Effectiveness of treatment modalities Brief look at the differences in evaluating the elderly patient ignificance Difficulties Approximately 5% of primary care visits Nearly 3% of all emergency room visits ymptoms are nonspecific Differential is broad Final diagnosis not obtained in 20% cases. Categories tep one rule out other causes Vertigo 45-54% Disequilibrium 16% Presyncope 14% Lightheadedness 10% Caffeine Nicotine Alcohol Hypoglycemia Head trauma and whiplash injuries. 1

2 Commonly associated medications Rule out: Migraines Cardiac Alpha blockers, beta blockers, ACE inhibitors, clonidine, dipyridamole, diuretics, hydralazine, methyldopa, nitrates, reserpine CN Antipsychotics, opioids, Parkinsonian drugs, skeletal muscle relaxants, TCAs Episodic vertigo with signs of migraine Photophobia, phonophobia, aura During at lease 2 episodes of vertigo Urologic Phosphodiesterase type 5 inhibitors, urinary anticholinergics tep 2: Description Timing Vertigo: pinners- false sense of motion Disequilibrium: off-balance Presyncope: feeling of losing consciousness Lightheadedness: Woozy- a more vague disconnected feeling Vertigo is never continuous for more that a few weeks Permanent vestibular lesion CN system adapts Frequent episodic dizziness can be vestibular Constant dizziness lasting months generally psychogenic. Vertigo Benign Paroxysmal Positional Vertigo Benign Paroxysmal Positional Vertigo Vestibular Neuritis Meniere s Disease Labyrinthitis 2

3 Benign paroxysmal positional vertigo Diagnosis: BPPV Brief, self limited episodes of vertigo Provoked by typical position changes No hearing loss Treatment: BPPV Epley Maneuver Epley maneuver: approximately 5 times more likely to have objective and subjective improvement Objective: OR= % CI ( ) ubjective: OR= % CI ( ) Vertigo: Vestibular Neuritis Meclizine Commonly used despite no RCT support Vestibular suppression can lead to brainstem compensation and actually prolong symptoms Vestibular rehabilitation therapy (VRT) exercise-based program designed to promote central nervous system compensation for inner ear deficits. No direct evidence Benzodiazepine Not significant difference between treatment and placebo group. Viral infection of vestibular nerve 3

4 Presentation: Vestibular Neuritis Diagnosis: Vestibular Neuritis Persistent vertigo evere vertigo Without hearing loss Typically post viral URI Generally self limited 2-3 days. Treatment options: Vestibular Neuritis Vestibular Rehab Therapy For prolonged symptoms Vestibular rehabilitation therapy (VRT) exercise-based program designed to promote central nervous system compensation for inner ear deficits. teroids 100mg methylprednisolone po daily then taper to 10 mg over 3 weeks Methylprednisolone more effective than valacyclovir RCT Goal: gaze and gait stabilization via compensation Involve head movement to stimulate and retrain the vestibular system Neural plasticity Changes in neural pathways in response to new stimuli Vertigo: Meniere s Disease Presentation Meniere s increased endolymphatic fluid in the inner ear Episodic spontaneous vertigo 20 minutes to 2 hours Ear fullness Tinnitus Hearing loss Any age most common Chronic disease 4

5 Treatments: Meniere s Vertigo: Labyrinthitis Medications For symptomatic relief of dizziness Meclinzine, diazepam, glycopyrrolate, lorazepam alt restriction and diuretics No RCT supporting Injections: 80% resolution Gentamicin 82% resolution Increased risk permanent hearing loss by damage to microcillia Dexamethasone 80% resolution Endolymphatic sac surgery Inflammation by viral or bacterial infection Presentation: Labyrinthitis Treatment: Labyrinthitis Positional vertigo + Hearing loss Vertigo resolves in days to weeks Return of hearing more variable Viral more common in adults y/o Typically occur post URI Bacterial more common in patients with cholesteatoma Acute Phase: ymptomatic Meclizine, antiemetics Treat underlying cause Chronic Phase: Vestibular rehabilitation therapy (VRT) exercise-based program designed to promote central nervous system compensation for inner ear deficits. Disequilibrium Presyncope Off balance or wobbly Parkinson Peripheral neuropathy troke Poor vision Medications Benzodiazepines and TCA in elderly Feeling of losing consciousness Orthostatic hypotension Medication review hypotensives Hydration 5

6 Presyncope: Presyncope: Cardiovascular evere orthostatic hypotension Pharmacotherapy: Midorine alpha 1 agonist Fludrocortisone mineralocorticoids increase Na and water retention Pseudoephedrine, Paxil, Desmopressin Arrhythmias upraventricular Tachycardia Myocardial infarction Carotid stenosis Cardiac medications Particularly in elderly Lightheadedness ymptoms more vague Disconnected feeling More likely psychiatric in origin Anxiety 25-28% Hyperventilation yndrome Depression 6