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Dizziness describes a variety of unpleasant sensations that often interfere with balance and walking. It is a common complaint of people over age 65, affecting 13%—38% of older Americans. Dizziness can have many different causes that can be difficult to diagnose. Dizziness doesn’t usually last long, but in about one-quarter of older adults with this problem, it can last a year or more. It is not usually associated with increased risk of death, unless it is a sign of heart disease. However, dizziness can increase the risk of falling and decrease quality of life, especially if it is persistent or severe.
Types of Dizziness People often use "dizziness" to describe faintness, lightheadedness, or poor balance. Blurred vision, double vision, and changes in blood pressure may also be interpreted as dizziness. Dizziness is classified into several distinct types based on symptoms: These different types have different causes and different treatments. Vertigo Vertigo is dizziness accompanied by a sensation of spinning. The most common causes of vertigo are middle or inner ear problems. Benign positional vertigo (BPV) involves the middle ear. Spells of BPV are brought on by changes in head position, such as from turning, rolling over, lying down, sitting up, or bending over. These spells often last only 5—15 seconds, and they are milder than attacks of vertigo seen with conditions of the inner ear. Generally, BPV gets better on its own, but it can come back. In some people, it is long lasting and disabling and warrants prompt attention and treatment. Most vertigo associated with the inner ear happens suddenly, lasts for several days, and then goes away on its own. These episodes may be caused by viral infections or inflammation of the nerves in the inner ear. In this condition, the eyes may "swing" rhythmically and quickly back and forth (left to right or right to left), which is called nystagmus. People may also have difficulty walking, nausea, or vomiting. Usually, hearing is not affected, and there are no other problems with the nervous system. One particularly severe type of inner ear problem is called Ménière’s disease. In this disease, there are repeated episodes of severe vertigo, nausea, and vomiting. Between episodes, there is often mild dizziness and ringing in the ears. Ménière’s disease can worsen over time, leading to deafness and, sometimes, problems with balance and walking. Diseases of the brain, such as stroke, brain tumors, multiple sclerosis, or blood vessel problems, can occasionally cause vertigo. These disorders are more commonly accompanied by other neurologic problems, such as weakness or inability to move an arm or a leg, difficulty walking, or vision problems such as double vision. Unsteadiness Some people who complain of dizziness actually feel unsteady when standing and especially when walking. The medical term for this is "disequilibrium." It can be caused by anything that leads to unsteadiness or lack of balance, including poor vision, middle ear problems, arthritis, and foot problems. An older person with more than one of these problems is much more likely to experience disequilibrium. It can also be caused by problems with the nervous system, such as those often seen after a stroke. Unsteadiness is associated with difficulty walking and with falls (see Walking Problems and Falling). Near fainting Some people who complain of dizziness feel like they are going to faint. This problem is usually due to a lack of blood flow to the brain. The most common cause is "orthostatic hypotension," in which blood pressure drops when someone stands up from a bed or chair (see also Fainting). Near-fainting spells can also be caused by the straining associated with coughing or going to the bathroom. An older person who gets up to urinate in the middle of the night, who strains to have a bowel movement, or who has a respiratory problem may experience near fainting, or even fainting (see also Fainting). Probably the most serious causes of near-fainting spells are heart problems, including narrowed heart valves and problems with heart rhythm. Lightheadedness Some people who complain of dizziness actually feel lightheaded. Although lightheadedness may occasionally be used to describe other types of dizziness, it is most often used as a vague description for symptoms that do not fit vertigo or near fainting. Many people use lightheadedness or unsteadiness to mean the same thing. Feelings of lightheadedness may be associated with psychological or mood disorders, such as depression or anxiety. Often, no cause can be found. Diagnosis and Evaluation A detailed history is the most useful part of the evaluation. The information you provide is critical in helping your healthcare provider determine the cause of the dizziness. You should make sure to give your healthcare provider the following information:
The physical examination will include multiple blood pressure measurements in both arms, while you are lying down, standing, and sitting. An electrocardiogram and other testing (eg, stress test) may be recommended to evaluate your heart. Your healthcare provider may also want to perform some tests that involve putting your head and body in various positions. This can help identify signs of inner ear problems (eg, if characteristic eye movements are brought on) or BPV (if symptoms are reproduced). More than 75% of cases of dizziness can be diagnosed by history and physical examination. However, depending on the results of the history and physical, your healthcare provider may recommend other tests, such as an MRI, CAT scan, inner ear tests, etc. Treatment and Management The prognosis for most cases of dizziness is good, often with no treatment. In up to 50% of cases, dizziness goes away on its own or improves substantially within about 2 weeks. For example, many common causes of vertigo (eg, inner ear inflammation or BPV) typically resolve within days or weeks. If BPV is disabling, comes back frequently, or just hangs on too long, it is important to know that there is safe and effective treatment. Because BPV is caused by crystals floating freely in the inner ear, those crystals can be coaxed to land and stay put using head positioning. Generally, this is done by an audiologist, although some primary healthcare providers may do this as well. One treatment is usually sufficient. Orthostatic hypotension may occur because the older adult is taking medications that affect blood pressure, and these will need to be adjusted or discontinued. Other people have disorders of blood pressure control that cause orthostasis, and they may need medicine to increase blood pressure, to increase blood return to the heart (eg, specially-fit support stockings). If symptoms occur with position change and there is little or no drop in blood pressure, people can be reassured that it isn’t something more serious, and they can usually learn to make position changes more slowly. Unsteadiness while walking (eg, related to vision problems, arthritis, etc) usually improves immediately when the person holds onto the arm of and walks with a companion. These people can be greatly helped by using a properly fit cane (see Canes in Chapter on Rehabilition). Also, physical therapy for strengthening and balance will reduce symptoms of unsteadiness. Treatments for this type of unsteadiness may include proper glasses or hearing aids. Keeping the lights on at night can also help unsteadiness and help prevent falls. If unsteadiness is caused by arthritis or other problems that make moving difficult, treatment for pain is needed (see Pain Management). In some older adults with severe episodes of vertigo with vomiting, a short hospital stay may be needed to replace lost fluids. This is most likely to occur in Ménière’s disease. Once the vomiting has stopped, recurrence of Ménière’s can usually be prevented with a very low-sodium diet. Usually, counseling from a dietician is necessary to learn how to maintain such a diet. Surgery is reserved for only the most severe cases of Ménière’s disease, because it involves destruction of the nerve of hearing on the affected side. Dizziness secondary to other problems It is important to remember that dizziness may have two or more possible causes, each contributing to symptoms. These can include depression or anxiety, vision or hearing loss, the use of multiple medications, balance or walking problems, orthostatic hypotension, diabetes, and heart disease. In these cases, all possible causes need to be evaluated and addressed (either together or one after another) to reduce the frequency or severity of dizziness. Drugs Any heart and blood pressure problems should be managed appropriately for the specific condition. Acute attacks of vertigo from a viral inner ear infection can be treated with drugs used for motion sickness, eg, meclizine. If symptoms last more than several days, meclizine should be discontinued, and the older adult should revisit their healthcare provider. Any of the medications used for this purpose may cause sleepiness or confusion and are not recommended for long-term use. Mild sedatives can also be used in older adults hospitalized for acute episodes of vertigo. Drug treatment with antidepressants or pain relievers may be needed to treat underlying problems. |
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Published: 3/15/2005