DOWNWARD SPIRAL

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DOWNWARD SPIRAL

• Dizziness in Elders
• Presented by Mary Sokolowski, BSN, RN

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Introduction

• Definition of Dizziness
• Various abnormal sensations
• Generic term giddiness, lightheadedness,
  faintness, vertigo, ataxia
• Syncope
• Loss of consciousness fall

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SCOPE OF PROBLEM

• 90 million Americans seek care each year
• (Kovar, Jepson, Jones, 2006)
• Most common complaint gt age 75
• 1/3 to 1/4 of older adults c/o dizziness
• (Nettina, 2001)
• Syncope a main reason for inpatient care
• (Wohrle Kochs, 2003)

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GERIATRIC SYNDROME?

• Nonspecific nature multiple causes
• Peripheral Vestibular 4 71
• Cerebrovascular 6 70
• Postural Hypotension 2 15
• Psychogenic 6 40
• (Kao, Nanda, Williams, Tinetti, 2001)

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APPROACH

• Lack of clear guidelines
• Suggested approach
• Treat as syndrome
• Rule out treatable causes
• Assess risk factors for chronic dizziness
• (Salles, Kressig, Michel, 2003)

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PATHOPHYSIOLOGY

• Several different body systems
• Disruption of stability affects balance
• Balance coordination of brain nerve impulses
  from eyes, ears, neck, limbs, joints

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REVIEW Vestibular System

• SEE HANDOUT
• Labyrinth
• 1) Cochlea (auditory receptors)
• 2) Vestibule, utricle, saccule
• 3) Semicircular canals
• Endolymph
• Hair cells
• Otoconia ear rocks
• (Hain Ramaswamy, 1999)

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BALANCE

• Head movement ? hair cells bent by otoconia or
  endolymph ? signal from inner ear ? 8th cranial
  nerve ? cerebellum
• Sensory system (eyes, muscles, joints) ? input to
  brain
• Brain interprets ? balance
• Distortion in any system
• Dizziness

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HEIGHTS
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MOTION SICKNESS
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SPINNING
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SUBTYPES / CATEGORIES

• Presyncope
• Vertigo
• Disequilibrium / Ataxia
• Psychogenic / Other
• (Nettina, 2001)
• SEE HANDOUT

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Benign Paroxysmal Positional Vertigo

• 1 cause of vertigo
• Accounts for 50 of dizziness in elders
• Profile
• Abrupt dizziness with position changes
• /- nausea and vomiting
• Episodes lt 1 minute
• Accompanied by nystagmus
• (Kovar, et al., 2003)

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BPPV Causes

• Otoconia in semicircular canals
• ½ - Idiopathic
• Other causes
• Head Injury
• Infection
• Degenerative changes of aging
• Migraines
• (Kovar et al. 2003)

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SYNCOPE

• Definition
• A main reason for inpatient treatment
• Rapid onset with rapid recovery
• Episode lasts lt 20 seconds
• Misdiagnosis possible
• (Wohrle Kochs, 2003)

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SYNCOPE Causes

• Cardiac disease, arrhythmia
• Reflex syndrome
• Orthostatic hypotension
• Carotid Sinus Syndrome
• Autonomic Failure
• (Wohrle Kochs, 2003)

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DIAGNOSIS Dizziness

• 1st PRIORITY Recognize treatable conditions
• History
• Structured interview S/S, PMH
• Medication History
• DHI Scale see HANDOUT
• (Salles et al., 2003)

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DIAGNOSIS Dizziness

• Physical Exam
• Broad Review of systems
• Rule out emergent conditions
• Vision, hearing, otoscopic exam
• Arthritis, neck pain, neuropathy
• (Wohrle Kochs, 2003)

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DIAGNOSIS Dizziness

• Provocative Tests
• Orthostatic changes
• Hyperventilation
• Rapid head/neck movement
• Carotid sinus massage
• (Wohrle, 2003)

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DIAGNOSIS Dizziness

• Provocative tests
• Vestibular testing
• Tilt testing
• Electrophysiology (EPS) studies
• Psychological testing
• Dix-Hallpike Maneuver HANDOUT
• (Kovar, et al., 2006)

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DIAGNOSIS Dizziness

• 2nd Priority Assess Risk Factors for Chronic
  Dizziness
• 7 Risk factors
• Depressive S/S, cataracts, abnormal
  balance/gait, postural BP changes, DM, past MI, gt
  3 medications
• Multifactoral syndrome
• (Kao et al. 2001)

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Management/ Treatment

• Early Recognition of S/S KEY
• Treatment of etiologic factors
• Cardiac
• Sensory problems correction
• Vasovagal avoid triggers, salt, water, meds,
  pacing
• (Wohrle Kochs, 2003)

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Management / Treatment

• Carotid sinus syndrome pacing, salt,
  vasoconstriction
• Orthostatic hypotension avoid meds, ETOH, large
  meals caution with position changes
• Cognitive behavioral therapy - ? anxiety
• (Wohrle Kochs, 2003)

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Balance / Vestibular Rehab

• Repeated exposure to causative stimulus
• Epleys bedside maneuver
• Repositioning therapy
• Success rate
• DHI before and after
• (Kovar et al., 2006)

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Antivertigenous Meds

• Meclizine / Antivert
• ? Labyrinth excitability
• Most effective motion sickness, vertigo
• Diphenidol nausea vertigo

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PATIENT EDUCATION

• Minimize contributing factors
• Rise slowly, support stockings, avoid
• movements associated with vertigo
• Balance / Vestibular rehab
• Post V.R. sleep / head position
• recommendations
• Balance rehab muscle strengthening,
• Tai Chi
• Antivertigenous meds side effects, etc

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SAFETY PLAN

• Environmental safety proofing home
• Driving discussion
• Emergency plan

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CASE STUDY

• See HANDOUT
• (Nettina, 2001)

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THE END

• ?? QUESTIONS ??