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Dizziness and imbalance are common complaints in the elderly, with etiologies ranging from benign (e.g., benign paroxysmal positional vertigo) to potentially life-threatening (e.g., cerebellar stroke). Therefore, the stakes can be high and an organized and methodical approach to the history and examination is essential. The days of classifying based on the symptom quality alone – “dizzy,” “vertigo,” “lightheadedness” – are over, as this approach is often misleading and can result in an incorrect diagnosis. Instead, identifying the timing and onset, duration, triggers, and associated symptoms allows the clinician to substantially narrow the differential diagnosis. From the history, a focused examination is be performed depending on the clinical scenario (e.g., Dix-Hallpike for positional vertigo; the “HINTS” exam in the acute vestibular syndrome), and the most appropriate test(s) can then be selected when appropriate. In the elderly, there are many potential non-neuro-vestibular contributors that must also be considered (e.g., polypharmacy, blood pressure), and to complicate the history and examination further, dizziness and imbalance are often multifactorial. This chapter offers a practical step-by-step approach to the evaluation of elderly patients presenting with balance and vestibular disorders.
The core principle that should guide any health professional caring for older adults and their families is that the “secret of caring for the patient is in caring for the patient” (Peabody). Practitioners must understand the most up-to-date biomedical and psychosocial aspects of aging, health, wellness, and disease, and strive to support the older adult to remain as active, functional, and engaged as possible. At the same time, practitioners must recognize and help patients and families understand when a palliative approach will be most effective at meeting their goals. The Choosing Wisely campaign launched by the American Board of Internal Medicine provides targeted guidance to clinicians to provide care that is effective and efficient, consistent with the essential principles. Also, the 4Ms (what Matters, Medication, Mentation, and Mobility) proposed by The John A. Hartford Foundation and Institute for Healthcare Improvement provide a framework for an Age-Friendly Health System through which practitioners can deliver optimal care for older adults.
This eighth edition of Dr Reichel's formative text remains the go-to guide for practicing physicians and allied health staff confronted with the unique problems of an increasing elderly population. Fully updated and revised, it provides a practical guide for all health specialists, emphasizing the clinical management of the elderly patient with simple to complex problems. Featuring four new chapters and the incorporation of geriatric emergency medicine into chapters. The book begins with a general approach to the management of older adults, followed by a review of common geriatric syndromes, and proceeding to an organ-based review of care. The final section addresses principles of care, including care in special situations, psychosocial aspects of our aging society, and organization of care. Particular emphasis is placed on cost-effective, patient-centered care, including a discussion of the Choosing Wisely campaign. A must-read for all practitioners seeking practical and relevant information in a comprehensive format.
Dizziness is a common symptom in the elderly characterized by a distorted sense of spatial orientation. Vertigo, a related symptom, includes the illusion of self-motion. Dizziness (spatial disorientation without an illusion of self-motion) occurs when distorted input to the vestibular system is relatively symmetrical, while vertigo often occurs when the input is relatively asymmetrical. Patients may use terms such as lightheaded, woozy, off-balance, or spinning to describe dizziness or vertigo. Characterizing the experience (e.g., “What do you mean by dizziness?”) is not specific enough to identify the cause. More important is determining the timing, triggers, and associated findings of the experience. ‘Timing’ refers to the continuity and duration of symptoms, with three categories: episodic vestibular syndrome (EVS)—brief, intermittent episodes lasting seconds to hours; acute vestibular syndrome (AVS)—continuous symptoms for days to weeks; and chronic vestibular syndrome (CVS) persisting for months to years. ‘Triggers’ are actions that initiate dizziness (e.g., specific head movements, standing posture, or exercise).