Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Geriatric Balance Disorders Abstract Objective: Balance disorders are an important cause of morbidity and mortality in the elderly. We determined the prevalence of unrecognized benign paroxysmal positional vertigo (BPPV) in normal elderly patients, and examined associated lifestyle sequelae. Study Design: Cross-sectional. Setting: Public, inner city geriatrics clinic. Patients: One hundred racially mixed, poor, frail, elderly patients. The only inclusion criterion was the ability to communicate verbally. Interventions: None. Main Outcome Measures: Neuro-otologic examination findings, prevalence of BPPV, and functional status measures, including activities of daily living (ADL), instrumental activities of daily living (IADL), geriatric depression scale (GDS), and mini mental status exam (MMSE). Results: Dizziness was a complaint in 61 patients, while balance disorders were found in 77 patients. Nine patients were found to have unrecognized BPPV. Univariate analysis revealed symptomatology typically ascribed to BPPV (a positional spinning sensation with nausea). Multivariate analysis revealed that the presence of unrecognized BPPV could be predicted by a two-question history (sensitivity 56%, specificity 98%). Patients with unrecognized BPPV were more likely to have reduced ADL scores (p=0.029), to have sustained a fall in the last 3 months (p=0.026), and to have been diagnosed with depression (p=0.028). Conclusions: These data indicate that unrecognized BPPV is common within the elderly and is associated with limitations in lifestyle and freedom. Case Presentation: N.P. is a 67-year-old female with multiple medical problems, including coronary artery disease, hypertension, insulin-dependent diabetes mellitus, and depression. She has had at least one myocardial infarction in the past. Her medications include an anti-hypertensive, a diuretic, an anti-depressant, and a sedative. She is unable to walk long distances, but can stand up. Typically she propels herself in a wheelchair. She has had at least one fall within the last three months. Her activities of daily living (ADL) score is 3/6, instrumental activities of daily living (IADL) score is 2/8, her geriatric depression scale (GDS) score is 3/15, and her mini mental status exam (MMSE) score is 30/30. On specific questioning, she complains of episodic dizziness that occurs monthly, and lasts a few minutes. It is triggered by standing up, bending over, and rolling over in bed. She describes a sensation of spinning and associated nausea. She also has confusion, lightheadedness, shortness of breath, and heart palpitations. Physical examination revealed an obese woman of height 5' 2", weight 205 lbs., and body-mass index (BMI) 37.6. She was normotensive, but did have orthostatic hypotension on standing. Neurologic examination was normal. Otologic examination was normal. During the Dix-Hallpike maneuver, the patient had a delayed onset of vertigo and rotary nystagmus in the right ear down position, with one emesis. She was diagnosed as having a balance disorder with two causative factors: BPPV and orthostatic hypotension. Bibliography: Baloh RW. Dizziness in older people. J Am Geriatr Soc 1992;40:713-721. Belal A, Jr., Glorig A. Dysequilibrium of ageing (presbyastasis). J Laryngol Otol 1986;100:1037-1041. Bloom J, Katsarkas A. Paroxysmal positional vertigo in the elderly. J Otolaryngol 1989;18:96-98. Cohen H, Heaton LG, Congdon SL, Jenkins HA. Changes in sensory organization test scores with age. Age Ageing 1996;25:39-44. Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population- based study in Olmsted County, Minnesota. Mayo Clin Proc 1991;66:596-601. Froehling DA, Silverstein MD, Mohr DN, Beatty CW. Does this dizzy patient have a serious form of vertigo? JAMA 1994;271:385-388. Furman JM, Cass SP. Balance Disorders: A Case-Study Approach. Philadelphia: F.A. Davis Company; 1996. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998;339:680-685. Jenkins HA, Furman JM, Gulya AJ, Honrubia V, Linthicum FH, Mirka A. Dysequilibrium of aging. Otolaryngol Head Neck Surg 1989;100:272-282. Katsarkas A. Dizziness in aging: a retrospective study of 1194 cases. Otolaryngol Head Neck Surg 1994;110:296-301. Leske MC. Prevalence estimates of communicative disorders in the U.S. Language, hearing and vestibular disorders. ASHA 1981;23:229-237. McClure JA. Vertigo and imbalance in the elderly. J Otolaryngol 1986;15:248-252. Norre ME. Diagnostic problems in patients with benign paroxysmal positional vertigo. Laryngoscope 1994;104:1385-1388. Norre ME. Reliability of examination data in the diagnosis of benign paroxysmal positional vertigo. Am J Otol 1995;16:806-810. Oghalai JS, Holt JR, Nakagawa T et al. Ionic currents and electromotility in inner ear hair cells from humans. J Neurophysiol 1998;79:2235-9. Sataloff J, Sataloff RT, Lueneburg W. Tinnitus and vertigo in healthy senior citizens without a history of noise exposure. Am J Otol 1987;8:87-89. Schuknecht HF. Pathology of the Ear, 2 ed. Philadelphia: Lea & Febiger; 1993. Sloane PD. Evaluation and management of dizziness in the older patient. Clin Geriatr Med 1996;12:785-801. Zane RS, Rauhut MM, Jenkins HA. Vestibular function testing: an evaluation of current techniques. Otolaryngol Head Neck Surg 1991;104:137 -138. Click here to view the slides from this presentation. Grand Rounds Archive | Department Home pageBCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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