Dizziness: A Geriatric Syndrome

abstracts & commentary

Sources: Tinetti ME, et al. Dizziness among older adults: A possible geriatric syndrome. Ann Intern Med 2000;132: 337-344; Drachman DA. Occam’s razor, geriatric syndromes, and the dizzy patient. Ann Intern Med 2000;132:403-404.

Tinetti and colleagues studied 1087 community-living elderly persons to determine the predisposing characteristics and situational factors associated with dizziness. Dizziness was categorized into four groups of symptoms: loss of balance, near-fainting, spinning or movement, and other or multiple sensations. Tinetti et al used an interview and questionnaire to assess medical history and symptoms, standard tests such as the mini-mental state exam, and psychiatric inventories to assess cognition, effect, and anxiety state. Physical examinations were limited to screening tests of blood pressure, balance, and hearing. Of the participants, nearly one-quarter (261; 24%) reported long-term recurrent episodes of dizziness. More than half of dizzy persons (56%) described several sensations and almost three-quarters (74%) reported several positions or activities that were associated with the occurrence of dizziness. Getting up from either lying down or sitting, turning either the head or the entire body, and being upset or anxious were the most frequently reported triggering activities.

Seven characteristics were associated with dizziness: anxiety, depression, impaired balance, previous myocardial infarction (MI), postural hypotension, five or more medications, and impaired hearing. The more of these characteristics that elderly patients had, the more likely they were to report dizziness. Tinetti et al conclude that dizziness may often be multifactorial in origin and, as such, is similar to other "geriatric syndromes" such as falling, delirium, and urinary incontinence.1,2

In an accompanying editorial, Drachman agrees with Tinetti et al that dizziness, especially among the elderly, is often due to multiple disorders involving multiple organ systems. He recalls the "all-too-familiar dizzy patient who has cataracts, hearing loss, peripheral neuropathy, cervical spondylosis, and atrial fibrillation and takes a number of medications for these conditions."

Drachman also points out that the questions asked and screening tests used by Tinetti et al in their epidemiologic study are not the way physicians, especially neurologists, diagnose the cause of dizziness in patients. The physician must sort out the diagnosis by taking a detailed history to identify specific and distinctive symptoms and then perform a physical examination that evaluates cognition, vision, vestibular function, coordination, peripheral sensation, and motor functions.

Finally, Drachman fears that identifying dizziness as a "geriatric syndrome" may suggest not only that multiple problems can produce the symptoms, but also that it is just another undiagnosable and untreatable condition of old age.

Commentary

Equilibrium and stability result from interactions among multiple organ systems. Therefore, it is not surprising that Tinetti et al found an association between multiple predisposing factors and dizziness. In their study, both depressive symptoms and antidepressant drugs were associated with dizziness. Furthermore, the strong relation between numbers of medications and dizziness supports the need to review the possible role of medication side effects in patients who have dizziness.

The study supports a comprehensive approach to the dizzy patient and suggests that clinicians should not only seek to diagnose one discrete cause for dizziness but also try to identify potentially treatable contributing factors. —jjc

References

1. Tinetti MC, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995; 273:1348-1353.

2. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852-857.

Dizziness in the elderly is "a geriatric syndrome" because:

a. it is a normal part of aging.

b. it is undiagnosable and untreatable.

c. it often is the product of multiple conditions.

d. None of the above

e. All of the above