Dizziness in old people

Summarized by Robert W. Griffith, MD
July 27, 2000 (Reviewed: December 13, 2002)

Introduction

Old people often complain that they get dizzy. Frequencies of 15% to 58% have been reported, depending on the definitions used and the population studied. As dizziness is associated with an increased risk of falls, it's important to try to find the cause (or causes) in individual patients. In the study summarized here, the incidence and etiological factors of dizziness in people over 72 years were examined.

Method

Over 1,000 participants were questioned about dizziness. The study was conducted in Connecticut, USA, in old persons living in the community. Participants completed a questionnaire that included demographic data (age, sex, ethnicity, education, income, etc), and asked whether there was a history of diabetes, myocardial infarction, cancer, stroke, Parkinson's disease, or arthritis. Participants' hospitalizations in the previous year were checked from monthly surveillance reports from the neighboring acute-care hospitals and from Medicare records. Interviewers recorded the medications being taken (both prescription and non-prescription), and asked about alcohol consumption. Cognitive status was assessed using the Mini-Mental State Exam, depression using the Center for Epidemiologic Studies-Depression test, and anxiety with the State-Trait Anxiety Inventory. Visual acuity, hearing, blood pressure (sitting and standing), and heart rate were measured, as well as tests of balance and gait.

For dizziness to be diagnosed, subjects had to reply "yes" to the question "during the past two months, have you had episodes of feeling dizzy, unsteady, or like you were spinning or moving, lightheaded, or faint?". In addition, the episodes had to be present for at least one month. Those who were listed as having dizziness were asked to identify the bodily positions or the specific activities that were associated with episodes, and the sensations that best describe them (categorized into loss of balance, near faint, spinning or other vertiginous movement, or other sensations).

As well as bivariate comparisons between participants with and without dizziness, statistical analyses included multivariable analyses providing adjusted relative risks (RR) with their 95% confidence intervals (CI 95%).

Results

Of the 1,087 participants, 310 (29%) reported dizziness in the previous two months. Of these, 261 (24%) reported having dizziness for more than one month. In 164 subjects the episodes had been occurring for at least one year.

The duration of episodes varied from less than one minute to two hours, in over 90% of cases. Duration longer than 2 hours was infrequent. The commonest sensation described in association with dizziness was a loss of balance or unsteadiness (59%), and the most frequent movements triggering episodes were getting up from a lying down position (54%), turning the head (41%), turning the body (38%), and getting up from sitting (31%). Being upset or anxious was associated with episodes in 31% of cases.

Bivariate analyses were done of the characteristics of participants with and without dizziness. A number were associated with an increased risk for dizziness, and were subjected to multivariate analyses. Seven characteristics were identified as being independently associated with episodes of dizziness:

• anxiety trait
• epression symptoms
• impaired balance
• previous myocardial infarction
• postural hypotension
• five or more medications
• impaired hearing

The frequency of dizziness increased according to the presence of more than one of these characteristics:

This translated to an adjusted relative risk for dizziness of 1.38 (CI 95%, 1.27 to 1.49) for each additional characteristic.

The presence of an association with postural hypotension depended on the method used to assess this characteristic. When defined by systolic blood pressure changes alone, there was no such association, regardless of the cutoff used. On the other hand, there was a positive association for decreases in mean blood pressure of at least 20% on standing.

Depressive symptoms and antidepressant use were identified as significant characteristics in the bivariate analyses. In stratified analyses, 19% of those without depressive symptoms who were not taking antidepressants reported dizziness. These rates increased to 46% in participants without depressive symptoms but who were taking antidepressants, 41% in those with depressive symptoms who were not taking antidepressants, and 53% in those with depressive symptoms who were on antidepressants.

Comment

The frequency of dizziness, as defined here, was similar to that reported in other community-based studies. The proportion of those with predisposing characteristics was similar across the different types of dizziness sensations, and across categories of duration and frequency of episodes, indicating that there was no specific linkage of types of dizziness to specific causes.

The investigators conclude that the results of the analyses suggest that dizziness is a multifactorial problem, similar to other geriatric syndromes, such as falling, delirium and incontinence. No single factor had an overwhelmingly strong relation with dizziness.

This does not negate the possibility that a single disease may be primarily responsible in an individual or a subset of persons. Rather, since equilibrium and stability result from interactions among a wide range of physiological processes, dizziness may result when a single system is severely impaired or, alternatively, when several such systems have mild to moderate impairment.

The consequence of this hypothesis, supported by this study, is that the physician confronted by dizziness should focus not on diagnosing one of several discrete diseases, but rather identify potentially treatable contributing factors e.g. cardiovascular diseases, depression, sensory, balance and gait impairment, postural blood pressure changes, and excessive medication.

You can read more on dizziness in our Syllabus.

Source

• Dizziness among older adults: a possible geriatric syndrome. ME. Tinetti, CS. Williams, TM. Gill, Ann Int Med, 2000, vol. 132, pp. 337--344

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