By M. Lorraine Purino, M.D.

Arcadia Methodist Hospital

Imbalance and DizzinessObjectives

  1. Summarize the causes of falls in seniors (50+years old).
  2. Outline the various cultural diversities (age, gender, race, religion, ethnicity, language, sexual orientation, socio-economic, etc) that are associated with imbalance, dizziness and falls.
  3. Describe the major causes of dizziness and imbalance including neuropathies.
  4. Apply the diagnostic neuropathy criteria according to the American Academy of Neurology.
  5. Choose treatment options for these patients.

Causes of Falls in Seniors

Falls among individuals aged 65 and up are recognized to be one of the most common causes of injury or death. One out of three older adults (65 or older) falls each year but less than half talk to their healthcare providers about it. Among older adults, falls are the leading cause of both fatal and non fatal injuries. In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments and more than 734,000 of these patients were hospitalized. In 2012, the direct medical costs of falls, adjusted for inflation, were $30 billion.

What outcomes are linked to falls?

Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, and head traumas. These injuries can make it hard to get around or live independently, and increase the risk of early death. Falls are the most common cause of traumatic brain injuries (TBI). In 2000, 46% of fatal falls among older adults were due to TBI. Most fractures among older adults are caused by falls. The most common are fractures of the spine, hip, forearm, leg, ankle pelvis, upper arm, and hand. Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities, which leads to reduced mobility and loss of physical fitness, and in turn increases their actual risk of falling.

Cultural Diversities

Who is at risk?

The death rates from falls among older men and women have risen sharply over the past decade. In 2011, about 22,900 older adults died from unintentional fall injuries. Men are more likely than women to die from a fall. After taking age into account, the fall death rate in 2011 was 41% higher for men than for women. Older whites are 2.7 times more likely to die from falls as their black counterparts. Rates also differ by ethnicity. Older non-Hispanics have higher fatal fall rates than Hispanics.

People age 75 and older who fall are four to five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer. Rates of fall-related fractures among older women are more than twice those for men. Over 95% of hip fractures are caused by falls. In 2010, there were 258,000 hip fractures and the rate for women was almost twice the rate for men.

Fortunately, falls are a public health problem that is largely preventable.

Risk Factors for Falls

Scientists have linked a number of personal risk factors to falling (NIH Senior Health):

  1. Muscle weakness, especially in the legs
  2. Balance and gait are key factors
  3. Postural hypotension
  4. Slower reflexes
  5. Painful feet and unsafe footwear
  6. Neuropathy
  7. Poor vision: cataracts, glaucoma, poor depth perception
  8. Confusional state
  9. Medications

Robinovitch et. al did a 3 year observational study to video the circumstances of falls in elderly people residing in long-term care.

Findings- causes of falling:

incorrect weight shifting 41%
trip and stumble 21%
hit or bump 11%
loss of support 11%
collapse 11%
slipping 03%

 

The three activities associated with the highest proportion of falls:

forward walking 24%
standing quietly 13%
sitting down 12%

 

Fall Risk Checklist

From CDC and Prevention

The Timed Up and Go test (TUG) is a simple test used to assess a person’s mobility and requires both static and dynamic balance.

It uses the time that a person takes to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down. During the test, the person is expected to wear their regular footwear and use any mobility aids that they would normally require.The TUG is used frequently in the elderly population, as it is easy to administer and can generally be completed by most older adults.

One source suggests that scores of ten seconds or less indicate normal mobility, 11 – 20 seconds are within normal limits for frail elderly and disabled patients, and greater than 20 seconds means the person needs assistance outside and indicates further examination and intervention. A score of 30 seconds or more suggests that the person may be prone to falls. Alternatively, a recommended practical cut-off value for the TUG to indicate normal versus below normal performance is 12 seconds. A study by Bischoff et al. showed the 10th to 90th percentiles for TUG performance were 6.0 to 11.2 seconds for community-dwelling women between 65 and 85 years of age, and determined that this population should be able to perform the TUG in 12 seconds or less. TUG performance has been found to decrease significantly with mobility impairments.

Causes of Recurrent Vertigo and Dizziness

Recurrent attacks of vertigo and dizziness often remain undiagnosed because the etiologic spectrum spans several medical subspecialties so that many doctors feel inadequately knowledgeable. Also, both the clinical examination and testing results are often negative in between attacks. The diagnosis rests largely on recognition of symptom clusters and temporal features by means of careful history taking.

  1. Méniere disease
    Vertigo attacks lasting 20 minutes to several hours with concurrent hearing loss, tinnitus and aural fullness. Progressive hearing loss over years. It reflects an unstable inner ear that progressively loses function over years.
  2. Vestibular migraine
    Attacks of spontaneous or positional vertigo lasting minutes to days, history of migraine, migraine symptoms during vertigo, and/or migraine-specific precipitants provoking vertigo.
  3. Labyrinthitis
    An infection or inflammation of the inner ear that causes dizziness and loss of balance. It i often associated with an upper respiratory infection such as the flu. It can last days to weeks. It can be associated with hearing loss. Associated symptoms include nystagmus, nausea and anxiety.
  4. Vestibular neuronitis
    An inflammation of the vestibular nerve that can be caused by a virus, and primarily causes vertigo. This can be a single attack, series of attacks or persistent condition that diminishes in 3-6 weeks. One can have nystagmus, nausea, vomiting and unsteadiness but no hearing loss.
  5. Autoimmune inner ear disease
    Vertigo attacks of variable duration (weeks to months) and slowly progressive bilateral sensorineural hearing loss.
  6. Otosclerosis
    Vertigo attacks of variable duration and slowly progressive bilateral hearing loss, predominantly conductive type.
  7. Perilymph fistula
    Vertigo appearing after head trauma, barotrauma, or stapedectomy that is provoked by coughing, sneezing, straining, or loud sounds. Symptom duration is variable.
  8. Vestibular paroxysmia
    Brief attacks of vertigo (seconds) several times per day with or without cochlear symptoms. Responsive to carbamazepine.
  9. Superior canal dehiscence
    Brief attacks of vertigo induced by loud sounds or pressure in the middle ear. Auto phony occurs in 50% of patients.
  10. Cardiac arrhythmia
    Dizziness lasting seconds. May be accompanied by palpitations. Can be caused by bradycardia <40/s or tachycardia>170/s.
  11. Panic attacks
    Attacks lasting seconds. Often provoked by specific situations, such as leaving the house, riding on buses, driving, heights, crowds, and elevators. Accompanied by shortness of breath, palpitations, tremor, heat and anxiety.
  12. Benign Paroxysmal Positional Vertigo
    Vertigo is is triggered by change in head position in relationship to gravity. It can last seconds to minutes. It is due to abnormal stimulation of the cupola in the semicircular canals. In the young, it may be due to trauma. In the older individuals, it is due to degeneration of the vestibular system of the inner ear.
  13. Orthostatic hypotension
    Brief episodes of dizziness lasting seconds to minutes after standing up. Relieved by sitting or lying down. Drop of systolic blood pressure of >20 mm Hg after standing up.
  14. Vertebrobasilar TIA
    Attacks of vertigo lasting minutes or 1 to 2 hours, often accompanied ataxia, dysarthria, diplopia, or visual field defects. Isolated recurrent vertigo may result from posterior fossa ischemia in older adults with vascular risk factors.
  15. Drug-induced dizziness
    Variable clinical presentation according to pharmacologic mechanism: sedation, vestibular suppression, ototoxicity, cerebellar toxicity, orthostatic hypotension, hypoglycemia.
Mechanism Class of Drugs
Sedation Tranquilizers, neuroleptics, tricyclics
Vestibular suppression Antihistamines, benzodiazepines, anticholinergics
Ototoxicity Aminoglycosides
Cerebellar toxicity Antiepileptics, benzodiazepines, lithium
Orthostatic hypotension Diuretics, vasodilators, antihypertensives, tricyclics, antiparkinsonian
Hypoglycemia Antidiabetics, beta-blockers

Neuropathies

Characterization of a neuropathy includes consideration of the temporal profile (tempo of onset and duration), heredity, and anatomic classification. Anatomic classification involves (1) fiber type (motor versus sensory, large versus small, somatic versus autonomic), portion of fiber affected (axon versus myelin), and gross distribution of nerves affected (eg, length-dependent, length-independent, multifocal).

The practice parameters recommend the following tests: fasting blood glucose, electrolytes to assess renal and liver function, complete blood count and differential, serum vitamin B12, erythrocyte sedimentation rate, thyroid-stimulating hormone or thyroid function tests, and serum immunofixation electrophoresis (IFE).

Clinicians’ Evaluation of Patients with Dizziness or Imbalance

A challenge for the clinical neurologist is to decide which of the myriad patients with symptoms of dizziness, lightheadedness, or imbalance have a genuine vestibular disorder, be it peripheral or central. The clinical examination is often the key. A series of systematically applied, physiologically based maneuvers, designed to probe static and dynamic function of the vestibulo-ocular reflexes and the individual labyrinthine sensors, will almost always reveal the evidence of a vestibular system anomaly, which either clarifies the diagnosis or points to a need for a further evaluation.

They include:

  1. dynamic visual acuity
  2. occlusive ophthalmoscopy
  3. head impulse (rotational vestibulo-ocular reflex) and head heave (translational vestibulo-ocular reflex) testing
  4. mastoid vibration-induced nystagmus (equivalent of a hot-water caloric stimulus in a patient with unilateral vestibular loss)
  5. hyperventilation-induced nystagmus (abnormal in fistula, craniocervical junction anomalies, compressive and demyelinating lesions, and cerebellar degenerations)
  6. Valsalva-induced nystagmus (abnormal in fistula and craniocervical junction anomalies), head-shaking-induced nystagmus (vertical nystagmus after horizontal head shaking points to a central disorder)
  7. positional nystagmus (lateral canal, posterior canal, central) and sound-induced nystagmus (superior canal dehiscence).

When combined with a careful examination of eye alignment, gaze holding, saccade accuracy and speed, and smooth pursuit, a central or peripheral localization is usually possible.

How can older adults prevent falls?

Older adults can stay independent and reduce their chances of falling.18,19 They can:

  1. Exercise regularly
    It is important that the exercises focus on increasing leg strength and improving balance, and that they get more challenging over time. Tai Chi programs are especially good.
  2. Ask their doctor or pharmacist to review their medicines
    both prescription and over-the counter—to identify medicines that may cause side effects or interactions such as dizziness or drowsiness.
  3. Have their eyes checked by an eye doctor
    at least once a year and update their eyeglasses to maximize their vision.  Consider getting a pair with single vision distance lenses for some activities such as walking outside.
  4. Make their homes safer
    by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding railings on both sides of stairways, improving the lighting in their homes and nit-skid devices in bathrooms, etc.

To lower their hip fracture risk, older adults can:

  • Get adequate calcium and vitamin D—from food and/or from supplements.
  • Do weight bearing exercise.
  • Get screened and, if needed, treated for osteoporosis.

 

Bibliography

 

Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall–related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3.

Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) (http://www.cdc.gov/injury/wisqars).

Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing 1999;28:121–5.

Gillespie, LD, Robertson, MC, Gillespie, WH, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community.  Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3.

Hayes WC, Myers ER, Morris JN, et al. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcified Tissue International 1993; 52:192–198.

Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Academic Emergency Medicine 2000;7(2):134–40.

Lempert, Thomas MD. “Recurrent Spontaneous Attacks of Dizziness.” Continuum: Lifelong Learning in Neurology Vol 18-Issue 5, Neuro-otology Oct 2012: p1086-1101.

Moyer VA. Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2012;157(3):197–204.

National Hospital Discharge Survey (NHDS), National Center for Health Statistics. Available at: www.cdc.gov/nchs/hdi.htm. Assessed September 14, 2011.

Robinovitch Phd, Stephen and Feldman PhD, Fablo. “Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study.” The Lancet Vol 381, No 9860 January 2013: p47-54.

Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing 2008;37:19–24.

Scott JC. Osteoporosis and hip fractures. Rheumatic Diseases Clinics of North America 1990;16(3):717–40.

Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma–Injury, Infection and Critical Care 2001;50(1):116–9.

Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. “Gender differences in seeking care for falls in the aged Medicare Population.” American Journal of Preventive Medicine 2012; 43:59-62.

Stevens JA, Corso PS, Finkelstein EA, Miller TR. “The costs of fatal and nonfatal falls among older adults.” Injury Prevention 2006a; 12:290-5.

Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older Americans 1990–98: sex, race, and ethnic disparities. Injury Prevention 2002;8:272–5.

Stevens JA. Fatalities and injuries from falls among older adults – United States, 1993–2003 and 2001–2005. MMWR 2006b;55.45:1222–24.

“Timed Up and Go (TUG)”. Minnesota Falls Prevention. Retrieved 2010-02-16.

Tromp AM, Pluijm SMF, Smit JH, et al. “Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly.” J Clin Epidemiology 2001; 54 (8): 837-844.

Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age and Ageing 1997;26:189–193.

http://www.nidcd.nih.gov/health/balance/pages/balance_disorders.aspx#5

http://nihseniorhealth.gov/balanceproblems/aboutbalanceproblems/01.html

http://nihseniorhealth.gov/videolist.html#balanceproblems

http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html