Old and Dizzy: The Profile of Dizziness After 65

Dizziness is a common symptom that increases in frequency with age.   Patients, family members and primary care physicians encounter this symptom.   Dizziness as a symptom is endorsed by up to 30% in older populations surveys. 

A recent primary care study looked at a large series of adults 65 and older presenting to their physicians.  This study was conducted in 45 group practices in the Netherlands is published in the readily accessed PLOS One.  The authors had previously published a series of 21 tests feasible for primary care practices in the diagnosis of dizziness (Dross et al, CMAJ, 2010, see below).  These tests were selected by a panel of experts  and included patient history elements, physical examination elements, diagnostic questionnaires (i.e. Patient Health Questionairre) or tests of specific functions, i.e. EKG or audiometry.

After administering these diagnostic tests to a series of 417 consecutive patients in primary care, the authors explored the profile of results.  Using a statistical method called principal component analysis, the profiles of diagnoses were grouped into the fewest number of components explaining the variance.  The authors identified six components that were able to classify 88% of all the subjects with subjects able to be classified in more than one component:

Cardiovascular(N=206): history of cardiovascular disease, hypertension, history of arrhythmia, polypharmacy, use of cardiovascular drugs, fall risk increasing drugs

Presyncope (N=180): lightheadedness as subtype of dizziness description, dizziness duration >60 seconds, associated symptoms of: tinnitus/hearing decline, nausea, diaphoresis, being pale or clammy, palpitations, chest pain, dyspnea, gait problems, falling/near falling

Non-specific (N=180): Infrequently dizzy, no provocation by turning head, bending over, looking up, getting up from lying or standing position, negative Dix-Hallpike test, low total score and low score on the physical subscale of Dizziness Handicap Inventory (DHI)

Psychological (N=163): female, history of anxiety or mood disorder, psychotropic drug use, somatoform disorder, major depression or anxiety disorder by PHQ, high total score and high scores on emotional, functional and physical scales of the DHI indicating high disability

Ear, Nose, Throat-ENT (N=160): history of ENT disease or surgery, use vertigo drugs, use hearing aid, duration of dizziness hours to days, associated nausea, impaired hearing

Frailty (N=131): older age, nursing home residence, living alone, using hearing and walking aid, impaired stability at rest, impaired walking, impaired knee mobility, abnormal tandem gait, slow functional mobility, poor vision, impaired hearing

None (N=51)

This is an important paper demonstrating that easily available “tests” can identify the key components to the presenting symptoms of dizziness in older individuals.   The research group notes that it  is not unexpected to find more than one component present in many individuals.  In this population, dizziness is often multifactorial and may require more than one diagnosis and a multiple component treatment plan.  The authors note that this approach may better target additional diagnostic assessment.   Rather than getting a “complete” work-up for every patient presenting with dizziness, the author’s approach allows targeting more costly or invasive tests.        


3D Brain Image of Cerebellum in Purple-Damage Can Cause Dizziness--iPad Screen Shot Courtesy of Yates Photography                       
                                                                                                                                                                                                                                 

Dros J, Maarsingh OR, van der Horst HE, Bindels PJ, Ter Riet G, & van Weert HC (2010). Tests used to evaluate dizziness in primary care. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 182 (13) PMID: 20643840