Episode 1.9 Dizziness and Balance

MDTea Episode 9: Dizziness & Balance

Posted 10th May 2016

Presented by: Jo Preston (Consultant Geriatrician at St George’s Hospital) and Iain Wilkinson (Consultant Geriatrician at East Surrey Hospital).

Core Faculty: Adam Buckler – Pharmacist, Tracey Szekely – Occupational Therapist.

Guest Faculty: Gaggandeep Alg – Geriatrics Registrar

In this episode will look at the complex interplay of dizziness and balance and explore some of the causes of and importance of managing ‘dizziness’ in older people.

Click here for the show notes for this episode.

Here is a Sip of MDTea for this episode.

 

 

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Episode 9 Show Notes

Dizziness (and balance)

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Presented by: Dr Jo Preston & Dr Iain Wilkinson

Faculty:

Tracey Szekely, Adam Buckler, Dr Gaggendeep Alg

 

Broadcast Date: 10th May 2016

 

Learning Outcomes

Knowledge:

• To understand the physiological mechanisms that contribute to balance, and how these can go wrong in older people
• To know the common causes of balance disorders in older people

Skills:

• To be able to identify potential causes for the symptom of ‘dizziness’ and use alternative words to describe this

Attitudes:

•         Understand that balance disorders may have a large effect on the quality of life of an older adults

 

Definitions:

Formal / Scientific Definition:

Dizziness: a term used to describe a range of sensations, such as feeling faint, woozy, weak or unsteady. Dizziness that creates the false sense that you or your surroundings are spinning or moving is called vertigo.

Postural stability / balance can be defined as the ability of an individual to maintain the position of the body (more specifically, its centre of mass) within specific boundaries of space. Maintaining postural stability requires the complex integration of many sensory  inputs (ear, eyes, brain and joints) which is then processed by the brain and actions are carried out to keep us upright.
Practical Definition:

Practically dizziness is intertwined with balance and postural stability. When you feel dizzy there is a mismatch between the inner ear or vestibular system and the visual system and the somatosensory system. A clear description of the symptoms is really important and takes time to unpick exactly what the patient means when they say they are ‘dizzy’.

 

Key Points from Discussion

Try to get detail in the history from your patients – what do they mean when they say they feel dizzy? What were they doing at the time? What other symptoms did they have?

Symptom complexes

Pre-syncope – That feeling just before you faint. May well need further investigation, and refer to the transient loss of consciousness guidelines as to how to do this.

NICE Guidelines – T-LOC

European Society of Cardiology Guidelines (2009)

 

Vertigo

Related to vestibular function – can be peripheral or central.

The head impulse test can help with working out one from the other.

Youtube video of impulse test

Videos on Imperial website also

Vestibular reflexes and positional manoeuvres

 

Characteristic	Peripheral (are the most common eg. VN / BPPV)	Central
Starting	Sudden	Insidious
Clinical Picture	Paroxysmal	Continuous
Intensity	Maximum = initial	Mild
Duration	Minutes / hours	Days / Weeks
Vertical Nystagmus	Absent	Common
Influence of Movement	Marked	Mild or none
Tinnitus / Deafness	Common	Absent

Vertigo/dizziness as a Drugs’ adverse reaction. J Pharmacol Pharmacother. 2013 Dec; 4(Suppl1): S104–S109

 

Disequilibrium

Really a problem with gait and walking – can be lower level, mid level or higher level.

Lower level is problems with the sensory inputs – outside of central nervous sytem – eg. peuph. neuropathy / musculoskeletal problems or vision.

Middle – a central problem – e.g Basal ganglia – PD, Cerebellum – Ataxia, hemiplegic. There is a link between the structure and the problem.

Higher – Problem with the higher cognitive function – eg. cautious gait (e.g fear of falling in episode 5)

 

Treatments:

Specific manouvers and vestibular rehabilitation

Mini GEM video on balance assessment – on youtube by AEME

Other – non-specific

• Medications can be a large cause for patients ‘dizziness’ symptoms and the article below explores this in more details. Adjusting the medications may be a quick win with some patients to remove a proportion of their symptoms.

Causes of persistent dizziness in elderly patients in primary care

 

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

 

Curriculum	Area
NHS Knowledge Skills Framework	Suitable to support staff at the following levels: Personal and People Development: Levels 1-3 Service Improvement: Level 1 – 2
Foundation Curriculum 2012	1.3 Continuity of care 1.4 Team working 2.1 Patient as centre of care 7.9 Interface with different specialities and other professions
Foundation Curriculum 2016	2. Patient cetred care 4. Self-directed learning 6. Interface with other healthcare professionals 11. Diagnosis
Core Medical Training	Common competences: Management of long term conditions and promoting self-care   Symptom based competences: Blackout and Collapse Unsteadiness / Balance Disturbance System specific competences: Neurology – Vertigo Geriatric Medicine
GPVTS program	Section 2.03 The GP in the Wider Professional Environment Core Competence: Managing medical complexity Section 3.05 – Managing older adults Core Competence: Managing medical complexity Core Competence: Working with colleagues and in teams Section 3.15 – Care of people with ENT, Oral and Facial problems Core competence: Making decisions Core competence: Clinical management
ANP (Draws from KSF)	7.11 Syncope, pre-syncope, dizziness 7.20 Falls, dizziness, syncope 13. Therapeutics and safe prescribing
Physician Associate – Core clinical conditions	Section 7.1.5 – Vertigo