Dizziness and Falls

Patients often present to a GP with ‘funny turns’ which are described as ‘dizziness’, ‘giddiness’, ‘wooziness’, ‘unsteadiness’, ‘light-headedness’, or ‘feeling faint’.  The GP’s most important task is to establish what exactly the patient has experienced, because that understanding will give valuable clues to the diagnosis.  It is usually best to start with an open question such as asking the patient to explain exactly what they experienced.  Sometimes a clear picture will emerge.  More often, however, it is necessary to ask very specific closed questions in order to narrow down the possible diagnoses.  The most important question is whether the experience was ‘faintness’ – i.e. a feeling that they might ‘pass out’ or an illusory sensation of movement (vertigo).  Those two symptoms are discussed in turn below.

This chapter also covers falls in the elderly.  Loss of consciousness and seizures are only discussed briefly because they are less common in general practice, and they are covered in other modules.  

Faintness and syncope

A 15 year old girl explains to the GP that she has had two episodes of feeling dizzy at school.  The first happened after she stood up at the end of a lesson and the second while she was waiting in the lunch queue.  On the second occasion, she fell to the floor and was unconscious for a few minutes.  Her friend said that she was very pale before she fell, and that she twitched several times whilst unconscious.  She also complained of several months of feeling very tired.  

‘Faintness’ refers to a patient feeling that they might ‘pass out’ (lose consciousness .  In simple terms, it results from a transient reduction of oxygen supply to the brain which can be caused by a benign physiological response or by serious or non-serious pathology.  All causes of faintness can lead to a transient loss of consciousness (LOC).  The underlying causes are summarised in table 1. 

Most episodes presented to GPs are feelings of faintness where spontaneous recovery occurs once the patient sits or lies down.  If the patient loses consciousness, the above causes should be considered, as well as the possibility of an epileptic seizure.   

Vertigo

People with vertigo usually describe rotatory or spinning symptoms. To determine that the person has vertigo rather than non-rotatory dizziness (for example presyncope, disequilibrium, or lightheadedness) ask in detail about their symptoms. If the person has nystagmus it is likely that their dizziness is vertigo.

Consider asking: ‘When you have dizzy spells, do you feel light-headed or do you see the world spin around you as if you had just got off a playground roundabout?

History

• Timing of symptoms – duration, onset, frequency, aggravating factors (such as movement of the head), severity and effect on daily activities (such as walking).
• Associated symptoms – nausea and vomiting, otological (hearing loss, ear discharge, a feeling of fullness in the ear, or tinnitus), neurological (headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness, ataxia, migraine aura).
• Relevant medical history – recent URTI/ear infection suggesting vestibular neuronitis or labyrinthitis, migraine, head trauma or recent vestibular neuronitis (may suggest benign paroxysmal positional vertigo or central cause if trauma), direct trauma to head or ear (perilymphatic fistula), anxiety or depression, cardiovascular risk factors (previous angina or myocardial infarction, diabetes, hypertension, smoking, atrial fibrillation – all increase likelihood of stroke as the cause of vertigo), drugs (aminoglycosides, furosemide, antidepressants, antipsychotics), acute intoxication with alcohol, family history of migraine or Meniere’s disease.

Examination

Examine the ear — look for discharge, vesicular eruptions (indicating herpes zoster infection) and signs of cholesteatoma (for example a retraction pocket).

Perform a neurological examination:

• Look at the person’s face for signs of asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event.
• Test cranial nerves and cerebellar function (for example heel to toe walking). x Examine the eyes for nystagmus — note its direction and whether it is affected by changing the direction of gaze, or fixing the eyes on an object.
• Perform fundoscopy. x Check for signs of peripheral neuropathy. x Examine the person’s gait, coordination, and their ability to stand unaided. If symptoms are too severe to allow walking, ask the person to sit upright without holding on to anything.
• Perform a cardiovascular examination (blood pressure, heart rate and rhythm, carotid examination for bruits).

Consider using specific clinical tests:

• Romberg’s test — to identify instability of either peripheral or central cause (although it is not a sensitive test for differentiating between them). o   Dix-Hallpike manoeuvre — (if the person has positional vertigo affected by moving the head) to help make a diagnosis of benign paroxysmal positional vertigo. o    Head impulse test — to detect unilateral hypofunction of the peripheral vestibular system, and to help differentiate between cerebellar infarction and vestibular neuronitis.
• Unterberger’s test — to identify dysfunction of one of the labyrinths. o Alternate cover test — an abnormal result suggests an increased likelihood of stroke in a person with acute vestibular syndrome.
• Features of vertigo characteristic of central causes:
• Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent.
• Central neurological symptoms or signs (for example new type of headache [especially occipital], gait disturbance, truncal ataxia, vertical nystagmus).
• Acute deafness without other typical features of Meniere’s disease.

Management

Dizziness and loss of consciousness understandably cause high levels of anxiety and, for some, the fear of dizziness is more disabling than the symptom itself.  General measures include explanation and reassurance.  Specific management will depend on the cause.  

The GP can manage most cases of ‘dizziness’.  A small proportion of patients will need to be referred to secondary care for clarification of diagnosis, investigations and specialist treatments.  It is important that patients are referred to the most appropriate specialist clinic.  Most cases of vertigo (unless a central cause is suspected) will be referred to ENT.  Most cases of loss of consciousness (LOC) will be referred to cardiology, and if seizures are suspected, to neurology.   

In severe cases, if the cause is central vertigo, admit the person to hospital (severe nausea and vomiting and unable to tolerate oral fluids).  Consider managing people with known migrainous vertigo at home. However, admit or refer people with suspected migrainous vertigo for investigation to confirm the diagnosis. Consider offering short-term symptomatic drug treatment while the person is waiting to be admitted or seen by a specialist, but do not allow this to delay

referral. To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine. To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or cinnarizine, cyclizine, or promethazine teoclate (antihistamines).  

Falls in the elderly

Falls are common in older people, especially those aged 65 years and over, and the prevalence increases with age. About 30% of people aged 65 years and over have a fall at least once each year, increasing to 50% in people aged 80 years and over. In 2016–2017 there were around 210,553 falls related emergency hospital admissions among people aged 65 years and over, with around 141,362 (67%) of these people aged 80 years and over.

The risk of falling is multifactorial, and prevention is usually based on assessing multiple risk factors. A history of falls is one of the strongest risk factors for a fall, and all older people in regular contact with healthcare professionals should be asked routinely whether they have fallen in the past year.

Other risk factors for falls include:

• Conditions affecting balance: arthritis, diabetes, incontinence, stroke, syncope, Parkinson’s disease.
• General conditions: muscle weakness, poor balance, visual impairment, cognitive impairment, depression, alcohol misuse.
• Polypharmacy, psychoactive drugs, drugs that cause postural hypotension (for example antihypertensive drugs).
• Environmental hazards: loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially the bathroom), loose fittings (such as handrails) and poor footwear.

Impact of falls

Falls are the main cause of injury, injury-related disability, and death in older people. About 40-60% of falls result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people who live in the community result in a fractures or hospitalization. About 95% of all hip fractures are caused by falls, with poor short and long-term outlooks. The increased one-year mortality post hip fracture is 18-33% and is also associated with negative effects on daily living activities, such as shopping and walking. The risk of getting a fragility fracture depends on the person’s risk of falls, their bone mineral density (BMD and the presences of other risk factors such as age, use of corticosteroids and smoking.

Other consequences of falls include distress, pain, loss of self-confidence, reduced quality of life, and loss of independence. In addition, falls can trigger a cycle of fear of falls, leading to activity avoidance, social isolation, increasing frailty, functional decline, reduced quality of life, depression and institutionalisation.

Falls and fractures place a huge financial burden on the NHS with the total cost of fragility fractures in the UK being estimated at £4.4 billion.

You make an urgent house-call to a 76 year old patient who was found on the floor.  She has osteoarthritis, and has had a myocardial infarction. She takes paracetamol and an ace-inhibitor.

Assessment 

The most important aspect of assessing falls in the elderly is that all possible risk factors should be considered.  An accurate history is essential both from the patient and from a carer, preferably someone who has witnessed the fall. 

Ask about how the person has fallen, the circumstances in which the fall(s) occurred (such as place, time, activity being performed, and preceding symptoms), and the consequences of the fall(s). This will help to distinguish a simple fall (caused by a chronic impairment of cognition, vision, mobility, or balance) from a collapse (caused by an acute medical problem, for example, arrhythmias, transient ischaemic attack, or vertigo).

For people who have had one or more falls or are considered to be at risk of a fall, assess their gait and balance, for example by using the “Timed Up & Go test (TUGT ” and/or the “Turn 180° test”. For the TUGT the patient is asked to rise from a chair, walk 3m, return and sit down.  More than 30 seconds suggests a high risk of falls.  Inspection of the patient’s home is often more important than a clinical examination, for example checking there are no rugs or cords near where the episodes occurred, to suggest a trip.  

Examination should be guided by the history but will usually include a neurological and cardiological examination.  If a medical condition is suspected, it should be investigated appropriately (see above).  There should be an assessment of visual acuity (referral to an optician) and assessment of cognitive functioning.  Gait and mobility can be tested using the ‘Timed Up and Go’ (TUGT test, in which patients are asked to rise from a chair, walk 3m, return and sit down.  More than 30 seconds suggests a high risk of falls.  Inspection of the patient’s home is often more important than a clinical examination, for example checking there are no rugs or cords near where the episodes occurred, to suggest a trip.    

Management

When considering management, it is important to identify any area of risk that can be managed. The following areas can be considered when formulating a management plan:

• History of falls.
• Gait, balance and mobility, and muscle weakness.
• Osteoporosis risk.
• Perceived impaired functional ability and fear relating to falling.
• Visual impairment.
• Cognitive, neurological, and cardiovascular problems.
• Urinary incontinence.
• Home hazards.
• Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example, drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).

Consider sign posting to written information on reducing the risk of falls, for example articles found on www.ageuk.org.uk and www.csp.org.uk. Consider referral to a specialist falls service where support such as strength and balance training, home hazard assessment and intervention, visual assessment and referral and medication reviews may be carried out.

Management of falls will depend on the cause, but for typical multi-factorial falls, the following measures have been shown to be effective:

•  Exercise interventions
• Home safety interventions
• Medication adjustments
• Podiatry
• Cataracts
• Referral to falls clinic x Referral to a day centre may be useful in preventing further falls. 

Reference

https://cks.nice.org.uk/falls-risk-assessment#!scenario