The most detailed analysis of "Dizziness/vertigo assessment for the elderly", 8 steps!

*For medical professionals to read and reference, help to standardize the diagnosis and treatment of dizziness/vertigo Dizziness/vertigo is a common symptom of the elderly, and it is also a common complaint of the elderly in the outpatient and emergency departments of hospitals at all levels
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These dizziness/vertigo and balance disturbances were previously thought to be the result of normal aging, and the real cause was rarely analyzed and explored
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But these symptoms can limit the daily activities of older adults, reduce opportunities for outdoor activities, reduce quality of life, and increase the risk of falls, trauma, and fractures
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In the clinic, we can make a preliminary diagnosis of dizziness/vertigo in the elderly through detailed medical history collection and physical examination.
Medical history and physical examination of patients with vertigo (picture from the original guideline) Medical history collection Many elderly patients cannot accurately describe the nature and characteristics of their own dizziness and dizziness, and sometimes even inconsistent descriptions before and after, but the diagnosis of dizziness and dizziness mainly relies on the patient's detailed dizziness and dizziness.
History of seizures for initial diagnosis and differential diagnosis
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First of all, clinicians should improve their ability to capture reliable and key medical history information, follow the standard procedures to gradually inquire and complete a good medical history collection, which is convenient for later diagnosis and treatment
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At the same time, due to the particularity of the elderly population, the collection of medical history needs to be obtained from multiple channels.
In addition to repeated verification with the patient, it is also necessary to refer to the supplementary information of family members or daily caregivers to ensure the reliability and accuracy of the medical history information
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1 First, ask the patient about the specific manifestations of dizziness/vertigo, and clarify the nature of the patient's dizziness/vertigo.
There are currently two more recognized classification methods (1972 dizziness classification, 2009 consensus classification of vestibular symptoms)
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Most domestic clinicians like to use the dizziness classification definition proposed by the United States in 1972.
This classification regards dizziness as a general term for all dizziness/vertigo symptoms, and is divided into four categories: dizziness, vertigo, imbalance and presyncope (state)
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①Vertigo: A movement illusion caused by spatial disorientation.
Patients often describe themselves or the external environment as feeling like spinning, rolling, and falling
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②lightheadedness: also known as dizziness, the concept is relatively vague, often refers to lightheadedness, dizziness, dizziness, body floating,
etc.

The main difference from vertigo is that the patient has no illusion of movement of himself or the external environment
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③ Disequilibrium: refers to the feeling of instability, imbalance or falling down when walking.
Such patients generally have no symptoms of instability when lying or sitting
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④ Presyncope: refers to the feeling of amaurosis, about to lose consciousness, and about to faint after the general decline of blood supply to the brain
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The prejuicy state is often accompanied by symptoms such as dizziness, chest tightness, palpitations, and fatigue
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Using such a symptom classification, each type of "dizziness" represents a different potential disease category, and this classification is conducive to further finding the exact cause of the patient: when the patient complains of dizziness, it is mainly a vestibular nerve pathway.
series of diseases
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When patients experience dizziness and no nausea and vomiting, a small part of them are residual discomfort after the symptoms of dizziness are relieved, but more are related to mental illnesses and systemic diseases related to depression and anxiety
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When the imbalance occurs, it is mainly related to the patient's deep sensation, cerebellar ataxia, pyramidal and extrapyramidal system, and lower extremity muscle and joint damage
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The presyncope state is mainly associated with decreased cardiovascular function
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With the development of basic research on dizziness/vertigo, the Barany Association first proposed a consensus classification of vestibular symptoms in 2009.
The definition of vestibular symptoms in this classification is relatively broad, covering typical vestibular diseases (most dizziness/vertigo symptoms) The spectrum of clinical symptoms caused by disease) is divided into four categories: dizziness, vertigo, vestibular-visual symptoms, and postural symptoms
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① The definitions of dizziness and vertigo are the same as the previous classification method
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②Vestibular-visual symptoms: Visual symptoms due to vestibular lesions or visual-vestibular interactions, including false sensations of movement, tilt of vision, and visual distortion (blur) associated with loss of vestibular function (rather than visual acuity)
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It can manifest as vibrophantasia, visual delay, visual tilt, or motion-induced blurred vision
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③ Postural symptoms: Balance symptoms related to maintaining postural stability when in an upright position (such as standing), which can be manifested as a sense of instability and a sense of falling
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Postural symptoms occur in upright positions (sitting, standing, walking), but do not include a range of gravity-related symptoms (eg, the "stand up" movement) when changing positions
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This classification method clearly defines the symptoms of dizziness and vertigo, and each type of symptoms has a certain specificity.
Compared with the concept in 1972 and the previous domestic concept, it is a significant improvement, but the clinical application effect is still unsatisfactory
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Dizziness and dizziness are only subjective descriptions of patients.
Everyone has different perceptions of dizziness, and the descriptions of dizziness are also inconsistent.
Even the descriptions of the same patient before and after may not be consistent, and the same patient may have ≥2 types of "dizziness".
"
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Therefore, after a detailed consultation and physical examination, it is necessary to further clarify which category the patient's "halo" description belongs to
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2.
Clarify the onset form and attack frequency.
Patients can basically accurately describe whether they have had similar dizziness and dizziness in the past
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Acute single persistent symptoms need to be differentiated from vestibular neuritis, sudden deafness with vertigo, and posterior circulation stroke
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Recurrent symptoms should be differentiated from benign paroxysmal positional vertigo (BPPV), vestibular migraine, Meniere's disease, vestibular paroxysmal syndrome, transient ischemic attack (TIA), panic attacks, seizures, seizures Sexual ataxia type 2,
etc.

Chronic persistent symptoms are mainly considered as chronic progressive exacerbations, which are common in intracranial space-occupying diseases (such as brainstem cerebellar tumors), central nervous system degenerative diseases, and paraneoplastic subacute cerebellar degeneration.
Postural perception dizziness (PPPD), bilateral vestibular disease, chronic poisoning,
etc.

In addition, many systemic diseases, such as hypotension, anemia, sleep apnea syndrome, etc.
, drug-induced causes can also manifest as chronic persistent dizziness, especially in the elderly
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3.
Duration of symptoms Dizziness and dizziness symptoms are very important in judging dizziness/vertigo diseases.
When inquiring, you should try to clarify how long the patient's dizziness symptoms lasted.
Is it a few seconds? how many minutes? hours? Or days or more? Patients with seizures of short duration tend to exaggerate the duration of the seizures, while patients with seizures of long duration are relatively accurate
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Different durations may represent different dizziness/vertigo disorders
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4 Predisposing factors The description of predisposing factors is often very accurate in patients, which can provide reliable clues for the diagnosis of dizziness and dizziness
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If vertigo symptoms occur when you change your position, such as lying down, sitting up, looking up, or turning over in bed, you must consider whether it is BPPV
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At this time, the frequency of episodes of previous position-induced vertigo and the time to resolution of each episode should be asked, and the subsequent physical examination should be combined to identify whether it is BPPV or central positional vertigo
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If the patient is asymptomatic when sitting or lying down, and if he/she experiences instability and shaking when walking, clinical consideration should be given to whether he has deep sensory disturbance, cerebellar ataxia, pyramidal and extrapyramidal diseases, and similar discomfort in bilateral vestibulopathy.

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Dizziness or dizziness symptoms appear or aggravate on special occasions, such as in claustrophobic spaces such as elevators, or in open spaces such as squares, or in supermarkets, shopping malls, or when going upstairs normally but going downstairs.
Combined mental illness
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Vestibular migraine should be considered clinically in women who experience vertigo attacks around menstrual periods or after irregular sleep, even without a clear history of migraine.
Certain foods can also cause vestibular migraine
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Vestibular neuronitis is the first consideration for a history of proviral infection, but it should be noted that less than 30% of patients with vestibular neuronitis can ask about such a history of proviral infection
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There are also rare precipitating factors, such as seizures after coughing, suffocating breath or hearing noises.
Clinically, it should be considered that in addition to the round window and the oval window, there may be a third window in the inner ear
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5 Accompanying symptoms are prominent with autonomic symptoms such as nausea, vomiting, bradycardia, blood pressure change (increase or decrease), hyperperistalsis, frequent bowel movements, etc.
, caused by vestibular vagal hyperreflexia, common in peripheral vestibular vertigo and partial vestibular vertigo Vestibular central vertigo disorders
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Tinnitus, a feeling of fullness in the ears, hearing loss, or hyperacusis can be seen in Meniere's disease
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Vertigo with hearing loss and ear or mastoid pain can be seen in sudden deafness, labyrinthitis, otitis media, and occasionally in infarction in the blood supply area of ​​the anterior inferior cerebellar artery
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If dizziness/vertigo is accompanied by diplopia, dysarthria, facial and limb sensation, movement disturbance, or ataxia, it is highly suggestive of brainstem cerebellar disease
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If acute occipital pain persists, vertebrobasilar dissection should be alerted; the acute onset and persistence of the above symptoms suggest possible posterior circulation infarction or bleeding; the slow onset of persistent facial and limb sensorimotor disturbance or ataxia suggests craniocervical junction malformation , hereditary or acquired cerebellar ataxia
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Elderly people often have cardiovascular diseases.
If dizziness/dizziness is accompanied by palpitations, chest tightness, chest pain, pale complexion, syncope and other symptoms, it is necessary to be highly alert to the possibility of heart disease, such as acute coronary syndrome or arrhythmia, pulmonary embolism
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If the patient is obviously nervous, worried, restless, depressed, fearful, sleep disorders (such as difficulty falling asleep, easy to wake up, early awakening) and other manifestations, it indicates that there may be combined or concurrent anxiety, depression, or PPPD
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In addition, binocular diplopia in patients with dizziness suggests brainstem, oculomotor nerve, extraocular muscle or neuromuscular junction lesions; monocular diplopia, monocular amaurosis, monocular visual acuity decreased, strabismus, etc.
, suggest eyeball, intraocular muscle or optic neuropathy
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If the patient presents with neck and shoulder pain, dizziness/vertigo related to neck movement, and numbness in the upper limbs or fingers, it may indicate cervical instability, cervical spondylosis, and craniocervical dysplasia
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Cervical vertigo is difficult to be diagnosed clinically due to the lack of objective diagnostic indicators.
The current mainstream view is that the concept of cervical vertigo should be abandoned.
Such dizziness/vertigo is attributed to the involvement of deep senses
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6.
To clarify the patient's drug use and drinking conditions, the elderly often have multiple drug use due to coexistence of multiple diseases.
Many drugs have side effects such as dizziness/vertigo and unsteady walking
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Therefore, when dizziness/vertigo or walking instability occurs in the elderly, it is necessary to ask the patient about the medication history, especially the newly added medication
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History of drug use can help differentiate drug-induced dizziness/vertigo from drug-induced orthostatic hypotension
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Drugs that affect attention and the neuropsychiatric system, such as benzodiazepines, antihistamines, opioid pain relievers, tricyclic antidepressants, serotonin reuptake inhibitors, antiepileptic drugs, ethanol, can cause Non-vertigo dizziness
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Drugs affecting the function of the basal ganglia and extrapyramidal system, such as antipsychotics, metoclopramide, oxythiazides, serotonin reuptake inhibitors, corticosteroids, colchicine, statins, interferons, and Causes non-dizzying dizziness
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Miotic drugs, such as pilocarpine, can cause a decrease in the visual field and non-vertigo dizziness
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Drugs that cause orthostatic hypotension, such as the prostate smooth muscle relaxant terazosin hydrochloride, can also cause nondizzying dizziness
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Our country is a country with far-reaching influence of wine culture, especially elderly men have many long-term drinkers
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Long-term drinkers eat less staple food and have insufficient vitamin B1 intake.
At the same time, alcohol metabolism also consumes a large amount of vitamin B1.
In addition, the direct damage effect of alcohol on nerves can lead to peripheral neuropathy, deep sensory impairment, and non-vertigo dizziness.

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In addition, long-term drinking history can also cause white matter lesions, cardiovascular and cerebrovascular diseases, anemia, malnutrition and other diseases that can cause dizziness/vertigo, so special attention should be paid during consultation
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7 Past history and complications: Patients with acute dizziness/vertigo with a history of hypertension, diabetes, hyperlipidemia, smoking and drinking, cardiovascular and cerebrovascular diseases should first identify whether there is cerebrovascular disease
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Patients with a history of ear diseases, such as chronic otitis media, are prone to later complications such as labyrinthitis and fistula formation
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Temporal bone fractures and perilymphatic fistulas often have a history of trauma surgery
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Motion sickness patients often have a history of motion sickness and seasickness
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Patients with vestibular migraine often have a family history of headache, dizziness, or motion sickness
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Patients with vestibular migraine, Meniere's disease, and hereditary cerebellar ataxia may have a family history
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There is increasing evidence that migraine and vertigo are closely related, but patients are prone to forgetting previous migraine attacks, often requiring repeated questioning.
Family history, etc.
should be clarified; because patients with vertigo are prone to be accompanied by symptoms of anxiety and depression, and dizziness symptoms are also common in patients with anxiety and depression, it is recommended that each patient should be asked about the relevant medical history and symptoms, and relevant scales should be assessed if necessary
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8 Psychological and cognitive conditions For elderly patients with long-term recurrent dizziness/vertigo, chronic persistent dizziness, or orthostatic/postural dizziness, anxiety and depression assessment should be performed, and attention should be paid to the analysis of the relationship between chronic dizziness/vertigo and anxiety and depression disorders (causal or comorbidity)
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Cognitive function includes six basic domains: complex attention, executive function, learning and memory, language, sensory-motor function, and social cognition
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Among them, complex attention, executive function and sensory-motor function are most closely related to gait stability
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The anatomical basis of executive function is located in the prefrontal cortex and is associated with various gait parameters including pace, stride length, and timing of leg movement during the gait cycle
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Decreased executive function can lead to increased variability in gait parameters during walking, a hallmark of impaired gait control
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In addition, executive function was also associated with functional gait outcomes, such as stair climbing time or standing and walking tests
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Decreased executive function was associated with decreased gait speed with age, regardless of the patient's baseline cognitive impairment
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Cognitive impairment due to a variety of neurological diseases affects activities of daily living, starting with changes in gait
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Studies have shown that the interaction of gait and cognition is most pronounced during the development of dementia, and elderly patients with dementia are more likely to fall than their peers with normal cognitive function
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Elderly patients who are afraid of falling are prone to gait instability and dizziness.
Therefore, it is necessary to pay attention to the emotional and emotional problems of elderly patients, such as anxiety and depression
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After a systematic consultation, a detailed physical examination is required to further clarify the diagnosis of the disease and distinguish between central and peripheral dizziness and dizziness.
Due to space limitations, please look forward to the next exciting continuation
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References: [1] Ju Yi, Zhuang Jianhua, Han Junliang, etc.
, "Multidisciplinary Expert Consensus on Diagnosis and Treatment of Dizziness/Vertigo in the Elderly (2021)", Chinese Journal of Geriatrics, Vol.
40, No.
10, 2021
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[2] Zhao Yan and Ju Yi, "Diagnostic evaluation and treatment of elderly patients with dizziness and dizziness", Chinese Journal of General Practitioners, Vol.
20, No.
1, 2021
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[3] Zhuang Jianhua, "Thinking of Diagnosis and Treatment of Dizziness and Dizziness", Journal of Chongqing Medical University, Vol.
46, No.
7, 2021
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[4] Jiang Shujun, Shan Xizheng, "Common Causes of Dizziness in the Elderly" Chinese Journal of Otolaryngology, Volume 25, Issue 5, 2017 [5] "Guidelines for Primary Care of Dizziness/Vertigo (2019)", "Chinese Journal of General Practitioners, Issue 3, 2020
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[6] Zhang Yingdong, "The relationship between gait and cognitive function and its clinical significance", Practical Geriatric Medicine, Vol.
35, No.
11, 1182-1186, November 2021
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First release of the text: Neurology Channel of the Medical World This article author: Xin Huaping Review of this article: Wang Yan Editor in charge of Beijing Tiantan Hospital Affiliated to Capital Medical University: Mr.
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