Remember this!

It is important to remember that dizziness may have two or more possible causes, each contributing to symptoms. These can include depression or anxiety, vision or hearing loss, the use of multiple medications, balance or walking problems, orthostatic hypotension, diabetes, and heart disease. In these cases, all possible causes need to be evaluated and addressed (either together or one after another) to reduce the frequency or severity of dizziness.

Dizziness

Treatment and Management

The prognosis for most cases of dizziness is good, often with no treatment. In up to 50% of cases, dizziness goes away on its own or improves substantially within about 2 weeks. For example, many common causes of vertigo (eg, inner ear inflammation or BPV) typically resolve within days or weeks.

If BPV is disabling, comes back frequently, or just hangs on too long, it is important to know that there is safe and effective treatment. Because BPV is caused by crystals floating freely in the inner ear, those crystals can be coaxed to land and stay put using head positioning. Generally, this is done by an audiologist, although some primary healthcare providers may do this as well. One treatment is usually sufficient.

Orthostatic hypotension may occur because the older adult is taking medications that affect blood pressure, and these will need to be adjusted or discontinued. Other people have disorders of blood pressure control that cause orthostasis, and they may need medicine to increase blood pressure, to increase blood return to the heart (eg, specially-fit support stockings).

If symptoms occur with position change and there is little or no drop in blood pressure, people can be reassured that it isn’t something more serious, and they can usually learn to make position changes more slowly.

Unsteadiness while walking (eg, related to vision problems, arthritis, etc) usually improves immediately when the person holds onto the arm of and walks with a companion. These people can be greatly helped by using a properly fit cane (see Canes in Chapter on Rehabilition). Also, physical therapy for strengthening and balance will reduce symptoms of unsteadiness. Treatments for this type of unsteadiness may include proper glasses or hearing aids. Keeping the lights on at night can also help unsteadiness and help prevent falls. If unsteadiness is caused by arthritis or other problems that make moving difficult, treatment for pain is needed (see Pain Management).

In some older adults with severe episodes of vertigo with vomiting, a short hospital stay may be needed to replace lost fluids. This is most likely to occur in Ménière’s disease. Once the vomiting has stopped, recurrence of Ménière’s can usually be prevented with a very low-sodium diet. Usually, counseling from a dietician is necessary to learn how to maintain such a diet. Surgery is reserved for only the most severe cases of Ménière’s disease, because it involves destruction of the nerve of hearing on the affected side.

Dizziness Diagnosis

Diagnosis and Evaluation

A detailed history is the most useful part of the evaluation. The information you provide is critical in helping your healthcare provider determine the cause of the dizziness. You should make sure to give your healthcare provider the following information:

Is the dizziness characterized by sensations of spinning, fainting, unsteadiness, or lightheadedness?
Is the dizziness related to different body positions?
Do you have other symptoms (eg, nausea, vomiting, fainting, fatigue, depression, or ringing in the ears, etc) along with the dizziness?
Is the problem most likely to occur after a meal, with coughing, urinating, while turning over in bed, or with other specific activities? How often does it happen?
What medications are you taking? A "brown-bag" inventory (see Health Assessment) can help make sure that all drugs are accounted for, including over-the-counter preparations.
The physical examination will include multiple blood pressure measurements in both arms, while you are lying down, standing, and sitting. An electrocardiogram and other testing (eg, stress test) may be recommended to evaluate your heart. Your healthcare provider may also want to perform some tests that involve putting your head and body in various positions. This can help identify signs of inner ear problems (eg, if characteristic eye movements are brought on) or BPV (if symptoms are reproduced).

More than 75% of cases of dizziness can be diagnosed by history and physical examination. However, depending on the results of the history and physical, your healthcare provider may recommend other tests, such as an MRI, CAT scan, inner ear tests, etc.

Lightheadedness

Lightheadedness

Some people who complain of dizziness actually feel lightheaded. Although lightheadedness may occasionally be used to describe other types of dizziness, it is most often used as a vague description for symptoms that do not fit vertigo or near fainting. Many people use lightheadedness or unsteadiness to mean the same thing. Feelings of lightheadedness may be associated with psychological or mood disorders, such as depression or anxiety. Often, no cause can be found.

Near fainting

Some people who complain of dizziness feel like they are going to faint. This problem is usually due to a lack of blood flow to the brain. The most common cause is "orthostatic hypotension," in which blood pressure drops when someone stands up from a bed or chair (see also Fainting). Near-fainting spells can also be caused by the straining associated with coughing or going to the bathroom. An older person who gets up to urinate in the middle of the night, who strains to have a bowel movement, or who has a respiratory problem may experience near fainting, or even fainting. Probably the most serious causes of near-fainting spells are heart problems, including narrowed heart valves and problems with heart rhythm.

Unsteadiness

Some people who complain of dizziness actually feel unsteady when standing and especially when walking. The medical term for this is "disequilibrium." It can be caused by anything that leads to unsteadiness or lack of balance, including poor vision, middle ear problems, arthritis, and foot problems. An older person with more than one of these problems is much more likely to experience disequilibrium. It can also be caused by problems with the nervous system, such as those often seen after a stroke. Unsteadiness is associated with difficulty walking and with falls.

Veritgo

Vertigo is dizziness accompanied by a sensation of spinning. The most common causes of vertigo are middle or inner ear problems. Benign positional vertigo (BPV) involves the middle ear. Spells of BPV are brought on by changes in head position, such as from turning, rolling over, lying down, sitting up, or bending over. These spells often last only 5—15 seconds, and they are milder than attacks of vertigo seen with conditions of the inner ear. Generally, BPV gets better on its own, but it can come back. In some people, it is long lasting and disabling and warrants prompt attention and treatment.

Most vertigo associated with the inner ear happens suddenly, lasts for several days, and then goes away on its own. These episodes may be caused by viral infections or inflammation of the nerves in the inner ear. In this condition, the eyes may "swing" rhythmically and quickly back and forth (left to right or right to left), which is called nystagmus. People may also have difficulty walking, nausea, or vomiting. Usually, hearing is not affected, and there are no other problems with the nervous system.

One particularly severe type of inner ear problem is called Ménière’s disease. In this disease, there are repeated episodes of severe vertigo, nausea, and vomiting. Between episodes, there is often mild dizziness and ringing in the ears. Ménière’s disease can worsen over time, leading to deafness and, sometimes, problems with balance and walking.

Diseases of the brain, such as stroke, brain tumors, multiple sclerosis, or blood vessel problems, can occasionally cause vertigo. These disorders are more commonly accompanied by other neurologic problems, such as weakness or inability to move an arm or a leg, difficulty walking, or vision problems such as double vision.

Types of Dizziness

People often use "dizziness" to describe faintness, lightheadedness, or poor balance. Blurred vision, double vision, and changes in blood pressure may also be interpreted as dizziness. Dizziness is classified into several distinct types based on symptoms:

Vertigo
Unsteadiness
Near fainting
Lightheadedness
These different types have different causes and different treatments.

Quality of Life

Dizziness describes a variety of unpleasant sensations that often interfere with balance and walking. It is a common complaint of people over age 65, affecting 13%—38% of older Americans. Dizziness can have many different causes that can be difficult to diagnose.

Dizziness doesn’t usually last long, but in about one-quarter of older adults with this problem, it can last a year or more. It is not usually associated with increased risk of death, unless it is a sign of heart disease. However, dizziness can increase the risk of falling and decrease quality of life, especially if it is persistent or severe.

VEDA- what it does...

Vestibular (inner ear) disorders can cause dizziness, vertigo, imbalance, hearing changes, nausea, fatigue, anxiety, difficulty concentrating, and other symptoms, with potentially devastating effects on a person's day-to-day functioning, ability to work, relationships with family and friends, and quality of life.
Diagnosing and treating vestibular disorders is not always straightforward. In addition, such disorders are often "invisible," making it difficult for others to understand how disabling they can be.
The Vestibular Disorders Association (VEDA) is a non-profit organization that serves people with vestibular disorders and the health professionals who treat them.
VEDA provides information, resources, support, and advocacy. We strive to elevate public awareness about vestibular disorders in order to promote understanding, access to diagnosis and treatment, research, and help for those facing the challenges of living with a vestibular disorder.

Pediatric Vestibular Disorders

Vestibular disorders in children are generally considered uncommon. They are not as easily recognized as vestibular disorders in adults, in part because children cannot describe their symptoms as well. Symptoms and signs that may indicate vestibular dysfunction in children include developmental and reflex delays, visual-spatial problems, hearing loss, tinnitus, motion sensitivity, abnormal movement patterns, clumsiness, decreased eye-hand and eye-foot coordination, ataxia, falls, nystagmus, seizures, dizziness, nausea, ear pressure, difficulty moving in the dark, behavioral changes, and/or delays in performance of developmental activities such as riding a bicycle, hopping, and stair climbing involving alternating left-right leg movements. Possible causes include head-neck trauma, chronic ear infections, maternal drug or alcohol abuse during pregnancy, cytomegalovirus, immune-deficiency disorders, migraine with or without headache, meningitis, metabolic disorders (e.g., diabetes), ototoxic medications, neurological disorders (e.g., cerebral palsy, hydrocephalus), genetic syndromes (e.g., branchio-otorenal syndrome, Mondini dysplasia, Wallenberg syndrome), posterior brain tumors (e.g., malignant medullo-blastomas or the less frequently seen benign acoustic neuromas), and a family history of vertigo, motion sensitivity, hearing loss, or vestibular disorders. Dizziness can be the first symptom of depression in a teenager. Alcohol intoxication can produce dizziness, imbalance, staggering, and abnormal eye movements. Children may also develop a vestibular disorder for no known reason. The underlying reasons often cannot be determined even with the most aggressive testing. This does not preclude successful treatment or recovery. Children can experience the same vestibular disorders as adults. Benign paroxysmal positional vertigo (BPPV) in children is typically associated with physical trauma and can result from accidents, falls, or sports injuries. Infrequently, BPPV has also been observed following cochlear implantation. Vestibular neuritis or labyrinthitis occurs in children, as well as ototoxicity. Children that experience ototoxicity can have severe imbalance, falls, and visual-motor problems, including oscillopsia (bouncing vision). Less common in children is Meniere's disease, enlarged vestibular aqueduct, perilymph fistula, autoimmune disease, and vascular insufficiencies. In addition to all the vestibular disorders that adults are subject to, children have two of their own. Childhood paroxysmal vertigo, often referred to as migraine equivalent, is typically seen in children 2–12 years old and is characterized by true spinning vertigo, nystagmus, nausea, and vomiting. Children tend to “grow out of” this condition, but it may progress into benign positional vertigo or migraine-associated vertigo in adulthood. Paroxysmal torticollis of infancy consists of head-tilt spells that may be associated with nausea, vomiting, pallor, agitation, and ataxia. Evaluation and treatment: Age-specific techniques are used for assessment and treatment of vestibular dysfunction in children. A diagnostic work-up might include a history and physical exam, a hearing test, and possibly brain scans to rule out other pathologies. In addition, a vestibular therapist can help evaluate the child's ability to use the vestibular system for balance and visual-motor control, as well as test the child's developmental reflexes that have control mechanisms in the vestibular system. Using these results, the therapist develops vestibular-therapy exercises, which are tailored to the individual child. Children with vestibular disorders can respond well to such intervention. In fact, children typically respond more quickly than adults, because of their greater plasticity—the ability of their neurological systems to more quickly compensate for and adapt to vestibular deficits. In addition, children tend to be less fearful of movement than adults, so they participate well in the balance and movement aspects of therapy. Vestibular therapy can be effective for reducing or eliminating vertigo, improving visual-motor control, improving balance and coordination, and promoting normal development in children with vestibular disorders.

balance problems in seniors

As people grow older, they may have difficulty with their balance. Roughly 9 percent of adults who are 65 and older report having problems with balance. Having good balance means being able to control and maintain your body's position, whether you are moving or remaining still. An intact sense of balance helps you
walk without staggering
get up from a chair without falling
climb stairs without tripping
Many people experience problems with their sense of balance as they get older. Disturbances of the inner ear are the main cause. People feel unsteady, or as if they were moving, spinning, or floating.
Vertigo, the feeling that you or the things around you are spinning, is also a common symptom. Experts believe that more than 40 percent of Americans will experience dizziness that is serious enough to go to a doctor.

Inner Ear Fluid Balance

The fluid-filled hearing and balance structures of the inner ear normally function independently of the body's overall fluid/blood system. The fluid that bathes the sensory cells of the inner ear (known as endolymph) maintains a constant volume and contains specific and stable concentrations of sodium, potassium, chloride, and other electrolytes.

With injury or disease, the volume and composition of endolymph may fluctuate with changes in the body's fluid/blood. This fluctuation is thought to cause the symptoms of endolymphatic hydrops or Meniere's disease—pressure or fullness in the ears, tinnitus (ringing in the ears), hearing loss, dizziness, and imbalance. Thus, for people with Meniere's disease (primary idiopathic endolymphatic hydrops) or secondary endolymphatic hydrops, (which may follow damage to the inner ear) maintaining stability in the body's fluid/blood system is important.

APTA

The American Physical Therapy Association (APTA) is a national professional organization representing physical therapists, physical therapist assistants, and students throughout the United States.
Physical therapists are vital members of the multidisciplinary health care team. They provide treatment and can refer clients to other health care specialists. APTA serves its members and the public by promoting understanding of the physical therapists increasing role in the health care system. APTA also promotes excellence in the field with advancements in physical therapy practice, research, and education.

Balance Is A Skill You Can Keep Or Recapture

The good news is that balance is a skill that almost all of us can keep throughout our lives. Much of the deterioration in balance associated with age is simply due to not using this skill. Sometimes this happens because of change in lifestyle most of us become more sedentary as we grow older or it can happen due to fear of falling.
Working with a physical therapist can produce exceptional results in many cases. Even if some of your innate sense of balance has been diminished over time, physical therapists are experts at retraining your body to make the most of its capabilities.

Physical therapy

How Physical Therapy Can Help Balance
If you consult a physical therapist about falls and balance, he or she will likely review your medical history and determine your general physical condition, as well as conduct an inventory of tests specifically designed to measure balance and gait (your individual style of walking). If you have fallen before, your physical therapist will ask you to describe the accident in some detail to find out what caused the fall. (Just as important as actual falls are near-falls-instances in which you were on your way down but managed to hang on.)
After your physical therapist has determined what is impairing your balance, he or she will design a program of exercises and activities just for you, with an emphasis on strength, flexibility, and proper gait. All exercises would be planned for maximum safety and security. Your physical therapist may also perform specific interventions to increase your range of motion and musculoskeletal flexibility. These may include electrical stimulation, massage, hydrotherapy, heat, cold, and ultrasound. If you have balance problems related to the inner ear, your physical therapist may also try interventions known as vestibular rehabilitation. Vestibular rehabilitation includes techniques that help the inner ear respond to a change in position. Conditions that may require vestibular rehabilitation include vertigo, dizziness, or nausea.
If necessary, your physical therapist may also prescribe assistive devices for walking (such as canes, crutches, or walkers). Make sure the tips on canes and crutches are large (and spiked, if necessary, for icy conditions), and that canes are high enough (they should come up to your hip).
Appropriate footwear is another major consideration. Wearing a good pair of lace-up walking shoes will help support your foot and provide necessary cushioning for your joints; this will make walking safer and more comfortable. Avoid high heels, slippers, and open-toed sandals, which can cause you to trip.

Strength, flexibility, and endurance

Strength, flexibility, and endurance are crucial to maintaining balance and preventing falls. Even if your basic perception of balance is good” you have normal vision and no inner ear problems” you can still be at risk for falls if your muscles are weakened or stiff, or if you tire easily. Older adults” particularly those with osteoporosis (the disease that causes brittle bones)” have very legitimate concerns about falling and often restrict their physical activities to prevent such a mishap. Ironically, lack of exercise only makes it more likely that a fall will occur” and a vicious cycle has been put into motion.
Fortunately, physical therapy can help you learn to cultivate and maintain higher levels of strength, flexibility, and endurance in a way that still feels safe and secure. Research indicates that the risk of falling in older adults can be reduced dramatically when specific exercises, activities, and interventions are prescribed by physical therapists. There are instances, however, in which physical therapy alone may not be appropriate. If you have an inner ear disorder, for example, you will need to consult a physician.

Other factors

Some non-dietary substances can increase symptoms of vestibular disorders. Aspirin can increase tinnitus, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can interfere cause water retention or electrolyte imbalance. Nicotine (found in tobacco products and some cease-smoking aids) can increase symptoms, because it decreases the blood supply to the inner ear by constricting blood vessels; it also causes a short-term increase in blood pressure.

Many of these guidelines are commonly recommended to people with Meniere's disease, endolymphatic hydrops, or vestibular migraine. A physician or dietician may incorporate some of these principles into an individualized treatment plan.

How Balance Works

Your brain, muscles, and bones work together to maintain your bodys balance and to keep you from falling, whether youre walking, rising from a chair, or climbing stairs. They also let you navigate sloping or uneven surfaces.
Balance relies on three types of sensory information. The first of these is visual: Your eyes tell you about your environment and your place within it. They help you sense obstacles and potential dangers, and form motor memories that prevent falls. The second type of sensory information comes from your bodys internal sense of spatial orientation, independent of vision. This allows you, for example, to close your eyes and then wiggle your foot in any direction, while still knowing which way your foot is pointed. The third type of sensory information is provided by your inner ears, which contain fluid-filled semicircular canals. These canals provide your brain and eyes with crucial information on the position of your head and its movement in space with respect to gravity. (Common problems related to the workings of the inner ear include dizziness on escalators and sea-sickness.) When your sense of balance is in good working order, the three elements of balance work together automatically with your musculoskeletal system to keep you mobile and to prevent falls.
There are various reasons why your sense of balance can become impaired. In older adults, poor posture particularly if you tend to slouch forward and have rounded upper shoulderscan sometimes cause unsteadiness. Furthermore, your base of support is important in keeping you balanced: if you have a wide type stance, youre less likely to lose your balance or fall than if your feet are close together in a stance. Disease can also rob you of a strong sense of balance. People with diabetes, for example, may suffer from numbness in the lower extremities and feet— a problem that makes detecting obstacles or dangers more difficult. People with arthritis, or who have had surgery on their hips, knees, or feet, may lack the flexibility and range of motion necessary to avoid falling.

Commonly prescribed medications include the following:
Meclizine hydrochloride (Antivert)
Diphenhydramine (Benadryl)
Scopolamine transdermal patch
Promethazine hydrochloride (Phenergan)
Diazepam (Valium)